Last Updated: October 2026
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Composite Quality Score

Comprehensive rating based on CMS data, staffing, quality measures, and compliance

A-
Grade
63
Score
CMS Ratings
14.7/22
Staffing Quality
13.8/20
Quality Measures
0.0/22
Compliance
18.0/18
Safety
13.0/13
Availability
6.0/10

Current Availability Estimate

Occupancy Rate87.3%
59
Total Beds
52
Occupied
7
Available

Basic Information

Address:

2520 MADISON

EVERETT, WA 98203

Number of Beds:

59

Estimated Occupancy:

87% (~8 available)

Chain:

THE MANDELBAUM FAMILY

Quality Ratings

Overall Rating:3/5 Stars
Health Inspection:3/5 Stars
Staffing Rating:4/5 Stars
Quality Measures:4/5 Stars

Safety Information

Abuse Issues:No Issues Reported
Special Focus:Not Under Special Focus

Additional Information

CMS Certification Number:

505463

Provider Type:

Medicare and Medicaid

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Staffing Metrics

Higher staffing hours generally indicate better care quality. Lower turnover indicates more experienced, stable staff.

Registered Nurse (RN) Hours

Per resident per day

Above Average

This Facility

0.81

hours

National Avg

0.64

hours

Total Nursing Staff Hours

RN + LPN + Nurse Aides per resident per day

Average

This Facility

4.21

hours

National Avg

3.89

hours

Breakdown:

RN: 0.81hLPN: 0.98hAide: 2.43h

Staff Turnover Rate

Annual nursing staff turnover

Below Average

This Facility

35.2%

National Avg

46.6%

RN Turnover: 64.7%

Understanding Staffing Metrics

Staffing hours: Higher hours generally mean more staff attention per resident. Federal minimum is 3.5 total hours per resident per day, but quality facilities often exceed 4+ hours.

Turnover: High turnover (>50%) can indicate staffing issues and affect care continuity. Lower turnover means more experienced staff familiar with residents' needs.

Detailed Quality Measures

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Health Inspections & Deficiencies

Critical Deficiencies Found

This facility has 4 deficiency citations involving actual harm to residents. Review these carefully before making a decision.

Total Deficiencies

162

Inspections

3

Critical

4

High

6

Aug 7, 2024 - Health Survey

28 deficiencies cited

Medium - PatternTag F0561

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected: Sep 20, 2024
Medium - PatternTag F0584

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected: Sep 20, 2024
Medium - PatternTag F0636

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected: Sep 20, 2024
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Sep 20, 2024
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Sep 20, 2024
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Sep 20, 2024
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Sep 20, 2024
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Sep 20, 2024
Medium - PatternTag F0730

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Corrected: Sep 20, 2024
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Sep 20, 2024
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Sep 20, 2024
Low - IsolatedTag F0912

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Corrected: Sep 20, 2024
Medium - PatternTag F0947

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected: Sep 20, 2024
Medium - PatternTag F0585

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected: Sep 20, 2024From Complaint
Medium - PatternTag F0584

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected: Sep 20, 2024
Medium - PatternTag F0636

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected: Sep 20, 2024
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Sep 20, 2024
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Sep 20, 2024
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Sep 20, 2024
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Sep 20, 2024
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Sep 20, 2024
Medium - PatternTag F0730

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Corrected: Sep 20, 2024
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Sep 20, 2024
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Sep 20, 2024
Low - IsolatedTag F0912

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Corrected: Sep 20, 2024
Medium - PatternTag F0947

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected: Sep 20, 2024
Medium - PatternTag F0585

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected: Sep 20, 2024From Complaint
Medium - PatternTag F0561

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected: Sep 20, 2024

Oct 16, 2023 - Health Survey

52 deficiencies cited

Medium - PatternTag F0685

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Corrected: Nov 30, 2023
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Nov 30, 2023
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Nov 30, 2023
Medium - PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: Nov 30, 2023
Medium - PatternTag F0693

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected: Nov 30, 2023
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: Nov 30, 2023
Medium - PatternTag F0744

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected: Nov 30, 2023
Medium - PatternTag F0758

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected: Nov 30, 2023
Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Nov 30, 2023
Medium - PatternTag F0791

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Corrected: Nov 30, 2023
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Nov 30, 2023
Low - IsolatedTag F0912

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Corrected: Nov 30, 2023
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Nov 30, 2023
Medium - PatternTag F0685

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Corrected: Nov 30, 2023
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Nov 30, 2023
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Nov 30, 2023
Medium - PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: Nov 30, 2023
Medium - PatternTag F0693

