Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Mountrail Bethel Home during CMS and state inspections, most recent first.
Failure to provide CNA dementia management training. Review of the facility assessment showed 15 residents with cognition issues, including dementia, but the new employee checklist and CNA orientation packet lacked evidence of dementia management training. An administrative staff nurse confirmed the CNA orientation did not include this required training and that current staff had not received it for over a year.
Failure to Provide Dementia and Behavioral Health Training: The facility assessment identified 15 residents with cognition issues and dementia, but review of the nursing orientation checklist, new employee checklist, CNA orientation packet, and employee handbook found no evidence of dementia management or behavioral health care training. An administrative staff nurse confirmed that the facility did not provide this training for new or current staff.
A resident’s MDS was not coded accurately for PASRR and serious mental illness. A PASRR Level II identified bipolar disorder and anxiety disorder, but the comprehensive MDS did not code Section A1500 or Section A1510 correctly. An administrative staff member confirmed the coding error during interview.
A resident with weakness, decreased mobility, and a fall risk was transferred by two CNAs without a gait belt or the walker within reach. Staff pulled the resident up by the armpits, then stood and pivoted her into a wheelchair while holding her pants, despite the care plan calling for assist of 2 with a 4WW and the facility policy requiring gait belt use for transfers.
Failure to provide documented catheter care for a resident with an indwelling Foley catheter. The resident was identified as being at risk for catheter-related complications and UTI, with orders for BID catheter cares and as needed. Staff reported cares were sometimes done once a day or not at all, while the record lacked documentation of completed cares or refusals. The resident also had multiple antibiotic treatments for UTI and was observed keeping the catheter bag in a chair next to him.
Hand hygiene was not consistently performed during perineal care for two residents. CNAs entered rooms, used gloves for brief changes and perineal care, but one or both staff failed to clean hands before donning clean gloves, between glove changes, and before handling other items or assisting with transfers, despite the facility's hand hygiene policy.
The facility failed to follow infection control standards, impacting five residents. CNAs did not perform hand hygiene after glove removal during perineal care and failed to disinfect equipment. A resident with a catheter did not receive proper care, and staff did not wear gowns during high-contact activities for residents requiring enhanced barrier precautions. A nurse also failed to perform hand hygiene during a dressing change. These actions indicate non-compliance with infection control policies.
A resident with dementia and a history of falls was involved in an altercation and later experienced a fall. The facility failed to notify the resident's representative about these incidents, contrary to its policies. The representative learned of the incidents from another family member. Interviews with administrative nurses confirmed the lack of notification.
A facility failed to protect residents from abuse, resulting in physical and psychosocial harm. A resident with impaired cognition was assaulted by another resident, causing anxiety and distress. Another resident was involved in an altercation with the same aggressor, resulting in a physical hit to the face. Both incidents were reported to the health department.
The facility failed to report two incidents of resident abuse to the SSA within the required 24-hour timeframe. One resident was physically assaulted by another, causing significant anxiety, and the incident was reported two days later. Another resident was allegedly hit in the face, with the incident reported three days later. Both residents had moderately impaired cognition.
A facility failed to follow professional standards for insulin administration when a nurse gave rapid-acting insulin to a resident without ensuring timely access to food, risking hypoglycemia. Additionally, a nurse stored personal medications in a treatment cart, contrary to facility protocols.
A facility failed to use a gait belt during transfers for a resident, as required by their care plan and facility policy. Staff were observed lifting the resident without a gait belt, leading to a loss of balance and the need for assistance. An administrative nurse confirmed the expectation for gait belt use, indicating non-compliance with safety protocols.
A staff nurse left a medication cart unlocked and unattended for five minutes while administering insulin, with visitors, staff, and residents present. Administrative staff confirmed that carts should be locked when out of sight.
Failure to Provide CNA Dementia Management Training
Penalty
Summary
The facility failed to provide required CNA training in dementia management. Review of the most recent facility assessment showed the facility was licensed for 36 LTC beds and that 15 residents had cognition issues, including dementia. Review of the facility checklist for new employees and the CNA orientation packet found no evidence of dementia management training. During an interview, an administrative staff nurse confirmed that the new hire/CNA orientation did not include dementia management training and that the facility had failed to provide this required training to all current staff for over a year.
Failure to Provide Dementia and Behavioral Health Training
Penalty
Summary
The facility failed to provide required behavioral health training, including dementia-specific care training, based on its facility assessment and staff education records. The facility assessment stated that the 36-bed LTC facility had 15 residents diagnosed with cognition issues and dementia. Review of the facility training documents, including the nursing orientation checklist, new employee checklist, CNA orientation packet, and employee handbook revised 06/27/24, found no evidence of dementia management or behavioral health care training. During an interview, an administrative staff nurse confirmed that the facility did not provide dementia management training or behavioral health care training for new or current staff members.
