Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethesda during CMS and state inspections, most recent first.
Improper food storage was observed in unit refrigerators when a resident-labeled take-out container was found without a date and a bag of peeled hard-boiled eggs was found open and unlabeled. A DA verified both items were not stored per expected food safety practices, and the IP stated unit refrigerator food was expected to be labeled, sealed, stored, and discarded per policy to prevent foodborne illness.
Failure to use EBP, respiratory precautions, and hand hygiene: Staff did not wear gowns during high-contact care for several residents who were on EBP for wounds, feeding tubes, or catheters, and a resident on enhanced respiratory precautions for COVID-19 had no precaution sign on the door. Staff also failed to keep a catheter drainage bag off the floor and did not perform hand hygiene between resident cares, despite facility policy and staff interviews confirming these practices were expected.
A facility failed to complete self-administration assessments before leaving medications in residents’ rooms. One resident who was cognitively intact but legally blind had nystatin powder on the nightstand despite a care plan stating staff should administer meds; another cognitively intact resident with DM had miconazole powder left on a bedside refrigerator without a self-administration order; and a third cognitively intact resident with COPD and chronic rhinitis kept an inhaler and nasal spray at the bedside without a completed assessment or order.
Missing Resident Clothing and Property: A resident with severe cognitive impairment and dependence for ADLs had multiple items of clothing missing, including shirts, pants, and underwear. Family reported the resident did not have clothes to wear, some items were unlabeled or found on an unmarked rack, and the facility documented a lost property investigation while staff described the labeling and search process.
Failure to provide grooming assistance for two residents with documented needs and preferences for shaving and personal hygiene. One resident with cognitive impairment and another resident with dementia and other diagnoses were both care planned for daily shaving or assistance as needed, yet observations and interviews showed they had facial hair and stated staff did not assist with shaving. Staff confirmed both residents had not refused ADLs and that assistance should have been offered.
A resident with severe cognitive impairment experienced a 20-pound weight loss over 18 days due to the facility's failure to monitor and assess for dehydration and weight loss. Despite being at risk, the facility did not implement interventions or notify the physician or heart failure clinic. Incomplete documentation and lack of communication among staff contributed to the resident's hospitalization and subsequent death.
A facility failed to notify a medical provider of significant weight changes for a resident with severe cognitive impairment and multiple health conditions, including heart failure. Despite documented weight fluctuations that met the criteria for notification, the facility did not inform the physician or heart failure clinic. Interviews confirmed the oversight, which prevented necessary evaluation and potential medication adjustments.
A facility failed to develop a comprehensive care plan within the required timeline for a resident with severe cognitive impairment and multiple health conditions. The resident's care plan did not address all identified risks and needs, such as pressure ulcers, falls, and medication use. Staff interviews revealed a misunderstanding of the timeline for completing the care plan, which should have been done within seven days after the CAAs were completed.
A resident's wheelchair was found to be in poor condition, with shredded fabric that was difficult to clean, posing a potential risk for injury. The resident, who has Parkinson's disease and polyneuropathy, relies on the wheelchair for mobility. Staff interviews revealed a lack of specific cleaning or maintenance schedules for wheelchairs, and facility documents lacked protocols for ongoing maintenance and repair.
A resident with multiple medical conditions, including a lung mass and knee pain, did not have her pain management needs addressed in her care plan. Despite receiving medications like Tylenol and Tramadol, the facility failed to document these interventions in the care plan, as confirmed by nursing staff. This oversight was contrary to the facility's policy requiring comprehensive care plans within 21 days of admission.
A facility failed to provide necessary adaptive supports for a resident with neurological conditions, resulting in improper wheelchair positioning. Additionally, the facility did not administer prescribed medication for a resident with COPD due to a failure in communication and follow-up with the pharmacy, despite the medication being available. These actions violated the facility's policies on resident care and medication administration.
