Bethel Lutheran Nursing & Rehabilitation Center
1515 2nd Ave West, Williston, ND 58801 · Non profit - Corporation · 90 certified beds · (701) 572-6766 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- nursing-staff turnover (63%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 25.2% | 19.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.0% | 5.8% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.6% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.6% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.8% | 4.4% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 8.8% | 5.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 15.4% | 17.6% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 12.7% | 17.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.8% | 98.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 13.2% | 4.9% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 30.3% | 24.9% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.9% | 22.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 82.8% | 88.3% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 15.9% | 19.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.2% | 11.4% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.52 | 1.49 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.80 | 1.86 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
44.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 59 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 70.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 20 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 44.2%CMS range 33.6–54.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.6%CMS range 6.4–14.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 70.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 55.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 65.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.5%CMS range 3.7–12.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.27 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 90 beds and averages 75.4 residents a day — about 84% occupied, or roughly 15 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.81 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.09 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.28 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.95 hrs/resident/day on weekends vs 5.16 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 1.21 to 0.78 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 63% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · G2026-04-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
1. Based on record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for 1 of 1 closed record (Resident #85) with an identified breast lump. Failure to ensure follow up on the identified breast abnormality prevented timely treatment interventions.Findings include: Review of the facility policy titled Bethel Lutheran Nursing & [and] Rehabilitation Center-Wound Treatment Management occurred on 04/16/26. This policy, dated February 2026, stated, Procedure . 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the wound care consultant, treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 5. Treatment decisions will be based on: . a. Etiology of the wound: . iv. Atypical (i.e. dermatological or cancerous lesion, pyoderma, calciphylaxis) . c. Location of the wound . 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-02-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility investigation, review of the facility policies, and staff interviews, the facility failed to ensure adequate supervision and assistance for 1 of 3 sampled residents (Resident #3) who required staff assistance and sit to stand mechanical lift transfers. Failure to provide adequate assistance as care planned for transfers may have resulted in Resident #3's fracture and placed all residents requiring assistance for transfers at risk for injuries. Findings include: Review of the facility policy titled Comprehensive Care Plans occurred on 02/07/24. This undated policy, stated, . It is the policy of [Facility Name] to develop and implement a comprehensive person-centered care plan for each resident, . to meet a resident's medical, nursing, and mental . needs . 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-16 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, review of facility policies, and staff interviews, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's dignity for 2 of 2 sampled residents (Resident #18 and #47) and 2 supplemental residents (Resident #74 and #76) observed during meals and 1 of 1 sampled resident (Resident #56) who requested assistance in their room. Failure to treat residents with dignity and respect has the potential to affect the residents' psychosocial wellbeing and does not enhance their quality of life. Findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, occurred on 04/16/26. This policy, revised 2025, stated, . It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Respond to requests for assistance in a timely manner. - Observations during…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-16 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 3 of 6 residents (Resident #3, #12 and #77) observed during medication administration. Four medication errors occurred during staff administration of 27 medications, resulting in a 14 percent error rate. Failure to follow physician's orders and/or pharmacy recommendations may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health.Findings include:Review of the facility policy titled Crushed Medications occurred on 04/16/26. This policy, dated June 2022, stated, . Medications shall be crushed in accordance with standard of practice for safety and accuracy in medication administration. Medications shall be crushed in accordance with physician orders.Review of the facility policy titled Insulin Pen occurred on 04/16/26. This policy, revised March 2026, stated, . Prime the insulin pen. i. Dial 2 units by turning the dose…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-16 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 4 of 18 sampled residents (Resident #1, #3, #12, #34, and #56) and 1 supplemental resident (Resident #77) observed during toileting cares and medication preparation and administration. Failure to practice infection control standards related to hand hygiene, glove use, and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 04/16/26. This policy, revised September 