Inaccurate MDS Coding for PASRR and Serious Mental Illness
Penalty
Summary
The facility failed to ensure accurate coding of the MDS for 1 of 17 sampled residents, Resident #1. Review of the resident’s record, the LTC Facility RAI 3.0 User’s Manual, and staff interview showed that a PASRR Level II dated 05/16/23 identified diagnoses of bipolar disorder and anxiety disorder, but the resident’s comprehensive MDS dated [DATE] did not code Section A1500 for PASRR and Section A1510 for serious mental illness. During an interview on 03/05/26 at 9:35 a.m., an administrative staff member confirmed that Sections A1500 and A1510 were not coded accurately.
Improper Transfer Assistance and Missing Assistive Devices
Penalty
Summary
The facility failed to properly use assistive devices during a transfer for Resident #24, who had weakness, decreased mobility, an ADL self-care deficit, and a care plan calling for assist of 2 with a 4WW and fall risk precautions. The facility policy stated gait belts are to be used with residents who need assistance to ambulate or transfer for safety. During observation, two CNAs transferred the resident from bed to wheelchair by placing their forearms under the resident's armpits to pull her from lying to sitting, then stood her without using a gait belt or placing the walker within reach, held onto her pants, and pivoted her into the wheelchair. An administrative staff member stated staff were expected to use a gait belt and place walkers within reach during transfers.
Failure to Provide Documented Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for one sampled resident with an indwelling urinary catheter. The resident had a Foley catheter and was identified in the care plan and CNA Kardex as being at risk for catheter-related complications and UTI, with instructions for staff to assist with catheter cares twice daily and as needed. The facility policy stated catheter care was to be provided to all residents with an indwelling catheter to reduce UTIs, and a nursing reference noted that accumulated secretions or excretions can irritate the skin, harbor microorganisms, and make a person prone to skin breakdown and infection. Review of the resident’s record showed antibiotics were prescribed for UTI on four separate occasions between August 2 and November 4, 2025. During observation, the resident had the urinary catheter bag in his chair next to him and said he placed it there so it would not get in his way, but he could not confirm how often staff performed catheter cares. A CNA stated the resident would allow cares maybe once a day and sometimes none. The record lacked documentation that staff provided catheter cares or that the resident refused them, and an administrative staff member confirmed the CNA task list did not include a place to document completion of catheter cares or resident refusal.
Hand hygiene not performed during resident cares
Penalty
Summary
Failure to follow infection control and prevention standards occurred during perineal care for two sampled residents, Resident #24 and Resident #32. The facility policy titled Hand Hygiene Policy, dated December 2020, stated that all staff will perform proper hand hygiene to prevent the spread of infection and that gloves do not replace hand hygiene; staff are to perform hand hygiene before donning gloves and immediately after removing them. During observation on 03/02/26 at 4:15 p.m., two CNAs entered Resident #24's room to complete perineal cares. Without performing hand hygiene, both CNAs applied gloves, removed the resident's pants, and one CNA removed the wet brief and provided perineal care. Using the same gloves, the CNA picked up the resident's shoes, then removed the gloves and, without performing hand hygiene, applied clean gloves and placed the shoes on the resident's feet before both CNAs transferred the resident into a wheelchair. During observation on 03/02/26 at 4:56 p.m., two CNAs entered Resident #32's room for perineal cares. Both CNAs performed hand hygiene and applied gloves, removed the resident's wet brief, and provided perineal cares. Without removing their gloves, both CNAs applied a clean brief. One CNA removed her soiled gloves, completed hand hygiene, and applied clean gloves, while the other CNA failed to remove her soiled gloves and assisted with applying the resident's pants and transferring the resident from the bed to a wheelchair. An administrative staff member confirmed staff were expected to perform hand hygiene before applying clean gloves, between glove changes, and to change soiled gloves before moving on to other tasks.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection prevention and control standards, impacting five residents. Observations revealed that certified nurse aides (CNAs) did not perform hand hygiene after removing gloves during perineal care for multiple residents. Specifically, two CNAs assisted a resident to the bathroom, performed perineal care, and removed their gloves without performing hand hygiene. This pattern was repeated with another resident, where the CNAs also failed to disinfect the mechanical lift after use. For a resident with a history of urinary tract infections and an indwelling catheter, CNAs did not follow proper hand hygiene protocols and used the same washcloth for cleaning the groin area and catheter tubing. Another resident with pressure ulcers required enhanced barrier precautions, but CNAs did not wear gowns during high-contact care activities and failed to perform hand hygiene after glove removal. Similar lapses were observed with a resident with stasis ulcers, where CNAs did not don gowns and failed to perform hand hygiene between glove changes. Additionally, a nurse performing a dressing change on a resident's lower extremities did not perform hand hygiene after removing soiled gloves before donning new ones. Interviews with an administrative nurse confirmed the expectation for staff to sanitize equipment after each use, perform hand hygiene after glove removal, and use appropriate personal protective equipment during high-contact care activities. These deficiencies highlight a lack of adherence to established infection control policies, potentially increasing the risk of infection spread within the facility.
