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BETHEL LUTHERAN NURSING & REHABILITATION CENTER Inspection Report, Violations & Safety Grade (WILLISTON, North Dakota)

1515 2ND AVE WEST, WILLISTON, North Dakota 58801

Phone: 7015726766

CMS Overall:3/5

Overview & Bed Count

Certified Beds
90
Avg Residents/Day
73.3
Ownership
Non profit - Corporation
Provider Type
Medicare and Medicaid
County
Williams
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall3/5
Health2/5
Staffing5/5
Quality3/5

Nurse Staffing Check

MetricThis FacilityNorth Dakota AvgDifference
RN Hours per Resident per Day0.990.93+0.06
Total Nurse Hours per Resident per Day5.104.47+0.63
CMS Staffing Rating5/54.3/5-
Nursing Staff Turnover58.6%47.5%-

Health Citation History

25 health citations on record

DateCategoryDescriptionSeverity
2026-04-16Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.G – Actual Harm
2026-04-16Resident Rights DeficienciesHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.E – Moderate Harm Potential
2026-04-16Pharmacy Service DeficienciesEnsure medication error rates are not 5 percent or greater.E – Moderate Harm Potential
2026-04-16Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential
2026-04-16Resident Rights DeficienciesImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.D – Moderate Harm Potential
2026-04-16Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.D – Moderate Harm Potential
2026-04-16Freedom from Abuse, Neglect, and Exploitation DeficienciesEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.D – Moderate Harm Potential
2026-04-16Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D – Moderate Harm Potential
2026-04-16Freedom from Abuse, Neglect, and Exploitation DeficienciesRespond appropriately to all alleged violations.D – Moderate Harm Potential
2026-04-16Resident Rights DeficienciesProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.D – Moderate Harm Potential
2026-04-16Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2026-04-16Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2026-04-16Quality of Life and Care DeficienciesProvide safe, appropriate dialysis care/services for a resident who requires such services.D – Moderate Harm Potential
2026-04-16Pharmacy Service DeficienciesEnsure 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.D – Moderate Harm Potential
2025-02-05Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.E – Moderate Harm Potential
2025-02-05Resident Rights DeficienciesHonor 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.D – Moderate Harm Potential
2024-02-07Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G – Actual Harm
2023-12-07Pharmacy Service DeficienciesEnsure 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.E – Moderate Harm Potential
2023-12-07Resident Rights DeficienciesNotify 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.D – Moderate Harm Potential
2023-12-07Resident Assessment and Care Planning DeficienciesCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.D – Moderate Harm Potential
2023-12-07Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2023-12-07Quality of Life and Care DeficienciesProvide appropriate pressure ulcer care and prevent new ulcers from developing.D – Moderate Harm Potential
2023-12-07Pharmacy Service DeficienciesImplement 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.D – Moderate Harm Potential
2023-12-07Administration DeficienciesArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.D – Moderate Harm Potential
2023-12-07Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential

Fire Safety Citation History

0 fire safety citations on record

No fire safety citations on record.

Total Penalties & Fines

$66,325
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
DateTypeFine AmountPayment Denial
2026-04-16Fine$66,325-

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