BETHANY AT PACIFIC
Open-data reference.
BETHANY AT PACIFIC is a non profit - church related facility in EVERETT, WA with 80 certified beds and a 4-star overall CMS rating. The facility has 50 deficiency records on file. Total penalties: $42K.
916 PACIFIC AVENUE 3RD-5TH FLOORS, EVERETT, WA 98201
Phone: 4252595508
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 505404
- Ownership
- Non profit - Church related
- Provider Type
- Medicare and Medicaid
- Beds
- 80
- Residents
- 72
- In Hospital
- No
- County
- Snohomish
- Last Inspection
- Apr 21, 2025
Staffing Data
- RN Hours
- 1.21 (nat'l avg: 0.68)
- LPN Hours
- 0.94
- CNA Hours
- 2.91
- Total Nursing Hours
- 5.06 (nat'l avg: 3.89)
- PT Hours
- 0.14
- Nursing Turnover
- 45.5%
- RN Turnover
- 38.9%
What the CMS Record Reveals About BETHANY AT PACIFIC
BETHANY AT PACIFIC operates 80 certified beds in EVERETT, WA with approximately 72 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (3★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 50 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $42K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 5.06 total nursing hours per resident day (national average 3.89), with RN coverage at 1.21 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Church related" ownership and operating as a "Medicare and Medicaid" provider, BETHANY AT PACIFIC falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 45.5%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (50 most recent)
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Category: Resident Rights Deficiencies
Corrected: Jul 18, 2025
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Category: Pharmacy Service Deficiencies
Corrected: Jun 3, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Jun 3, 2025
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 3, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 3, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 3, 2025
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.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 3, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 3, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 3, 2025
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 3, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 3, 2025
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 3, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 3, 2025
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 3, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Jun 3, 2025
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Jun 3, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Jun 3, 2025
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Category: Resident Rights Deficiencies
Corrected: Jun 3, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jul 17, 2024
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Category: Nursing and Physician Services Deficiencies
Corrected: Jul 17, 2024
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Category: Infection Control Deficiencies
Corrected: Jul 17, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Jul 17, 2024
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 17, 2024
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 17, 2024
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.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 17, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 17, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 17, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 17, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 17, 2024
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 17, 2024
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 17, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Jul 17, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Jul 17, 2024
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Jul 17, 2024
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 25, 2024
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Category: Resident Rights Deficiencies
Corrected: Jun 25, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Jun 25, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 17, 2024
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
Category: Administration Deficiencies
Corrected: May 17, 2024
Keep complete, dated laboratory records in the resident's record.
Category: Administration Deficiencies
Corrected: May 17, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: May 17, 2024
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.
Category: Resident Rights Deficiencies
Corrected: May 17, 2024
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.
Category: Resident Rights Deficiencies
Corrected: May 17, 2024
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 5, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 5, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 5, 2023
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 5, 2023
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Sep 5, 2023
Plan the resident's discharge to meet the resident's goals and needs.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 7, 2023
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Jul 7, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 9.6% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 3.9% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.7% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.6% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 85.7% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 1.9% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 98.7% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 99.0% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.4% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 18.2% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 3.9% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 91.5% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 95.6% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 1.9% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 25.2% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 5.3% | Yes |
Penalty History 1 penalties totaling $42K
| Date | Type | Amount |
|---|---|---|
| Apr 17, 2024 | Fine | $42K |
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County Health Data
Health outcomes, access, and quality metrics for Snohomish on PlainHealth
Frequently Asked Questions
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Does BETHANY AT PACIFIC have any deficiencies on record?
Has BETHANY AT PACIFIC received any fines or penalties?
Who owns BETHANY AT PACIFIC?
When was BETHANY AT PACIFIC last inspected?
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.