Failure to Notify Resident Representative of Incidents
Penalty
Summary
The facility failed to notify the resident representative for a resident involved in falls and a resident-to-resident altercation. The facility's policy required that the emergency contact be notified as soon as possible if a resident falls without injury, or by the next morning if the fall occurs overnight. Additionally, the policy on abuse and altercations required immediate reporting to the resident representative. However, the facility did not adhere to these policies for one resident who experienced multiple falls and an altercation with another resident. The resident, who had dementia and a history of falls, was involved in an altercation with another resident and later experienced a fall. The resident's representative was not informed of these incidents by the facility, learning instead from another family member residing in the facility. Interviews with administrative nurses confirmed the failure to notify the resident's representative about the incidents, which was against the facility's expectations and policies.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in physical and psychosocial harm to two residents. Resident #3, who had moderately impaired cognition, was in her room when another resident, Resident #17, entered and physically assaulted her by grasping her arm and hitting her. Staff intervened by physically removing Resident #17 from the room, but Resident #3 was left overwhelmed with anxiety and very upset. The incident was reported to the North Dakota Department of Health and Human Services. Similarly, Resident #34, also with moderately impaired cognition, was involved in an altercation with Resident #17. Staff heard hollering from Resident #34's room and observed both residents swinging their arms, with Resident #17 hitting Resident #34 in the face. No injuries were noted at the time, but the incident was reported to the North Dakota Department of Health and Human Services. The facility's failure to prevent these incidents placed residents at risk for abuse and psychosocial harm.
Removal Plan
- The interdisciplinary team met to implement changes and interventions for resident care and safety.
- Implemented a safety plan addressing the behaviors of Resident #17.
- Notified medical director and psychiatric provider for Resident #17 of the incidents.
- Notified resident representatives of the incident and actions implemented.
- Education provided to all staff on safety plan and behavioral interventions for Resident #17.
Failure to Timely Report Resident Abuse Incidents
Penalty
Summary
The facility failed to report incidents of physical abuse involving two residents to the State Survey Agency (SSA) within the required 24-hour timeframe. The facility's policy mandates immediate reporting of abuse incidents to the administrator and relevant authorities, including the SSA, in accordance with state law. However, in the case of Resident #3, an altercation occurred where another resident entered her room and physically assaulted her, causing significant anxiety. Despite the incident occurring on November 2, 2024, it was not reported to the North Dakota Department of Health and Human Services until two days later. Similarly, Resident #34 was involved in an altercation on October 19, 2024, where another resident entered his room and allegedly hit him in the face. This incident was reported to the authorities three days after it occurred. Both residents were identified as having moderately impaired cognition, which may have contributed to their vulnerability. The administrative nurses confirmed the facility's failure to adhere to the reporting timeline, as required by their policy and state regulations.
Insulin Administration and Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure that staff followed professional standards of practice for insulin administration for one resident. Specifically, a nurse administered 3 units of NovoLog, a rapid-acting insulin, to a resident at 11:04 a.m., but the resident did not have access to food until 11:45 a.m., 41 minutes after the insulin was given. According to the manufacturer's instructions, NovoLog should be followed by a meal within 5 to 10 minutes to prevent hypoglycemia. The facility's administrative staff confirmed that the expectation was for insulin to be administered between 11:00 a.m. and 12:00 p.m., but the timing of the meal was not aligned with the insulin administration. Additionally, the facility failed to ensure that the treatment cart contained only medications prescribed and labeled for residents. During an observation, a medication cup with loose tablets and capsules was found in the treatment cart, which a staff nurse admitted were her personal medications. The nurse removed the cup from the cart and placed it in her pocket. Administrative staff confirmed that personal medications should not be stored in the medication or treatment carts, indicating a lapse in medication management protocols.
Failure to Use Gait Belt During Resident Transfers
Penalty
Summary
The facility failed to utilize necessary assistive devices to prevent accidents during resident transfers, specifically for one resident who was observed during a transfer. The facility's policy, dated December 2020, mandates the use of gait belts for residents requiring assistance to ambulate or transfer for safety purposes. Physical Therapy is responsible for assessing residents upon admission to determine their need for a gait belt, and the facility is required to provide designated gait belts for each resident who requires one. Additionally, all employees are to be educated on the proper use of a gait belt. During observations, staff members were seen transferring a resident from a wheelchair to a bedside commode and back without using a gait belt, contrary to the care plan that specified the use of a gait belt for safety. Instead, the staff placed their hands under the resident's arms to lift her, which resulted in the resident losing her balance and needing assistance to sit back down. An administrative nurse confirmed that the expectation was for staff to use a gait belt during transfers, highlighting a failure to adhere to the facility's policy and the resident's care plan.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications in one of the two medication/treatment carts observed. On December 2, 2024, at 11:51 a.m., a staff nurse unlocked the treatment cart and left it unattended for five minutes while administering insulin. The cart was left unlocked and out of the nurse's view near the nurse's station, with visitors, staff members, and residents present. During an interview on December 4, 2024, two administrative staff members confirmed that it is their expectation for the carts to be locked when out of sight.
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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 Stanley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tioga Medical Center Ltc | 26 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.