A resident who was discharged from dialysis continued to receive unnecessary treatments and dietary restrictions due to the facility's failure to update medical orders and coordinate care with healthcare providers. The resident's central line and port were not promptly removed, posing an infection risk, and there was a lack of communication with the nephrologist and primary care physician to adjust the care plan.
A facility failed to monitor orthostatic blood pressures for a resident on Quetiapine Fumarate, an antipsychotic medication, for six months. Despite the resident's severe cognitive impairment and the known risk of postural hypotension, no orthostatic blood pressures were recorded. Staff interviews confirmed the oversight, with the consultant pharmacist, RN, and DON acknowledging the importance of monthly monitoring to detect side effects affecting mobility.
A resident did not receive the PCV20 vaccine despite consenting to it during an immunization fair. The infection preventionist was not informed of the updated consent, leading to a lapse in vaccine administration. The facility's policy to offer pneumococcal vaccines was not effectively implemented.
A resident with Type 1 Diabetes Mellitus received an incorrect insulin dose due to a misinterpretation of dosing instructions. Instead of the prescribed 5 units of Novolog insulin, the resident was administered 32 units, leading to a significant medication error. The error was discovered the following day, and staff acknowledged the mistake, citing unfamiliarity with carbohydrate counting as a contributing factor.
Improper Food Storage in Unit Refrigerators
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety in 1 of 2 refrigerators on the 100-units. On 12/9/25, surveyors observed a square foam take-out container labeled with a resident's name in the 101-120 unit refrigerator, but the container was not dated. The dietary aide verified the box was not dated and stated it should have been dated so the resident would not eat spoiled food. Later that day, surveyors observed a clear plastic bag containing approximately six peeled hard-boiled eggs in the 121-140 unit refrigerator; the bag was open and unlabeled. The dietary aide verified the package was not stored in a closed container and was not labeled with the opened date, and stated it should have been closed and labeled to ensure safety. The Infection Preventionist stated all food stored in unit refrigerators was expected to be labeled, sealed, stored, and discarded per facility policy to prevent foodborne illness.
Failure to Use EBP, Respiratory Precautions, and Hand Hygiene
Penalty
Summary
The facility failed to implement enhanced barrier precautions for multiple residents who were identified as needing them. R4 had diagnoses including pressure ulcers, had IV access and a feeding tube, and was care planned for EBP due to a wound, tube feeding, and PICC line. During observation, an LPN provided g-tube medication administration and drain care in R4’s room while coming into contact with the bedding and bedside table, but was not wearing a gown. The LPN stated nurses did not typically wear gowns for tube feeding care, medication care, or drain care and only gloves were required. R16 was cognitively intact, had an indwelling catheter and feeding tube, and was care planned for EBP due to the feeding tube. During observation, a nursing assistant assisted R16 with transferring from bed to the bathroom without wearing a gown. The nursing assistant stated she was unsure what the EBP precautions were for and did not usually wear a gown when helping with transfers or in the bathroom. R241 had diagnoses of urinary retention and infection related to an indwelling urethral catheter and was also care planned for EBP due to having a catheter. During observation, a nursing assistant assisted R241 to the bathroom without wearing a gown and stated he had not noticed the EBP magnet on the door frame and was not aware R241 was on precautions. R55 was cognitively impaired, needed assistance with ADLs, had an indwelling catheter, and was care planned for EBP due to infection or colonization risk related to the catheter. The resident’s catheter collection bag was observed lying on the fall mat and later on the floor next to the bed, with the tubing and drainage port in contact with the mat. During morning ADL care, a nursing assistant assisted R55 with dressing, hygiene, transfer, bathroom use, and oral care without wearing a gown. Staff interviews confirmed gowns were expected during high-contact care and catheter care, and that the catheter bag should not be touching the floor. The facility also failed to implement enhanced respiratory precautions for R67. R67 was cognitively intact, dependent on staff for dressing, toileting, and personal hygiene, and had a positive COVID test with enhanced respiratory isolation documented. During observation, R67’s doorway had no signage identifying the resident as being on enhanced respiratory precautions, although PPE supplies and a precaution sign were located outside the room. The infection preventionist and DON stated signage was important to prevent spread of infection, and the infection preventionist confirmed the door lacked the required signage. In addition, during observation of personal care for R67, a nursing assistant did not sanitize hands after providing incontinence care to R222 or before entering another resident’s room and assisting that resident to the commode. The nursing assistant confirmed she had not sanitized hands after the prior care or before the next resident encounter and stated she was not aware she needed to sanitize hands after removing gloves or before applying gloves. The infection preventionist and DON stated hand hygiene was expected before and after cares and before and after glove use. The facility policy on hand hygiene identified hand hygiene as the primary means of preventing transmission of infection, and the infection control and COVID-19 policies identified the use of PPE and signage for transmission-based and enhanced respiratory precautions.
Medications Left at Bedside Without Self-Administration Assessment
Penalty
Summary
The facility failed to ensure a self-administration of medication assessment was completed before medications were left at the bedside for three residents. The report identified that residents with medications in their rooms did not have documented self-administration assessments or orders authorizing them to keep and manage those medications independently, even though facility policy stated residents may self-administer medications only when the comprehensive assessment and plan of care indicate it is safe and all self-administered medications have a physician order and proper labeling. One resident was cognitively intact but legally blind, had urinary incontinence, skin issues related to moisture, and needed assistance with ADLs. That resident’s care plan stated staff should administer medications, and the resident’s self-administration assessment indicated nursing staff would administer medications except Orajel. Despite this, nystatin powder ordered for the groin folds was observed on the nightstand during two separate observations, along with other items on the bedside table. Nursing staff confirmed the resident did not have a self-administration order for the nystatin powder and that it should not have been left on the nightstand. A second resident was cognitively intact, had diabetes and anxiety, and needed assistance with ADLs. The resident’s care plan stated the resident wanted staff to administer medications, yet miconazole nitrate powder was observed on top of a small refrigerator next to the bed during two observations. Nursing staff verified there was no self-administration order and that the medication should not have been left in the room without one. A third resident was cognitively intact with COPD and chronic rhinitis, had inhaler and nasal spray medications on the bedside table, and stated the staff knew the resident kept and used them independently. Nursing staff and the ADON confirmed there was no completed self-administration assessment or order in the chart, although the medications had been signed off earlier that morning and were left unattended in the room.
Missing Resident Clothing and Property
Penalty
Summary
The facility failed to maintain respect and dignity for personal possessions for 1 of 1 residents reviewed, R140, who had missing clothing. R140’s MDS showed severe cognitive impairment and dependence on staff for ADLs including toileting, dressing, and personal hygiene. R140 also had multiple sclerosis and anxiety, and the care plan was revised to indicate he needed assistance with dressing, toileting, and transfers. During observation, R140 had only two long-sleeve shirts in his closet, with no pants or underwear found in the closet or dresser drawers. Family member FM-B reported that R140 had moved into the room two weeks earlier, that his clothing was labeled, and that he did not have clothes to wear the following day. FM-B stated the socks R140 was wearing did not belong to him, and reported that seven long-sleeve t-shirts and five pairs of pants were missing. The lost/found/damaged resident property report documented that FM-B reported two long-sleeve shirts, three pairs of underwear, and one pair of pants missing, with the items noted as missing around 11/12/25. The report also showed that R140’s room, laundry room, and an unmarked clothing rack were searched, and one item was found in the unmarked clothes and then marked. RNCC-B stated the process for missing items was to search and complete a lost and found form, and SS-A stated the facility would replace missing clothing if it could not be found. The administrator stated she was notified of the missing clothing and expected R140 to be provided clothing while the facility attempted to locate his items. Facility policy required resident clothing to be labeled on admission and outlined the process for lost/found/damaged resident property investigations.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to provide assistance with grooming for 2 residents who had documented needs and preferences for shaving and personal hygiene. One resident had moderate cognitive impairment, cataracts, hypertension, and care planning that identified a preference to be clean shaven, with staff to provide supervision or touching assistance for personal hygiene and reminders for grooming. The resident care sheet directed staff to provide supervision and cuing for grooming and to set up and give reminders for hygiene, yet the resident stated staff did not assist with shaving and only prompted him, and he wanted more help with ADLs. Observations showed the resident had approximately 2 cm of facial hair on two separate occasions. The second resident had moderate cognitive impairment and diagnoses including arthritis, dementia, anxiety, and depression, and was dependent on staff for ADL care including shaving, combing hair, and washing face. The care plan and resident care sheet identified the resident as dependent on staff for personal hygiene and to be clean shaven daily, with staff to shave daily and assist as needed. During observation and interview, the resident stated staff did not assist with shaving, and observations showed approximately 1 cm of facial hair on two occasions. Staff interviews confirmed that both residents had not refused ADLs in the past week, that both had long facial hair, and that staff should have offered assistance with ADLs.
Failure to Monitor and Address Resident's Dehydration and Weight Loss
Penalty
Summary
The facility failed to identify, monitor, and comprehensively assess a resident for dehydration and significant weight loss, which resulted in harm. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, experienced a 20-pound weight loss over 18 days. Despite being at risk for dehydration and weight loss due to multiple medical conditions and medications, the facility did not implement appropriate interventions or notify the resident's physician or heart failure clinic of the significant weight loss. The resident's care plan identified the risk for dehydration but lacked specific interventions. The facility's documentation showed inconsistent and incomplete records of the resident's food and fluid intake, and there was no evidence of a comprehensive assessment to determine the cause of the weight loss. Staff interviews revealed that changes in the resident's condition, such as decreased alertness and food intake, were reported to nursing staff, but no further assessments or actions were taken. The facility's failure to report the resident's weight loss and change in condition to the appropriate medical personnel contributed to the resident's hospitalization for dehydration, acute renal failure, and ultimately, the resident's death. Interviews with staff and family members highlighted a lack of communication and follow-up on the resident's declining condition, which was not addressed in a timely manner according to the facility's policies.
Failure to Notify Medical Provider of Significant Weight Changes
Penalty
Summary
The facility failed to adhere to a physician's order to notify the medical provider of significant weight changes for a resident with severe cognitive impairment and multiple health conditions, including heart failure and chronic kidney disease. The resident was on diuretics and required daily weight monitoring due to the risk of fluid imbalance. Despite documented weight fluctuations that met the criteria for notification, the facility did not inform the physician or the heart failure clinic of these changes. The resident's Treatment Administration Record indicated significant weight losses over several days, which should have been reported according to the physician's orders. Interviews with the Director of Nursing, the resident's primary care physician, and a registered nurse from the heart failure clinic confirmed that the weight changes were not communicated as required. This lack of communication prevented the necessary evaluation and potential adjustment of the resident's medication to manage their heart failure effectively.
Failure to Develop Comprehensive Care Plan in Timely Manner
Penalty
Summary
The facility failed to develop a comprehensive care plan within the required timeline for a resident with severe cognitive impairment and multiple health conditions. The resident, who was dependent on staff for all activities of daily living, had a history of cerebral vascular accident, heart failure, chronic kidney disease, diabetes mellitus, aphasia, hemiparesis, and urinary tract infections. The resident was also at risk for pressure ulcers and falls, was on a texture-modified diabetic diet, and was taking high-risk medications including antianxiety, antidepressant, diuretic, and antiplatelet medications. Despite these complexities, the facility did not complete a comprehensive care plan that addressed all identified risks and needs. The resident's Communication, Cognitive Loss/Dementia, Visual Function, Urinary Incontinence, Falls, Pressure Ulcer, and Psychotropic Drug Use Care Area Assessments (CAAs) indicated the need for care planning to ensure continuity of care. However, the care plan developed only included a baseline assessment and a nutrition care plan, failing to incorporate goals or interventions for the other identified risk areas. Interviews with facility staff, including a registered nurse and the director of nursing, revealed a misunderstanding of the timeline for completing the comprehensive care plan, which should have been completed within seven days after the CAAs were finished, rather than the 21 days from admission as the staff believed.
Failure to Maintain Clean and Safe Wheelchair Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for a resident's wheelchair, which is essential for promoting resident well-being. The resident, who has progressive neurological conditions including Parkinson's disease and polyneuropathy, relies on a wheelchair for mobility. Observations revealed that the wheelchair had significant wear and tear, particularly on the right side, with shredded fabric that was difficult to clean. This condition posed a potential risk for injury and compromised the ability to maintain hygiene. Interviews with staff, including a registered nurse and the director of nursing, confirmed the lack of a specific cleaning or maintenance schedule for wheelchairs. The facility's documents directed staff to clean wheelchairs after meals if needed, but there was no indication of ongoing maintenance or repair protocols for the physical structure of wheelchairs. The director of nursing acknowledged the potential for injury and the difficulty in cleaning the damaged wheelchair, highlighting a gap in the facility's procedures for ensuring a safe and clean environment for residents.
Failure to Address Pain Management in Resident Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was developed and readily available to promote acceptable pain management for a resident identified as R199. The resident, who was admitted to the care center from an acute care hospital, had multiple medical conditions including malignant neoplasm of the left lower lung lobe, repeated falls, essential hypertension, and bilateral primary osteoporosis of the knees. Despite these conditions, the facility did not address the resident's pain issues in the care plan, which is a critical component for continuity of care. Interviews and document reviews revealed that R199 had been experiencing increasing pain in her left chest and shoulder due to her lung mass, as well as knee pain. The resident was self-administering Voltaren Gel for knee pain and receiving Tylenol and Tramadol for chest and shoulder pain. However, the care plan did not reflect these pain management interventions, which were confirmed by the registered nurse/case manager and the assistant director of nursing as missing from the care plan. The director of nursing stated that it was her expectation for any resident with pain issues to have these addressed in the care plan to educate direct care staff on the prescribed interventions. The facility's policy on care planning emphasized the importance of developing a comprehensive care plan within 21 days of admission, involving an interdisciplinary care team. Despite this policy, the care plan for R199 did not include the necessary pain management interventions, leading to a deficiency in the resident's care.
Deficiencies in Resident Positioning and Medication Administration
Penalty
Summary
The facility failed to provide appropriate adaptive supports or assistive devices for a resident with moderate cognitive impairment and multiple neurological conditions, including Parkinson's disease and polyneuropathy. The resident was observed on multiple occasions seated in a rock-n-go wheelchair without lateral support, leaning to one side, and not interacting with others. Despite the resident's care plan indicating the use of a Gel cushion, it did not address positioning concerns or potential positioning aids. A registered nurse acknowledged the need for lateral support, and a therapy referral was eventually made. Additionally, the facility did not administer medications according to a physician's order for a resident with severe cognitive impairment and chronic obstructive pulmonary disease (COPD). The resident's medication administration record showed that several doses of Advair inhalation aerosol were documented as unavailable, although the medication had been delivered by the pharmacy. A trained medication aide admitted to not following up with the pharmacy promptly and failing to notify the nurse. The registered nurse confirmed that the medication was available but had not been administered, constituting a medication error. The facility's policies on wheelchair positioning and medication administration were not adhered to, leading to deficiencies in resident care. The director of nursing confirmed that the documentation in the medication administration record was inaccurate and acknowledged the medication error. The facility's pharmacy services policy indicated that medications should be received timely, but this was not reflected in the actions taken by the staff.
Failure to Coordinate Care Post-Dialysis Discontinuation
Penalty
Summary
The facility failed to properly coordinate care for a resident, identified as R102, who had recently been discharged from dialysis. Despite the resident's kidney function returning and dialysis being discontinued, the facility did not update or discontinue related medical orders, such as fluid restrictions, renal diet, and phosphorus-binding medication. This oversight was discovered through observations, interviews, and document reviews, revealing that the resident continued to receive treatments and dietary restrictions that were no longer necessary. Interviews with various staff members, including registered nurses, nursing assistants, and the assistant director of nursing, highlighted a lack of communication and understanding of the process for managing a resident coming off dialysis. The facility did not promptly arrange for the removal of the resident's central line and port, which posed a risk of infection. Additionally, there was no immediate follow-up with the nephrologist or primary care physician to adjust the resident's care plan and medication orders, leading to continued administration of unnecessary treatments. The facility's failure to update the care plan and communicate effectively with the dialysis clinic and healthcare providers resulted in the resident being subjected to unnecessary medical interventions. The director of nursing and medical director acknowledged the need for better communication and follow-up procedures to ensure that residents' care plans are accurately updated when significant changes, such as the discontinuation of dialysis, occur.
Failure to Monitor Orthostatic Blood Pressures for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to monitor orthostatic blood pressures for a resident who was prescribed Quetiapine Fumarate, an antipsychotic medication, for delusional disorders. The resident, identified as having severe cognitive impairment and requiring supervision with activities of daily living, had been on the medication since July 26, 2024. Despite the known side effects of antipsychotic medications, such as postural hypotension, which can increase the risk of falls, the facility did not obtain orthostatic blood pressures for the resident over a six-month period. Interviews with facility staff, including a consultant pharmacist, a registered nurse, and the director of nursing, confirmed the oversight. The consultant pharmacist and RN stated that orthostatic blood pressures should be monitored monthly for residents on antipsychotic medications to detect side effects that could affect mobility. The director of nursing acknowledged that the failure to monitor was a lapse in protocol, which should have been identified by the consulting pharmacist or the nurse manager. The facility's policy on antipsychotic medications emphasizes the residents' right to be free from unnecessary medications and the importance of monitoring for side effects.
Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to ensure that a resident, identified as R88, received the pneumococcal vaccine series as recommended by the CDC. R88, who is over the age of 65, had previously received the PCV13 and PPSV23 vaccines but refused the PCV20 vaccine on a prior occasion. However, during the facility's annual fall immunization fair, R88 consented to receive the PCV20 vaccine, as indicated by a signed consent form. Despite this consent, there was no evidence in the records that R88 received the PCV20 vaccine. The infection preventionist (IP) stated that immunizations are reviewed upon admission and that any wanted vaccines are administered after review with the provider. The IP was not notified of the updated consent for the PCV20 vaccine, which was a lapse in communication. The director of nursing (DON) expressed that her expectation was for RN case managers to relay all vaccination requests to the IP. The facility's policy indicated that all residents should be offered pneumococcal vaccines to prevent infections, but this policy was not effectively implemented in R88's case.
Significant Insulin Administration Error
Penalty
Summary
The facility failed to administer insulin according to the physician's orders for a resident with Type 1 Diabetes Mellitus. The resident was supposed to receive insulin based on carbohydrate intake and a sliding scale for blood sugar levels. On a specific day, the resident's blood sugar was recorded at 204 before supper, and she was administered 32 units of Novolog insulin instead of the correct dose of 5 units. This error was due to a misinterpretation of the insulin dosing instructions related to carbohydrate counting. The error was discovered by a licensed practical nurse the following morning, who then informed a registered nurse. The director of nursing and assistant director of nursing confirmed that the resident should have received only 5 units of insulin. The pharmacist and other staff acknowledged that administering 32 units was a significant medication error. The facility's policies directed that all medications should be given as prescribed, but the staff was not adequately familiar with counting carbohydrate grams, leading to the error.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Willmar
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cura Of Willmar | 1.7 mi | ★★★★★ | 2 | 0 |
| Glenoaks Senior Living Campus | 14 mi | ★★★★★ | 5 | 0 |
| Clara City Care Center | 19.4 mi | ★★★★★ | 9 | 1 |
| Olivia Restorative Care Center | 22.9 mi | ★★★★★ | 2 | 0 |
| Belgrade Nursing Home | 23.4 mi | ★★★★★ | 0 | 0 |
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