Map showing the location of BETHANY AT PACIFIC in EVERETT, Washington
916 PACIFIC AVENUE 3RD-5TH FLOORS, EVERETT, WA, 98201

Overall Score

CMS Five-Star Quality Rating
4/5Above averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • WashingtonAbove 58% of peers192 rated homes · average 3.2★
  • Snohomish CountyAbove 67% of peers16 rated homes · average 3.4★
  • United StatesAbove 61% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point3★+0.2 vs WA avg
  • StaffingCan add or remove a star3★−0.4 vs WA avg
  • Quality measuresCan add or remove a star5★+1.0 vs WA avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles3★Above only 45% of peersWA avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 18% of peersWA avg3.4★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 60% of peersWA avg4.0★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff5.06hrsTop 10%WA avg4.38Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only1.21hrsAbove 83% of peersWA avg0.88Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better46%Above only 49% of peersWA avg47%RN turnover39%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$42,477Above only 38% of peersWA avg$53,236Fines · denials1 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
50citations
7inspection dates
1actual harm (G–I)
0immediate jeopardy (J–L)
Jun 11, 2025most recent

Citations by monthJun 2023 – Jun 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Jun 11, 20251 citationCycle 1worst D · no actual harm
  1. F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Resident RightsD · isolatedCorrected Jul 18, 2025
Apr 21, 202517 citationsCycle 1worst E · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jun 3, 2025
  2. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Jun 3, 2025
  3. F758Implement 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.Pharmacy ServiceD · isolatedCorrected Jun 3, 2025
  4. F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareE · patternCorrected Jun 3, 2025
  5. F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsD · isolatedCorrected Jun 3, 2025
  6. F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Resident RightsD · isolatedCorrected Jun 3, 2025
  7. F578Honor 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.Resident RightsD · isolatedCorrected Jun 3, 2025
  8. F585Honor 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.Resident RightsD · isolatedCorrected Jun 3, 2025
  9. F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 3, 2025
  10. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 3, 2025
  11. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 3, 2025
  12. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Jun 3, 2025
  13. F646Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.Resident Assessment and Care PlanningD · isolatedCorrected Jun 3, 2025
  14. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jun 3, 2025
  15. F688Provide 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.Quality of Life and CareD · isolatedCorrected Jun 3, 2025
  16. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Jun 3, 2025
  17. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jun 3, 2025
Jun 12, 202416 citationsCycle 2worst G · actual harm
  1. F688Provide 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.Quality of Life and CareD · isolatedCorrected Jul 17, 2024
  2. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Jul 17, 2024
  3. F578Honor 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.Resident RightsE · patternCorrected Jul 17, 2024
  4. F584Honor 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.Resident RightsE · patternCorrected Jul 17, 2024
  5. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Jul 17, 2024
  6. F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningE · patternCorrected Jul 17, 2024
  7. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Jul 17, 2024
  8. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Jul 17, 2024
  9. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningE · patternCorrected Jul 17, 2024
  10. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jul 17, 2024
  11. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Jul 17, 2024
  12. F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareD · isolatedCorrected Jul 17, 2024
  13. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceE · patternCorrected Jul 17, 2024
  14. F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection ControlF · widespreadCorrected Jul 17, 2024
  15. F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesE · patternCorrected Jul 17, 2024
  16. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Jul 17, 2024
May 16, 20243 citationsCycle 2worst E · no actual harm
  1. 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.Resident RightsE · patternCorrected Jun 25, 2024
  2. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsE · patternCorrected Jun 25, 2024
  3. Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningD · isolatedCorrected Jun 25, 2024
Apr 17, 20246 citationsCycle 2worst D · no actual harm$42,477
  1. F585Honor 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.Resident RightsD · isolatedCorrected May 17, 2024
  2. F775Keep complete, dated laboratory records in the resident's record.AdministrationD · isolatedCorrected May 17, 2024
  3. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected May 17, 2024
  4. F779Keep signed and dated reports of x-rays and other diagnostic services in the residents record.AdministrationD · isolatedCorrected May 17, 2024
  5. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected May 17, 2024
  6. F584Honor 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.Resident RightsD · isolatedCorrected May 17, 2024
Aug 7, 20235 citationsCycle 3worst D · no actual harm
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Sep 5, 2023
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Sep 5, 2023
  3. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Sep 5, 2023
  4. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Sep 5, 2023
  5. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Sep 5, 2023
Jun 13, 20232 citationsCycle 3worst E · no actual harm
  1. F660Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care PlanningD · isolatedCorrected Jul 7, 2023
  2. F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsE · patternCorrected Jul 7, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined5.06hrsTop 10%+0.68 vs WA avg
  • Registered nursesRN hours only1.21hrsAbove 83% of peers+0.33 vs WA avg
  • Licensed practical nursesLPN hours0.94hrs
  • Nurse aidesCNA hours2.91hrs
  • Weekend nursingAll staff on Saturdays and Sundays4.09hrs
  • Washington average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better46%Above only 49% of peersWA avg 47%
  • RN turnoverRegistered nurses only39%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy80 certified beds · ~72 residents a day91%Above 83% of peersWA avg 76%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $42,477In fines
  • 1Fine
  • 0Payment denials
  • $53,236WA avg in fines
Above only 38% of peersFewer fines than 38% of rated homes in Washington

Actions on record

  1. Apr 17, 2024Civil money penalty$42,477

Ownership

As filed with CMS

Structure

Ownership type
Non profit - Church related
Chain
Independent
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Bethany of the Northwest
Operational or managerial control
  • Marlita Basada
  • Tristine Bauguess
  • Harpreet Mann
  • Joseph Scrivens
Corporate directors
  • Patricia Degroodt
  • Robert Dobler
  • Jeff Gay
  • Loren Ihle
  • Steven Jacobson
  • Veronica Knudson
  • David Koenig
  • Janice Nesse
  • +6 more
Corporate officers
  • Joseph Scrivens

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 505404 · 916 PACIFIC AVENUE 3RD-5TH FLOORS, EVERETT, WA, 98201.
  • Percentiles compare this facility with every rated nursing home in Washington and Snohomish County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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