Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethany At Silver Lake during CMS and state inspections, most recent first.
A new therapy company failed to deliver rehab services at the ordered frequency for 3 residents with PT/OT plans of 3-5x/week. Residents with a fractured arm, a left upper leg fracture, and toe amputations reported gaps in therapy, and logs showed missed PT visits, including periods with no PT, while the DOR later confirmed missed PT visits related to lack of PT staff and use of OT to fill gaps.
Failure to file and address a resident grievance for missing property. A cognitively intact resident reported a missing Samsung tablet that had been gone for months, but the grievance was not found in the facility's grievance records. Social Services staff acknowledged awareness of the missing item and stated that a grievance form is normally completed when a resident reports missing personal property, but no grievance form could be located for the tablet.
Inaccurate MDS coding affected one resident’s communication status and two residents’ insulin use. A resident with dementia and a language barrier was coded inconsistently for understanding and being understood despite staff using family translation, gestures, and simple English to communicate, and two residents were coded as receiving insulin injections even though the MARs showed no insulin documentation; staff said the coding was based on tirzepatide use, which the DON stated is not insulin.
Inadequate Activities and Stimulation for a Resident with Severe Cognitive Impairment: A resident with severely impaired cognition was observed in bed multiple times with no lights on and the TV off, and the collateral contact reported the resident was left alone for many hours without stimulation or activities. Staff stated the resident did not get out of bed, did not attend activities lately, and was often asleep during room visits, while the Activity Director said about 15 minutes per resident per day was not enough time to provide activity and stimulation.
A resident with stroke history, OA, RA, and severe cognitive impairment had a restorative PROM program, but surveyors observed rolled washcloths repeatedly placed in both clenched hands without supporting documentation in the care plan or orders. Staff described the resident’s hands as contracted and said the washcloths were used because the nails were digging into the palms, yet staff gave inconsistent accounts of who was responsible and the DCS reported no OT notes or skilled therapy involvement since 2023.
A facility failed to ensure timely annual performance evaluations for a CNA. The most recent evaluation available for the staff member was older than expected, and the DON acknowledged the evaluation was late even though yearly evaluations were the expectation.
Medication administration errors exceeded the allowed rate, with 2 errors in 25 opportunities. An RN gave lispro insulin to one resident without priming the pen needle first, and gave omeprazole to another resident after breakfast even though it was ordered before breakfast. The DON stated nurses were expected to prime insulin needles before each dose and give before-breakfast meds before breakfast arrived.
The facility failed to provide a summary of the baseline care plan to four residents within 48 hours of admission, as required by policy. The baseline care plan, which should be developed by the admitting nurse and signed by the resident, was not reviewed with the residents or documented in their EHRs. Interviews with staff revealed inconsistencies in the process, leading to a deficiency in meeting residents' immediate needs.
The facility failed to update and revise care plans for several residents, leading to deficiencies in care. A resident with Alzheimer's Dementia had outdated interventions, while another resident's Restorative Eating Program was not updated in their care plan. Discharge planning was not addressed for a resident with amputations, and dental needs were unmet for another. Communication aids were not included in a resident's care plan, and urinary management was not updated for an incontinent resident. Staff interviews revealed a lack of awareness and updates to care plans.
The facility failed to honor the preferences of three residents regarding daily routines and healthcare, impacting their quality of life. A resident was repeatedly woken up earlier than preferred, leading to refusals of care. Two residents faced issues with the shower schedule, receiving fewer showers than desired and not being offered alternatives when preferences for female aides were not met.
A resident reported a missing arthritis glove, which was not documented in the grievance logs despite informing multiple staff members. The facility's policy required immediate initiation of grievance procedures, but this was not followed, leading to delays in resolution and potential frustration for the resident.
A resident with diabetes type 2 had their blood sugar checked after eating, and insulin was administered without coordinating with mealtime, contrary to facility policy. Staff interviews revealed inconsistencies in following the policy, with some staff not notifying the provider for guidance when blood sugar was checked post-meal.
A facility failed to provide appropriate respiratory care for a resident with COPD by not adhering to physician orders for oxygen therapy. The resident was observed using oxygen at 4 lpm, contrary to the prescribed 2 lpm, risking unmet needs and diminished quality of life. Staff interviews revealed a lack of awareness of the correct order and inconsistent monitoring of oxygen settings.