2025, stated, . implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. employs targeted gown and gloves use during high contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g. chronic wounds such as . diabetic foot ulcers .) and/or indwelling medical devices (e.g. urinary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-16 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of facility policy, and staff interview, the facility failed to notify the physician or resident's representative for 1 of 1 closed records (Resident # 85) reviewed for change in breast tissue. Failure to notify the resident's representative and physician of an identified breast abnormality does not allow the representative or physician to be fully informed of the resident's care, current status, and to make informed decisions regarding medical care. Findings Include:Review of the facility policy titled Change in a Resident's Condition or Status occurred on 04/16/26. This policy, reviewed March 2026, stated, 2. Unless otherwise instructed by the resident. the Neighborhood Nurse Manager (or designee) or Social Worker will notify the resident's next of kin or representative (sponsor) when: . b. There is a significant change in the resident's physical, mental, or psychosocial status. c. There is a need to alter the resident's treatment significantly. -Review of Resident's #85 medical record occurred on April 15-16, 2026 and identified a right breast lump…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-16 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #48) reviewed for abuse. Failure to provide the necessary services to protect residents from physical abuse resulted in a bruise to Resident #48's arm. Failure to protect all residents from physical abuse placed all residents at risk for psychosocial harm and/or injury.Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, occurred on 04/16/26. This policy, dated February 2026, stated, . 'Physical Abuse' includes, but is not limited to hitting, slapping, punching, biting, and kicking. 'Sexual Abuse' is non-consensual sexual contact of any type with a resident . The facility will implement policies and procedures to prevent and prohibit all types of abuse. that achieves . the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Review of Resident #48's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-16 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from restraints for 1 of 1 sampled resident (Resident #9) reviewed for restraints. Failure to ensure staff refrained from using a manual method of restraining a resident placed Resident #9 at risk for increased behaviors, fear, anxiety, and injury.Findings Include:Review of the facility policy titled Use of Physical Restraints occurred on 04/16/26. This policy, dated February 2026, stated, . all residents have the right to be free from any physical restraints . Within 72 hours the interdisciplinary team must be notified of the application of the restraint so that they may complete a follow-up evaluation and determine the need to initiate the non-emergency physical restraint procedure.Review of Resident #9's medical record occurred on all days of survey. Diagnoses include irritability, anger, and dementia with agitation and psychotic disturbances. The current care plan stated, . I have potential to demonstrate physical and verbal behaviors. And at times will…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-16 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of facility policy, and staff interview, the facility failed to report incidents of potential abuse to officials including the State Survey Agency (SSA) for 3 of 3 sampled residents (Resident #9, #42, and #48) with allegations of physical or sexual abuse. Failure to report incidents of potential physical or sexual abuse to the State agency placed all residents at risk of abuse, mental and emotional distress, and or physical injury. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, occurred on 04/16/26. This policy, dated February 2026, stated, . The facility will have written procedures that include . Reporting of all alleged violations to the . state agency, adult protective services and to all other required agencies . within specified timeframes . Immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse .- Review of Resident #9's medical record occurred on all days of survey. Diagnoses included dementia with agitation, depression,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-16 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of facility policy, and staff interview, the facility failed to thoroughly investigate alleged violations of possible abuse for 3 of 3 sampled residents (Resident #9, #42, and #48) subjected to physical abuse, sexual abuse, and restraint use. Failure to thoroughly investigate allegations of abuse, implement corrective actions, and evaluate the effectiveness of those actions, placed all residents at risk of abuse, mental/emotional distress, and physical injury.Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, occurred on 04/16/26. This policy, dated February 2026, stated, . An immediate investigation is warranted when suspicion of abuse . or reports of abuse . occur. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following . analyzing the occurrence(s) to determine why abuse . occurred, and what changes are needed to prevent further occurrences. Defining how care provision will be changed and/or improved to protect residents receiving services .-…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-16 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and staff interview, the facility failed to provide the State Long Term Care Ombudsman with a written notice of discharge for 1 of 1 closed record (Resident #81) reviewed for facility discharge. Failure to notify the State Ombudsman does not provide residents with access to an advocate who can inform them of their options and rights, and to provide them with protection from being discharged inappropriately.Findings include: Review of Resident #81's medical record occurred on 04/14/26. A progress note dated 02/12/26 at 2:17 p.m., stated, Resident seen for rounds today . will be discharging home on 2/18/26 as therapy complete. The record failed to include evidence the facility notified the State Ombudsman of the discharge. During an interview on 04/14/2026 at 3:35 p.m. an administrative staff member (#2) confirmed Resident #81's medical record lacked the required notification to the State Ombudsman.
