Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 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.
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 A resident with Alzheimer's Dementia had outdated interventions, while another resident's Restorative Eating Program was not updated in their care plan.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.
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 | — | 6 | 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 | — | 5 | 0 |
| Alderwood Post Acute & Rehabilitation | 5.7 mi | — | 5 | 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 August 2026) and official state health department websites.