The facility failed to prevent sexual abuse between two cognitively impaired residents on a secured Special Care Unit (SCU). Resident 1, with a history of hypersexual behavior, was found providing oral sex to Resident 2, causing emotional distress. Both residents had severe cognitive impairment and were unable to consent to sexual activity. The facility's inadequate supervision and failure to follow care plans led to the incident.
Missed Rehab Visits Due to Therapy Staffing Gaps
Penalty
Summary
The facility failed to ensure skilled rehab services were delivered in accordance with resident evaluations and treatment plans for 3 of 4 residents reviewed for rehab and restorative services. Staff J, Director of Rehabilitation Services, stated a new therapy company started on 03/01/2026 and that transitional evaluations from the outgoing therapy company were used as the baseline for treatment, with residents set up to be seen at the maximum frequency and at least 5 times per week. However, review of therapy logs showed that the residents did not consistently receive therapy at the recommended frequency. Resident 119 was admitted with gait impairment and a fractured right arm and was transferred for skilled therapy to return to prior function; the resident was observed in bed with a sling on the right arm and stated they did not think they were getting as much therapy as expected. Their transitional evaluation recommended PT and OT 3-5 times per week, but March logs showed only 5 PT visits and 7 OT visits total, with only 2 OT and 2 PT visits during the week of 03/11-03/17. Resident 8 was admitted with a left upper leg fracture from a fall and stated they saw a lot of OT but not much PT and needed more strength training; their evaluation also recommended PT and OT 3-5 times per week, but logs showed no PT during the first 5 days of March, only 4 PT visits total, and only 2 PT visits in each of the weeks of 03/04-03/10 and 03/11-03/17. Resident 91 was readmitted with toe amputations due to infection and stated it had been at least 4 days since therapy and there were big gaps in treatment; their evaluation recommended PT and OT 3-5 times per week, but logs showed 5 PT visits total and no PT visits from 03/11-03/18. Staff J later confirmed missed PT visits related to lack of PT staff and stated OT was used to attempt to fill gaps, while Staff C and Staff B stated they were not aware of therapy staffing issues or resident concerns.
Failure to File and Address Resident Grievance for Missing Property
Penalty
Summary
The facility failed to ensure resident grievances were filed and addressed for one resident who was reviewed for grievances. The facility policy titled Grievance Policy and Procedure for Residents stated that any employee informed of a grievance by a resident would immediately initiate the procedures for resolution and that prompt action would be taken to resolve and provide a timely response. Resident 29 was admitted on [DATE] and was documented as cognitively intact on the quarterly MDS assessment dated [DATE]. During an interview on 03/16/2026, Resident 29 stated that a Samsung tablet had been missing for two to three months and that staff were aware of the missing item, but the resident had not heard of any follow-up. A review of grievances since April 2025 did not show the missing tablet as a listed grievance. Resident 29 later stated the missing tablet had been reported to Staff K in Social Services. Staff K stated they were aware of the missing tablet and had been trying to contact the resident's family to verify whether they had taken it, but no call back had been received. Staff K also stated that when a resident reports a personal item missing, a grievance form is completed, but on 03/19/2026 Staff K could not find a grievance form related to the missing tablet.
Inaccurate MDS Coding for Communication and Insulin Use
Penalty
Summary
The facility failed to accurately complete the MDS for Resident 2 regarding communication. Resident 2 was admitted with dementia and had a primary language that was not English. Staff reported communication occurred through family translation, staff who spoke the same language, gestures, and simple English phrases. During an interview with an interpreter, Resident 2 had difficulty understanding questions, gave answers that were not always related to the questions asked, and could not elaborate on concerns about food or missing clothing. The care plan documented a communication problem related to a language barrier and moderately impaired cognition, but the MDS coded the resident as understood and understanding in Section B and as rarely or never understood in Section C. Staff later acknowledged there was a discrepancy between the sections and that the resident could make basic needs known by gestures or with family translation. The facility also failed to accurately code insulin use for Resident 22 and Resident 86. Their MDS assessments documented that each resident had received one insulin injection in the prior seven days, but review of the February 2026 MARs showed no documentation of insulin injections for either resident. Staff stated the MDS had been coded because the residents received tirzepatide, which was recognized as a diabetes medication, but staff were not aware it was not an insulin product. The DON stated the MDS should be coded for insulin only when a resident actually receives insulin injections and not for a GLP medication.