- Potential for harm · Dcited before2026-04-16 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 1 of 18 sampled residents (Resident #9). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care. Findings include: Review of the facility's policy titled Comprehensive Care Plans occurred on 04/16/26. This policy, dated March 2026, stated, . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment. Review of Resident #48's medical record occurred on all days of survey. A nurse's note, dated 12/04/25 at 7:12 p.m., stated, Writer was doing evening med pass when writer heard a scream coming from the unit's lounge. Writer ran and saw [CNA's name] in between residents [Resident #48] and [Resident #9]. CNA informed writer that resident was yanked on left wrist and was slapped on left side of face x [times] 2 by [Resident #9]. Noted resident's left cheek was reddish in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · Dcited before2026-04-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, review of facility policy, review of manufacturer's instruction manual, and staff interview, the facility failed to ensure staff used a mechanical lift appropriately for 1 of 4 sampled residents (Resident #48) observed during sit-to-stand lift transfers. Failure to ensure staff used the mechanical lift according to manufacturer's instructions placed Resident #48 at risk for pain/discomfort and/or injury. Findings include: Review of the facility's policy titled, Safe Resident Handling/Transfers, occurred on 04/16/26. This policy, reviewed February 2026, stated, . All residents require safe handling when transferred to prevent or minimize the risk for injury . Staff will perform mechanical lifts/transfers according to the manufacturer's instructions . The facility provided a copy of the manufacturer's instructions for the Easy Way sit-to-stand lift. Review of the instructions occurred on 04/16/26. The instructions stated, . Raise the patient's arms on the outside of the harness and have them place their hands on the padded handles. As the patient…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-16 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, review of facility policy, review of the dialysis communications forms, and resident and staff interview, the facility failed to provide care and services consistent with professional standards of practice for 1 of 1 sampled resident (Resident #63) receiving hemodialysis. Failure to receive dialysis treatment communication on a consistent basis and complete post-dialysis assessments may result in an unidentified change in the resident's condition.Findings include: Review of the facility policy titled Hemodialysis occurred on 04/16/26. This policy, dated 2025, stated, . The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include . Ongoing assessment and oversight of the resident before, during and after dialysis treatment . Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-16 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of professional reference, and staff interview, the facility failed to ensure medication labels matched provider's orders for 1 of 2 residents (Resident #3) observed for insulin administration. Failure to ensure medication labels matched the provider's orders placed the resident at risk for medication errors.Findings include:Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 838, stated, . Obtain the appropriate medication. Compare the label of the medication container or unit-dose package against the order on the MAR [medication administration record] or computer printout. Rationale: This is a safety check to ensure that the right medication is given. If these are not identical, recheck the prescriber's written order in the client's chart. If there is still a discrepancy, check with the pharmacist. Prepare the medication. While preparing the medication, recheck each prepared drug and container with the MAR again. Rationale: This second safety check reduces the chance of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-05 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of facility policy, and resident and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 3 of 18 sampled residents (Residents #50, #55, and #63) and 1 supplemental resident (Resident #81). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Comprehensive Care Plans occurred on 02/05/25. This undated policy stated, . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive, quarterly MDS [Minimum Data Set] assessment, and PRN [as needed] when changes in the resident condition dictates. - During an interview on 02/03/25 at 3:59 p.m., Resident #50 stated she had pain to both knees. Review of Resident #50's medical record occurred on all days of survey and identified a diagnosis of right and left knee pain with a physician's order, dated 06/11/23, for Biofreeze (topically pain reliever) gel two times a day for bilateral knee…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-05 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment for 2 of 18 sampled residents (Resident #78 and Resident #285) reviewed for advanced directives. Failure to ensure all methods of communication and/or documentation of code status accurately reflected the resident/resident representative wishes has the potential to limit access to life-sustaining services or unwanted treatment. Findings include: Review of the facility policy titled Advanced Directives occurred [DATE]. This policy, revised [DATE], stated, . In view of its [sic] mission to respect the life and dignity of each person, Bethel Lutheran Nursing & [and] Rehabilitation Center recognizes that every competent adult has the right and responsibility to control the decisions relating to their own health care. Bethel Lutheran Nursing & Rehabilitation Center is transitioning forward using the North Dakota POLST (Physician Order for Life sustaining…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-07 · tag F0761 — failed to label and store drugs safely — patternEnsure 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.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, and review of facility policy, the facility failed to ensure safe and secure storage of narcotic medications for 2 of 4 medication carts (Harmony and Wheatland Units). Failure to store medications securely may result in unauthorized access to medications and/or medication errors. Findings include: Review of the facility policy titled Controlled Medication Storage occurred on 12/06/23. This policy, dated August 2022, stated, . B. Scheduled II medications are stored in a separate area under double lock. Observation on 12/05/23 at 8:22 a.m. showed a staff nurse (#4) assigned to the medication cart for the Harmony Unit showed narcotics/controlled medications (Schedule II-V), located in the bottom left-hand drawer not double locked. Observation on 12/05/23 at 4:10 p.m. showed a staff nurse (#5) assigned to the medication cart for the Wheatland Unit showed narcotics/controlled medications (Schedule II-V), located in the bottom left-hand drawer not double locked.
- Potential for harm · D2023-12-07 · tag F0625 — isolatedNotify 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.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide a bed hold notice to 2 of 5 sampled residents (Residents #15 and #79) reviewed with a hospital transfer. Failure to provide a bed hold notice does not allow the residents and/or their representatives to make an informed decision regarding their rights. Findings include: - Review of Resident #15's medical record occurred on all days of survey and identified a transfer to the hospital on [DATE]. The record lacked a bed hold notice for the hospital transfer. - Review of Resident #79's medical record occurred on all days of survey and identified a transfer to the hospital on [DATE]. The record lacked a bed hold notice for the hospital transfer. During an interview on 12/07/23 at 9:05 a.m., an administrative staff member (#2) confirmed Resident #15 and #79's medical records lacked a copy of the bed hold notices.