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected: Nov 30, 2023
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: Nov 30, 2023
Medium - PatternTag F0744

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected: Nov 30, 2023
Medium - PatternTag F0758

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected: Nov 30, 2023
Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Nov 30, 2023
Medium - PatternTag F0791

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Corrected: Nov 30, 2023
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Nov 30, 2023
Low - IsolatedTag F0912

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Corrected: Nov 30, 2023
Medium - PatternTag F0582

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected: Nov 30, 2023
Medium - PatternTag F0584

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected: Nov 30, 2023
High - Widespread PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Nov 30, 2023
Medium - PatternTag F0604

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected: Nov 30, 2023
Medium - PatternTag F0607

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected: Nov 30, 2023
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Nov 30, 2023
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Nov 30, 2023
Medium - PatternTag F0636

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected: Nov 30, 2023
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Nov 30, 2023
Medium - PatternTag F0644

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected: Nov 30, 2023
Medium - PatternTag F0645

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected: Nov 30, 2023
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Nov 30, 2023
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Nov 30, 2023
Medium - PatternTag F0582

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected: Nov 30, 2023
Medium - PatternTag F0584

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected: Nov 30, 2023
High - Widespread PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Nov 30, 2023
Medium - PatternTag F0604

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected: Nov 30, 2023
Medium - PatternTag F0607

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected: Nov 30, 2023
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Nov 30, 2023
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Nov 30, 2023
Medium - PatternTag F0636

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected: Nov 30, 2023
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Nov 30, 2023
Medium - PatternTag F0644

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected: Nov 30, 2023
Medium - PatternTag F0645

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected: Nov 30, 2023
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Nov 30, 2023
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Nov 30, 2023
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Nov 30, 2023

Aug 18, 2022 - Health Survey

82 deficiencies cited

Medium - PatternTag F0943

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Corrected: Sep 15, 2022
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Sep 15, 2022
Medium - PatternTag F0561

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected: Sep 15, 2022From Complaint
Medium - PatternTag F0563

Resident Rights Deficiencies

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Corrected: Sep 15, 2022
Medium - PatternTag F0578

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected: Sep 15, 2022
Medium - PatternTag F0584

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected: Sep 15, 2022
Critical - Actual HarmTag F0607

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected: Sep 15, 2022
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Sep 15, 2022
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Sep 15, 2022
Medium - PatternTag F0655

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected: Sep 15, 2022
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Sep 15, 2022
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Sep 15, 2022
Medium - PatternTag F0660

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Corrected: Sep 15, 2022
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Sep 15, 2022
High - Widespread PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Sep 15, 2022
Medium - PatternTag F0688

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected: Sep 15, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Sep 15, 2022
Medium - PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: Sep 15, 2022
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Sep 15, 2022
Medium - PatternTag F0725

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected: Sep 15, 2022
Medium - PatternTag F0726

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected: Sep 15, 2022
Medium - PatternTag F0730

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Corrected: Sep 15, 2022
High - Widespread PatternTag F0742

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Corrected: Sep 15, 2022
Medium - PatternTag F0745

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected: Sep 15, 2022
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Sep 15, 2022
Medium - PatternTag F0756

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected: Sep 15, 2022
Medium - PatternTag F0758

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected: Sep 15, 2022
Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Sep 15, 2022
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Sep 15, 2022
Medium - PatternTag F0835

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected: Sep 15, 2022
Medium - PatternTag F0837

Administration Deficiencies

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Corrected: Sep 15, 2022
Medium - PatternTag F0838

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected: Sep 15, 2022
Medium - PatternTag F0842

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected: Sep 15, 2022
Medium - PatternTag F0843

Administration Deficiencies

Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

Corrected: Sep 15, 2022
Medium - PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Sep 15, 2022
Critical - Actual HarmTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Sep 15, 2022
Medium - PatternTag F0881

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Corrected: Sep 15, 2022
Medium - PatternTag F0886

Infection Control Deficiencies

Perform COVID19 testing on residents and staff.

Corrected: Sep 15, 2022
Medium - PatternTag F0887

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected: Sep 15, 2022
Low - IsolatedTag F0912

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Corrected: Sep 15, 2022
Medium - PatternTag F0920

Environmental Deficiencies

Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.