Inadequate Activities and Stimulation for a Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that Resident 11 had an accurate assessment of recreational care needs and received an ongoing program of activities to meet the resident’s physical and mental needs. Resident 11 was admitted to the facility and, according to the quarterly MDS assessment, had severely impaired cognition. The resident’s collateral contact stated in a telephone interview that the resident was being left on their own for many hours without any stimulation or activities. During multiple observations, Resident 11 was found in bed with no lights on and the TV off, including times when the roommate’s light was on. A CNA stated that Resident 11 does not get out of bed and that they did not know what activities the resident did or attended, though they sometimes turned the TV on. The Activity Director stated that residents who do not get out of bed are provided room visits, conversation, and daily reading if requested, but Resident 11 had not attended activities lately and was usually asleep during room visits, so activities were not provided. The Activity Director also stated that they usually spend about 15 minutes on average with each resident they visit and did not think that 15 minutes a day was enough time to provide activity and stimulation for a resident in a 24-hour period.
Failure to Address Resident Hand Contractures and ROM Decline
Penalty
Summary
The facility failed to ensure that one resident with a history of stroke, generalized osteoarthritis, rheumatoid arthritis, and severe cognitive impairment received necessary care and services to maintain or improve range of motion and prevent further decrease in ROM and hand contracture. The resident’s care plan identified limited physical mobility related to chronic pain and advanced dementia, with interventions for passive range of motion to the upper and lower extremities five to six days a week and therapy referrals as needed. A restorative nursing referral form directed PROM to the upper and lower extremities six times a week as tolerated, and the resident remained identified in MDS progress notes as high risk for contractures. Provider notes later documented severe extremity contractures, and survey observations repeatedly showed rolled washcloths placed in both hands with the resident’s fingers clenched around them. During multiple observations across several days, the washcloths remained in place, but there was no documentation in the care plan or physician orders explaining the contracted hands or requiring washcloths to both hands. Staff interviews showed that nursing assistants, restorative staff, and nurses were aware the resident’s hands were contracted and that the washcloths were being used because the resident’s nails were digging into the palms, but staff gave differing accounts of who was responsible for placing them and maintaining them. The Director of Clinical Services stated no occupational therapy evaluations or notes could be located and that the resident had not been seen by skilled therapy services since 2023. Staff also stated they were not aware of any assessment or referral related to the contracted hands, and the DON and DCS were unable to explain the rationale or documentation supporting the washcloths. The report cited WAC 388-97-1060(3)(d).
Late Annual Performance Evaluation for CNA
Penalty
Summary
The facility failed to ensure that one of five staff reviewed, Staff H, received a timely annual performance evaluation. Staff H was hired on 02/18/2020 as a certified nursing assistant, and the most recent employee evaluation provided for Staff H was dated 08/13/2024. When employee evaluations were requested on 03/18/2026, the administrative assistant stated there were no more recent evaluations found for Staff H. The Director of Nursing Services later acknowledged the late evaluation and stated that the expectation was for evaluations to be completed yearly. The report cited WAC 388-97-1680(1)(2)(a)-(c).
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with 2 medication errors identified during 25 medication opportunities for an error rate of 8%. One error involved Resident 97, who had an order for lispro insulin 5 units three times daily. During observation, an RN attached a disposable needle to the insulin pen, set the dose to 5 units, and injected the insulin without priming the needle first. The RN stated they were not aware of how to prime the insulin needle prior to use, and the DON stated it was their expectation that nurses prime the needle before each insulin administration. The second error involved Resident 39, who had an order for omeprazole once daily before breakfast. The March 2026 MAR scheduled the medication for 7:30 AM, but during observation the RN gave the omeprazole after the resident had already eaten breakfast. The RN stated it was always an issue getting medications scheduled before breakfast given before breakfast, and the DON stated that when an order specified administration before breakfast, they expected the nurse to provide the medication before breakfast arrived.