- Potential for harm · D2023-12-07 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of the North Dakota Provider Manual for Preadmission Screening and Resident Review (PASRR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 2 of 4 sampled residents (Resident #2 and Resident #63) reviewed for PASRR. Failure to complete a change in status assessment for a newly diagnosed mental illness may result in the delivery of care and services that are inconsistent with residents' needs. Findings include: The North Dakota PASRR Provider Manual, revised December 2020, page 13, states, . Change in Status Process: Whenever the following events occur, nursing facility staff must contact [the contracted agency] to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC [mental illness, intellectual disability, and conditions related to intellectual disability (referred to in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-07 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the current status for 3 of 21 sampled residents (Resident #1, #43, and #89). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care and safety. Findings include: Review of the facility policy titled Comprehensive Care Plans occurred on 12/07/23. This policy, dated August 2022, stated, . develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive assessment and quarterly MDS [Minimum Data Set] assessment. - Review of Resident #1's medical record occurred…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment/services to promote the healing of pressure ulcers for 1 of 3 sampled residents (Resident #64) identified with a pressure ulcer. Failure to routinely assess, monitor, and measure pressure ulcers may result in delayed healing of the pressure ulcer. Findings include: Review of the facility policy titled Pressure Ulcer Management & [and] Surveillance occurred on 12/07/23. This undated policy stated, . 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment . monitoring the impact of the interventions . 4. Interventions for Prevention and to Promote Healing . ii. Treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate (if present), presence of pain, signs of infections, wound bed, wound edge and surrounding tissue characteristics. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-07 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from unnecessary psychotropic medications for 1 of 3 sampled resident (Resident #9) who received an as needed (PRN) psychotropic. Failure to limit PRN psychotropic use to 14 days unless reevaluated by a practitioner placed the resident as risk of receiving unnecessary medications and experiencing adverse drug effects. Findings include: Review of the facility policy titled PRN Orders for Phsychotropic [sic] Medications occurred on 12/07/23. This policy, dated August 2022, stated, . PRN orders for psychotropic drugs will be limited to 14 days. The attending physician or prescribing practitioner may extend the duration of the order . beyond 14 days provided their rationale is documented in the resident's medical record and duration for the PRN order is specified. Review of Resident #9's medical record occurred on all days of survey. A physician's order, dated 07/25/23, included Ativan (antianxiety) 0.5 milligrams every twelve hours PRN. The facility failed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-07 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and staff interview, the facility failed to ensure residents records contained the hospice election form and the certification of a terminal illness for 1of 1 supplemental resident (Resident #74) receiving hospice services. Failure to obtain these documents limits staff's ability to ensure coordination of care between the facility and the hospice. Findings include: Review of Resident #74's medical record occurred on 12/06/23 and identified Resident #74 elected Hospices services on 11/07/23. The medical record lacked the hospice election form and the physician's certification of the terminal illness. During an interview on 12/07/23 at 7:50 a.m., an administrative nurse (#1) confirmed the medical record for Resident #74 lacked the certification of terminal illness and the hospice election form.
- Potential for harm · Dcited before2023-12-07 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 3 of 6 sampled residents (Resident #32, #43 and #54) on precautions. Failure to practice infection control standards related to use of personal protective equipment (PPE) and perineal cares has the potential to spread infection throughout the facility. Findings Include: PERSONAL PROTECTIVE EQUIPMENT - Observation on 12/05/23 at 9:16 a.m. showed a sign outside Resident #43's room door that stated, Entering the room: Hand hygiene with sanitizer; Isolation gown; Use N-95 [type of mask]; Place tear away goggles on; gloves; enter room. Observation showed two certified nurse aides (CNAs) (#12 and #13) entered Resident #43's room without an isolation gown, N-95 mask, or goggles. Staff failed to wear PPE upon entering Resident #43's room. - An Enhanced Barrier Precaution sign outside Resident #54's room door stated, EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BETHEL LUTHERAN NURSING & REHABILITATION CENTER | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 01/01/1966 |
| AXTMAN, PAT | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/01/2024 |
| BRAATEN, RICHARD | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/01/2021 |
| GELTEL, KELSEY | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/01/2021 |
| HANSON, TINA | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/01/2021 |
| HARPER, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/01/2023 |
| JORGENSON, JENNY | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/01/2025 |
| MCKENZIE, JAMES | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/01/2022 |
| OSBORN, ROBERT | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/01/2022 |
| WEYRAUCH, DENISE | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/01/2023 |
| MOEN, BELINDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/21/2021 |
| SICKINGER, TIFFANY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2021 |
| SIEWERT, RYAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
CMS files one row per role, so the 17 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in ND
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the North Dakota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 355070. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-16, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.