Corrected: Sep 15, 2022
Medium - PatternTag F0943

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Corrected: Sep 15, 2022
Medium - PatternTag F0561

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected: Sep 15, 2022From Complaint
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Sep 15, 2022
Medium - PatternTag F0563

Resident Rights Deficiencies

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Corrected: Sep 15, 2022
Medium - PatternTag F0578

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected: Sep 15, 2022
Medium - PatternTag F0584

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected: Sep 15, 2022
Critical - Actual HarmTag F0607

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected: Sep 15, 2022
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Sep 15, 2022
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Sep 15, 2022
Medium - PatternTag F0655

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected: Sep 15, 2022
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Sep 15, 2022
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Sep 15, 2022
Medium - PatternTag F0660

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Corrected: Sep 15, 2022
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Sep 15, 2022
High - Widespread PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Sep 15, 2022
Medium - PatternTag F0688

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected: Sep 15, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Sep 15, 2022
Medium - PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: Sep 15, 2022
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Sep 15, 2022
Medium - PatternTag F0725

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected: Sep 15, 2022
Medium - PatternTag F0726

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected: Sep 15, 2022
Medium - PatternTag F0730

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Corrected: Sep 15, 2022
High - Widespread PatternTag F0742

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Corrected: Sep 15, 2022
Medium - PatternTag F0745

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected: Sep 15, 2022
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Sep 15, 2022
Medium - PatternTag F0756

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected: Sep 15, 2022
Medium - PatternTag F0758

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected: Sep 15, 2022
Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Sep 15, 2022
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Sep 15, 2022
Medium - PatternTag F0835

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected: Sep 15, 2022
Medium - PatternTag F0837

Administration Deficiencies

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Corrected: Sep 15, 2022
Medium - PatternTag F0838

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected: Sep 15, 2022
Medium - PatternTag F0842

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected: Sep 15, 2022
Medium - PatternTag F0843

Administration Deficiencies

Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

Corrected: Sep 15, 2022
Medium - PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Sep 15, 2022
Critical - Actual HarmTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Sep 15, 2022
Medium - PatternTag F0881

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Corrected: Sep 15, 2022
Medium - PatternTag F0886

Infection Control Deficiencies

Perform COVID19 testing on residents and staff.

Corrected: Sep 15, 2022
Medium - PatternTag F0887

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected: Sep 15, 2022
Low - IsolatedTag F0912

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Corrected: Sep 15, 2022
Medium - PatternTag F0920

Environmental Deficiencies

Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.

Corrected: Sep 15, 2022

Understanding Deficiencies

Deficiencies are violations of federal health and safety standards identified during CMS inspections. They are categorized by scope (isolated, pattern, or widespread) and severity (potential for harm vs. actual harm).

Critical deficiencies involve actual harm to residents and should be carefully considered. Facilities typically have opportunities to correct deficiencies and implement preventive measures.

Understanding deficiencies: Not all deficiencies indicate poor care. Learn how to interpret health inspection results and identify serious warning signs. Read our guide on warning signs →

Penalties & Enforcement

1 penalty in the past 3 years

Total fines: $71,318

FineOctober 16, 2023

$71,318

Data processed: August 1, 2026

About Penalties: This data comes from CMS (Centers for Medicare & Medicaid Services) and shows fines and payment denials issued for health and safety violations. Penalties indicate serious deficiencies that required enforcement action.

Key Highlights

👨‍⚕
Above Average RN Staffing
0.81 RN hours per resident/day (national avg: 0.64)
Low Staff Turnover
35.2% (national avg: 46.6%)
🛏
Beds Available
Approximately 8 beds potentially available
🏢
Part of Healthcare Chain
THE MANDELBAUM FAMILY

Frequently Asked Questions

What is the quality rating for MADISON POST ACUTE?

MADISON POST ACUTE has an overall CMS rating of 3 out of 5 stars. This rating is based on health inspections, staffing levels, and quality measures reported by Medicare.

How many beds does this facility have?

MADISON POST ACUTE has 59 certified beds. The facility averages 52 residents per day, with an occupancy rate of approximately 87%.

What type of ownership does this facility have?

This facility is for profit - partnership owned. It is part of the THE MANDELBAUM FAMILY network.

How can I contact MADISON POST ACUTE?

You can call MADISON POST ACUTE at (425)353-4040. The facility is located at 2520 MADISON, EVERETT, WA 98203.

What should I look for when choosing a nursing home?

When selecting a nursing home, consider: CMS star ratings (overall, health inspection, staffing, and quality measures), nurse staffing levels, staff turnover rates, recent health inspection results, complaint history, proximity to family, and available services. We recommend visiting facilities in person, talking to current residents and staff, and checking multiple sources of information before making your decision. Use our comprehensive tour checklist when visiting facilities.

Important Considerations for This Facility

Based on this facility's data, we recommend reading these guides to understand what to look for:

📚 Learn How to Evaluate Facilities

Understanding quality metrics helps you make better decisions. Check out these data-driven guides: