Cycle 1
Health 2025-05-01 · Fire 2025-05-01
1 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fargo, ND
Bethany On 42nd
5-star overall rating with 4-star inspections with 1 recent health deficiencies
4255 30th Ave S, Fargo, ND
(701) 478-8900
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
114
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-01-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
3.77
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
5.27
All reported nurse hours · state 4.41 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.79
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.59 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
5.20
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,067
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9907
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0
Baseline 5.66% · Performance 7.84% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.23
Baseline 52.13% · Performance 50.46% · Measure score 3.23 · Achievement 3.23 · Improvement 0.11
Adjusted total nurse staffing
8.02
Baseline 4.82 hours · Performance 5.36 hours · Measure score 8.02 · Achievement 8.02 · Improvement 5.09
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.02% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 78 · Observed rate 5.13% · Lower 95% interval 5.26% |
| Discharge to community | 43.77% |
50.57%
6.8 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 37.1% · Lower 95% interval 33.82% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 69 · Denominator 69 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 69 |
| Discharge self-care score | 39.66% |
53.69%
14 pts worse
|
Numerator 23 · Denominator 58 |
| Discharge mobility score | 53.45% |
50.94%
2.5 pts better
|
Numerator 31 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 1.45% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 69 · Adjusted rate 1.31% |
| Healthcare-associated infections requiring hospitalization | 7.84% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 9.52% · Lower 95% interval 4.66% |
| Staff COVID-19 vaccination coverage | 6.5% |
8.2%
1.7 pts worse
|
Numerator 21 · Denominator 323 |
| Staff flu vaccination coverage | 88.5% |
42%
46.5 pts better
|
Numerator 300 · Denominator 339 |
| Discharge function score | 48.28% |
56.45%
8.2 pts worse
|
Numerator 28 · Denominator 58 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 28 · Denominator 28 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 45.65% |
25.2%
20.4 pts better
|
Numerator 21 · Denominator 46 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.4
0.1 pts worse
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.9
1.5 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
98.3%
1.5 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.8%
1.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
5.1%
3 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.9% · Q3 0.0% · Q4 1.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
4.4%
3.7 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.5%
0.8 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 6.1% · Q3 1.3% · Q4 3.9% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.7% |
17.4%
8.3 pts worse
|
19.6%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 26.8% · Q3 30.8% · Q4 22.8% · 4Q avg 25.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.2% |
23.4%
6.2 pts better
|
16.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 18.3% · Q3 15.7% · Q4 13.3% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.7% |
19.0%
7.3 pts better
|
16.3%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.6% · Q2 4.5% · Q3 12.0% · Q4 13.2% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.8% |
20.1%
6.3 pts better
|
14.9%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 11.1% · Q3 11.5% · Q4 15.2% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
3.1%
1.4 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.9% |
25.2%
4.3 pts better
|
19.8%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 19.2% · Q3 14.9% · Q4 28.0% · 4Q avg 20.9% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.3%
0.7 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 5.6% · Q3 2.7% · Q4 1.3% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
93.6%
3.4 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 100.0% · Q3 94.7% · Q4 95.9% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.9% |
10.7%
4.8 pts better
|
12.0%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.9% · Observed 5.4% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 8.1% |
1.9%
6.2 pts worse
|
1.6%
6.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 3.2% · Q3 7.9% · Q4 13.9% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.6% |
88.3%
7.3 pts better
|
79.7%
15.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.2% |
20.5%
8.3 pts better
|
23.9%
11.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 10.7% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-14 · Fire 2024-03-14
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-03-30 · Fire 2023-03-30
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-23
E · Potential for more than minimal harm
2024-03-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-03-14
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-04-01
E · Potential for more than minimal harm
2023-03-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-30
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-03-30
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-03-30
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-05-03
Penalties and ownership
What sits behind the stars
Ownership
Anderson, Cheryl
Corporate Director · Individual
Angus, Kaye
Operational/Managerial Control · Individual
Angus, Kaye
Corporate Officer · Individual
Bell Bank Arrowhead Office
Operational/Managerial Control · Organization
Bell Bank Arrowhead Office
5% Or Greater Mortgage Interest · Organization
Bethany Homes, Inc
Operational/Managerial Control · Organization
Bethany On 42nd
Operational/Managerial Control · Organization
Blue Stone Therapy Inc
Operational/Managerial Control · Organization
Brantner-Adams, Jerilynn
Corporate Director · Individual
Davidson, Bruce
Corporate Director · Individual
Eide Bailly Llp
Operational/Managerial Control · Organization
Gupta, Parul
Operational/Managerial Control · Individual
Hertsgaard, John
Corporate Director · Individual
Ness Owens, Laura
Corporate Director · Individual
Olson, Roger
Corporate Director · Individual
Renner, Beth
Corporate Director · Individual
Rockstad, Lianne
Corporate Director · Individual
Rydell, Jack
Corporate Director · Individual
Steen, Rick
Corporate Director · Individual
Stuhaug, Shawn
Operational/Managerial Control · Individual
Stuhaug, Shawn
Corporate Officer · Individual
Wendt, Joseph
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Smp Health - St Catherine North
Fargo, ND
4-star overall rating with 4-star inspections with $6,168 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Bethany On University
Fargo, ND
5-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
The Meadows On University
Fargo, ND
2-star overall rating with 2-star inspections with $41,041 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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