Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Bethany On University during CMS and state inspections, most recent first.
Infection control and EBP practices were not followed for three residents on EBP. A CNA changed a catheter drainage bag without a gown and left the room without hand hygiene, another CNA performed close-contact care and incontinence care without proper gown use and with missed hand hygiene between glove changes, and an RN placed supplies on an uncleaned bedside table and accessed a PICC line without a gown or cleaning the table afterward.
Failure to provide written discharge instructions for a resident discharged from the facility. Review of the facility policy stated that a community discharge should include a discharge summary and plan of care, but the resident's record lacked evidence that written discharge instructions were given to the resident or the resident representative.
The facility failed to provide the State LTC Ombudsman written notice of a resident's discharge. Review of the facility policy showed the notice must include the reason for transfer or discharge and the effective date, and a copy must be sent to the Ombudsman. Record review showed the resident was discharged, but there was no evidence the Ombudsman was notified; an administrative staff member confirmed the omission.
A resident scheduled for surgery received warfarin (Coumadin) on two days when it should have been held, despite clear physician orders and documentation to withhold the medication. Facility staff confirmed the medication was not held as directed.
A facility failed to follow a physician's pre-operative medication orders for a resident, administering additional medications not approved for the day of surgery. This deviation from professional standards was identified during a review of the resident's medical records, highlighting a lapse in protocol adherence.
The facility failed to follow infection control standards for three residents with wounds, as staff did not use Enhanced Barrier Precautions (EBP) such as gowns during care activities. Observations showed a lack of EBP signage and improper gown use during dressing changes for residents with pressure ulcers and chronic wounds, leading to potential infection risks.
Infection Control and EBP Failures During Resident Care
Penalty
Summary
Failure to follow infection control standards occurred for 3 of 8 sampled residents who were on Enhanced Barrier Precautions (EBP). Facility policies reviewed on hand hygiene and EBP stated that hand hygiene is required after removing PPE, including gloves, and that EBP uses targeted gown and glove use during high-contact resident care activities such as device care and urinary catheter care. The facility also had care plans identifying Resident #11 as on EBP for catheter use, Resident #94 as on EBP for wound drain care, and Resident #118 as on EBP for wounds and a PICC line. During observation, a CNA changed Resident #11's catheter drainage bag without first applying a gown, then removed the gown and gloves and exited the room without performing hand hygiene. For Resident #94, one CNA applied heel boots and adjusted bedding while wearing gloves but did not apply a gown, and another CNA performed incontinence care, removed soiled gloves, and repeatedly applied clean gloves and continued care without performing hand hygiene between glove changes. For Resident #118, a nurse entered the room, performed hand hygiene, moved the bedside table, and placed gloves, laboratory tubes, and sterile syringes on the table without cleaning the surface or using a barrier; the nurse then performed hand hygiene again, applied gloves, and accessed the PICC line for blood draws and IV medication without a gown, and did not clean the bedside table after the procedure.
Failure to Provide Written Discharge Instructions
Penalty
Summary
The facility failed to provide written discharge instructions to Resident #190 or the resident representative after the resident was discharged from the facility. Review of the facility's TRANSFER AND DISCHARGE POLICY stated that for a community discharge, a discharge summary and plan of care should be prepared for the resident. Review of Resident #190's medical record showed a discharge from the facility, but the record lacked evidence that written discharge instructions were provided to the resident or the resident representative.
Failure to Notify State Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide the State Long Term Care Ombudsman with written notice of transfer/discharge for Resident #177. Review of the facility's Transfer And Discharge Policy showed that a copy of the notice must be provided to a representative of the Office of the State Long-Term Care Ombudsman and must include the reason for transfer or discharge and the effective date. Review of Resident #177's medical record showed the resident was discharged from the facility on 11/24/25, but the record lacked evidence that the facility notified the State Ombudsman of the discharge. During interview, an administrative staff member confirmed the facility failed to notify the State Ombudsman of Resident #177's discharge.
Failure to Hold Anticoagulant as Ordered Prior to Surgery
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not following physician's orders regarding the administration of warfarin (Coumadin). The resident had a surgical procedure scheduled, and preoperative orders directed staff to contact the Coumadin Clinic or prescribing provider about when to hold the medication. A progress note specified that Coumadin should be held from a certain date until after the procedure. Despite these orders, the resident received Coumadin on two days when it should have been withheld. An administrative nurse confirmed that staff did not hold the medication as ordered by the physician. Review of the resident's medical record and medication administration record confirmed the medication was administered contrary to the documented orders, and this was acknowledged by facility staff during an interview.
Failure to Follow Pre-Operative Medication Orders
Penalty
Summary
The facility failed to adhere to professional standards of practice by not following the physician's pre-operative medication orders for a resident scheduled for surgery. According to the physician's orders, certain medications were approved to be administered on the day of surgery, while all others were to be held. However, the facility staff administered additional medications that were not approved by the physician, including furosemide, Calcium plus Vitamin D, Cholecalciferol, and Acidophilus, on the morning of the surgery. This oversight was identified during a review of the resident's medical records, which included both electronic and paper documentation. The failure to hold these medications as per the physician's explicit instructions represents a departure from competent nursing practice, as outlined in the professional reference, Kozier & Erb's Fundamentals of Nursing. This incident highlights a critical lapse in following established protocols for medication administration prior to surgery, potentially compromising the resident's safety.
Infection Control Lapses in Wound Care
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for three residents receiving treatment for wounds or pressure ulcers. Resident #34 had an unstageable pressure ulcer on the coccyx, and observations revealed that staff did not use Enhanced Barrier Precautions (EBP) such as gowns during care activities. Despite the presence of a wound, there was no signage indicating EBP on the resident's door or in the room, and staff members were observed performing care without donning gowns. Resident #88 had multiple chronic ulcers on the lower extremities, and similar lapses in infection control were noted. A staff nurse was observed performing a dressing change without wearing a gown, despite the presence of open and weeping wounds. Again, there was no EBP signage on the resident's door or in the room, indicating a lack of adherence to infection control protocols. Resident #139 had a necrotic abdominal wound that had been debrided and was being packed twice daily. The resident reported that nurses wore gloves but not gowns during dressing changes. Observations confirmed the absence of EBP signage and the lack of gown use by staff. The nurse manager stated that the resident was not on precautions, which contributed to the failure to implement appropriate infection control measures.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fargo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Meadows On University | 0.8 mi | ★★★★★ | 2 | 0 |
| Smp Health - St Catherine South | 1.4 mi | ★★★★★ | 0 | 0 |
| Smp Health - St Catherine North | 1.6 mi | ★★★★★ | 4 | 0 |
| Eventide Lutheran Home | 1.6 mi | ★★★★★ | 1 | 0 |
| Bethany On 42nd | 3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.