Failure to Provide Baseline Care Plan Summary to Residents
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to four out of five residents within 48 hours of their admission, as required by their policy. The baseline care plan is intended to be developed by the admitting nurse using information from hospital records, physician orders, and discussions with the resident. It should be signed by the resident and included in the medical record. However, for Residents 28, 86, 35, and 508, the sections indicating that the baseline care plan was reviewed with the resident and that a copy was provided were left blank. Additionally, there was no documentation in the Electronic Health Records (EHR) for Residents 35 and 508 that a written summary was provided. Interviews with facility staff revealed inconsistencies in the process of developing and providing the baseline care plan. Staff H, an RN/NM, stated that the admission nurse should initiate the baseline care plan within 48 hours, and it was the social service's responsibility to arrange a meeting with the family, including nursing and therapy departments. Staff B, the Interim Director of Nursing, indicated that the admission nurse should compile the baseline care plan information within 24 hours and discuss it with the resident. The plan should be printed, signed by the resident or representative, and scanned into the EHR. However, there was no evidence that the baseline care plans for the mentioned residents were reviewed with them or their representatives, leading to a deficiency in meeting the residents' immediate needs upon admission.
Failure to Update and Revise Care Plans
Penalty
Summary
The facility failed to review and revise care plans for several residents, leading to deficiencies in their care. Resident 18, diagnosed with Alzheimer's Dementia, had a care plan that was not updated to reflect the absence of a memory care unit and the resident's current needs. Despite being at high risk for falls, interventions such as a floor mat and a four-wheeled walker were not present in the resident's room, and staff confirmed that these interventions were not being used. The care plan had not been updated to reflect the resident's current condition, as they no longer walked and required total assistance. Resident 69, who was cognitively intact, reported that staff left meals on their table without waking them up. The care plan indicated that the resident was on a Restorative Eating/Swallowing Program, but staff interviews revealed that the resident was no longer on this program, and the care plan had not been updated accordingly. Similarly, Resident 75, who had bilateral below-knee amputations, expressed a desire to return to the community, but no discharge planning was included in their care plan, and social services had not discussed discharge plans with the resident. Other deficiencies included Resident 40, who needed dental services but had a care plan indicating they did not want dentures, despite expressing a need for them. Resident 9, with communication issues due to hearing loss, had a care plan that did not include the use of a dry erase board, which the resident used for communication. Lastly, Resident 83, who was incontinent, had a care plan that did not reflect their current needs, as there was no information about establishing a voiding pattern. Staff interviews revealed a lack of awareness and updates to the care plans, contributing to these deficiencies.
Failure to Accommodate Resident Preferences in Daily Routines
Penalty
Summary
The facility failed to accommodate the preferences of three residents regarding their daily routines and healthcare, which compromised their quality of life. Resident 508 expressed a preference not to be awakened before 8:00 AM, as documented in their choice assessment. Despite this, staff continued to wake the resident at 6:00 AM, leading to the resident refusing vital checks, breakfast, and medication. Although the nurse practitioner was informed and responded to change the medication schedule, the orders were not updated, and the staff remained unaware of the resident's preferences due to a lack of care conference. Resident 35 preferred more frequent showers and specifically requested female aides for assistance. However, the resident only received one shower in 30 days, and their preference for female caregivers was not documented in their care plan. The facility's shower schedule did not accommodate the resident's preferences, and staff failed to offer alternative shower arrangements when male aides were the only option available. Resident 92 also experienced issues with the facility's shower schedule, which only allowed for one shower per week. When the resident refused a shower, they were not offered an alternative time or assistance from a female aide. Documentation showed that the resident received only one shower in November, and staff did not adequately address the resident's preferences or reasons for refusing showers.
Failure to Promptly Report and Document Resident Grievances
Penalty
Summary
The facility failed to promptly report and document resident grievances, specifically for a resident who was cognitively intact and had been admitted to the facility. The resident reported a missing left-hand arthritis glove, which provided comfort for their hands, and had been missing for one week. Despite informing multiple staff members, including aides, the grievance was not logged in the facility's grievance logs, which covered the period from July to December 2024. Interviews with staff revealed that the Occupational Therapist and the Registered Nurse/Nurse Manager were aware of the missing glove but did not complete a grievance form. The Social Service Director only received the grievance form after the resident had been without the glove for a week. The facility's policy required any employee informed of a grievance to immediately initiate the procedures for resolution, which was not followed in this case, leading to delays in grievance resolution and potential frustration for the resident.
Failure in Blood Sugar Monitoring and Insulin Administration
Penalty
Summary
The facility failed to ensure that blood sugar (BS) monitoring for Resident 82 was conducted according to professional standards of care. Resident 82, who was admitted with a diagnosis of diabetes type 2, had their BS checked after consuming lunch. Staff Q, an LPN, administered sliding-scale insulin based on the BS level of 292 without coordinating the insulin administration with mealtime as per the facility's policy. This action was contrary to the facility's policy, which requires insulin administration to be coordinated with meals and snacks. Interviews with various staff members revealed inconsistencies in the understanding and implementation of the facility's policy regarding BS monitoring and insulin administration. Staff R, an LPN, indicated that sliding-scale insulin should be administered even after a meal without notifying the provider. However, Staff E, an RN/Nurse Manager, and Staff B, the Director of Nursing Services, stated that the provider should be notified for guidance if BS is checked post-meal. Staff C, another RN/Nurse Manager, mentioned that a note should be placed in the resident's record if BS is taken after a meal. These discrepancies highlight a lack of adherence to the facility's policy and a failure to ensure professional standards of quality in BS monitoring and insulin administration for Resident 82.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident with heart failure and chronic obstructive pulmonary disease (COPD). The resident was observed using a nasal cannula connected to an oxygen concentrator set at 4 liters per minute (lpm), despite having a physician's order for oxygen therapy at 2 lpm to maintain oxygen saturations between 88-92 percent. This discrepancy was noted during observations on two consecutive days. Interviews with staff revealed that the Licensed Practical Nurse (LPN) was unaware of the correct physician order and stated that the resident's oxygen was usually set at 2 lpm. The Registered Nurse/Nurse Manager confirmed that oxygen settings should be checked each time a nurse enters a resident's room, or at a minimum, each shift. However, the resident's oxygen was consistently set higher than the prescribed amount, indicating a failure to adhere to the physician's orders and the facility's policy on oxygen administration.
Failure to Prevent Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that two residents residing on a secured Special Care Unit (SCU) were free from sexual abuse. Resident 1, who had severe cognitive impairment and a history of hypersexual behavior, was found in bed with Resident 2, who also had severe cognitive impairment and was rarely understood. Both residents were naked, and Resident 1 was observed providing oral sex to Resident 2. This incident caused emotional distress to Resident 2, who was tearful after the event. The facility's failure to prevent this sexual activity between two cognitively impaired residents who were unable to consent to sexual relations placed all residents on the unit at risk of unwanted sexual contact, injury, and psychological harm. Resident 1 had a history of wandering and hypersexual behavior, which was documented in their care plan. Despite these known behaviors, the resident was not adequately monitored, leading to the incident with Resident 2. Resident 1's care plan included interventions such as cueing, reorienting, and supervising as needed, but these measures were insufficient to prevent the incident. The resident was eventually placed on 1:1 monitoring after the incident, but this action came too late to prevent the harm. Resident 2, who also had severe cognitive impairment and a history of wandering, was found in a vulnerable position due to the facility's lack of adequate supervision and intervention. Staff interviews revealed that Resident 2 liked to hold hands with others and sometimes disrobed, behaviors that were documented in their care plan. However, the facility failed to provide the necessary supervision to prevent Resident 1 from entering Resident 2's room and engaging in sexual activity. This lack of oversight and failure to follow care plans contributed to the incident and the resulting emotional distress for Resident 2.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Everett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Everett Center | 2.8 mi | ★★★★★ | 15 | 0 |
| Madison Post Acute | 3.2 mi | ★★★★★ | 1 | 0 |
| View Ridge Care Center | 4.4 mi | ★★★★★ | 16 | 0 |
| Snohomish Health And Rehabilitation Of Cascadia | 5.6 mi | ★★★★★ | 39 | 1 |
| Alderwood Post Acute & Rehabilitation | 5.7 mi | ★★★★★ | 61 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.