Cycle 1
Health 2024-10-24 · Fire 2024-10-24
2 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 University
5-star overall rating with 4-star inspections with 2 recent health deficiencies
201 S University Dr, Fargo, ND
(701) 239-3000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
172
Certified beds
Average residents
167
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1978-12-01
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
1.05
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
3.62
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
5.31
All reported nurse hours · state 4.41 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.71
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
0.71
Weekend registered nurse coverage · state 0.59 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.04
CMS adjusted RN staffing hours
Adjusted total hours
5.23
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,985
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.45
Composite VBP score used to determine payment impact.
Payment multiplier
1.0070
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.02% · Performance 21.64% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
8.63
Baseline 6.01% · Performance 5.26% · Measure score 8.63 · Achievement 8.63 · Improvement 6.94
Total nurse turnover
3.67
Baseline 55.59% · Performance 48.68% · Measure score 3.67 · Achievement 3.67 · Improvement 1.75
Adjusted total nurse staffing
8.68
Baseline 5.39 hours · Performance 5.55 hours · Measure score 8.68 · Achievement 8.68 · Improvement 3.6
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 6.78% |
10.72%
3.9 pts better
|
Better than the National Rate · Eligible stays 381 · Observed rate 4.46% · Lower 95% interval 5.16% |
| Discharge to community | 43.71% |
50.57%
6.9 pts worse
|
Worse than the National Rate · Eligible stays 325 · Observed rate 38.46% · Lower 95% interval 38.25% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 360 · Denominator 360 |
| Falls with major injury | 0.56% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 360 |
| Discharge self-care score | 58.89% |
53.69%
5.2 pts better
|
Numerator 159 · Denominator 270 |
| Discharge mobility score | 66.3% |
50.94%
15.4 pts better
|
Numerator 179 · Denominator 270 |
| Pressure ulcers or injuries, new or worsened | 1.67% |
2.29%
0.6 pts better
|
Numerator 6 · Denominator 360 · Adjusted rate 1.73% |
| Healthcare-associated infections requiring hospitalization | 5.26% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 253 · Observed rate 3.56% · Lower 95% interval 3.34% |
| Staff COVID-19 vaccination coverage | 6.16% |
8.2%
2 pts worse
|
Numerator 36 · Denominator 584 |
| Staff flu vaccination coverage | 89.59% |
42%
47.6 pts better
|
Numerator 740 · Denominator 826 |
| Discharge function score | 64.81% |
56.45%
8.4 pts better
|
Numerator 175 · Denominator 270 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 178 · Denominator 178 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 79 · Denominator 79 |
| Resident COVID-19 vaccinations up to date | 31.35% |
25.2%
6.2 pts better
|
Numerator 58 · Denominator 185 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.4
0.2 pts worse
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.9
1.2 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
98.3%
1.3 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 100.0% · Q3 100.0% · Q4 99.2% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.3% |
98.8%
0.5 pts better
|
95.5%
3.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
5.1%
1.3 pts better
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.3% · Q3 4.7% · Q4 5.3% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
4.4%
2.2 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 4.7% · Q3 2.4% · Q4 0.0% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
5.5%
4.2 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.0% · Q3 0.0% · Q4 1.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.2% |
17.4%
17.8 pts worse
|
19.6%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.7% · Q2 32.4% · Q3 33.7% · Q4 40.0% · 4Q avg 35.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.1% |
23.4%
6.3 pts better
|
16.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 22.7% · Q3 17.8% · Q4 10.7% · 4Q avg 17.1% · 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 | 13.4% |
19.0%
5.6 pts better
|
16.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 13.7% · Q3 9.9% · Q4 12.9% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.0% |
20.1%
11.1 pts better
|
14.9%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 4.0% · Q3 7.4% · Q4 14.3% · 4Q avg 9.0% · 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 | 1.8% |
3.1%
1.3 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.6% · Q3 1.7% · Q4 3.1% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.1% |
25.2%
0.9 pts worse
|
19.8%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 23.4% · Q3 25.3% · Q4 25.9% · 4Q avg 26.1% |
| Percentage of long-stay residents with pressure ulcers | 1.4% |
5.3%
3.9 pts better
|
5.1%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.7% · Q4 2.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
93.6%
5 pts better
|
81.7%
16.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 99.2% · Q3 98.4% · Q4 97.0% · 4Q avg 98.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
10.7%
1.5 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 9.2% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.9%
1.1 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.7% · Q3 2.6% · Q4 2.8% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.9% |
88.3%
8.6 pts better
|
79.7%
17.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.2% |
20.5%
5.7 pts worse
|
23.9%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.2% · Observed 27.1% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-26 · Fire 2023-10-26
5 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-09-29 · Fire 2022-09-29
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
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
2025-06-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-01-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-05
D · Potential for more than minimal harm
2024-10-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-13
G · Actual harm
2023-10-26
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-26
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-26
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-26
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2023-11-20
D · Potential for more than minimal harm
2022-09-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-10-27
Penalties and ownership
What sits behind the stars
Ownership
American Lutheran Homes Inc
Operational/Managerial Control · Organization
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
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
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
#2
Smp Health - St Catherine South
Fargo, ND
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#3
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
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