Cycle 1
Health 2025-02-05 · Fire 2025-02-05
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Williston, ND
Bethel Lutheran Nursing & Rehabilitation Center
4-star overall rating with 4-star inspections with 2 recent health deficiencies
1515 2nd Ave West, Williston, ND
(701) 572-6766
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
95
Certified beds
Average residents
79
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1978-08-01
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
0.98
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.40
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
2.76
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
4.14
All reported nurse hours · state 4.41 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.67
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
0.69
Weekend registered nurse coverage · state 0.59 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.05
CMS adjusted RN staffing hours
Adjusted total hours
4.44
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,932
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9912
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.64
Baseline 18.54% · Performance 19.74% · Measure score 3.64 · Achievement 3.64 · Improvement 0
Healthcare-associated infections
2.36
Baseline 8.45% · Performance 7.46% · Measure score 2.36 · Achievement 1.25 · Improvement 2.36
Total nurse turnover
3.11
Baseline 66.38% · Performance 51.40% · Measure score 3.11 · Achievement 3 · Improvement 3.11
Adjusted total nurse staffing
6.11
Baseline 4.01 hours · Performance 4.82 hours · Measure score 6.11 · Achievement 6.11 · Improvement 4.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.6% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 4.92% · Lower 95% interval 6.44% |
| Discharge to community | 44.19% |
50.57%
6.4 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 35.59% · Lower 95% interval 33.57% |
| Medicare spending per beneficiary | 1.27 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 93.94% |
95.27%
1.3 pts worse
|
Numerator 31 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | 48.15% |
53.69%
5.5 pts worse
|
Numerator 13 · Denominator 27 |
| Discharge mobility score | 59.26% |
50.94%
8.3 pts better
|
Numerator 16 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 9.09% |
2.29%
6.8 pts worse
|
Numerator 3 · Denominator 33 · Adjusted rate 9.75% |
| Healthcare-associated infections requiring hospitalization | 7.46% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 7.84% · Lower 95% interval 3.68% |
| Staff COVID-19 vaccination coverage | 6.11% |
8.2%
2.1 pts worse
|
Numerator 8 · Denominator 131 |
| Staff flu vaccination coverage | 44.27% |
42%
2.3 pts better
|
Numerator 85 · Denominator 192 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 18 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| 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 | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.4
0.2 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.9 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
1.9
0.9 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
98.3%
1.1 pts worse
|
93.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 89.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 97.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
98.8%
About the same
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.9% |
5.1%
1.8 pts worse
|
3.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.4% · Q3 6.3% · Q4 9.0% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
4.4%
1.5 pts better
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.3% · Q3 1.5% · Q4 1.6% · 4Q avg 2.9% |
| Percentage of long-stay residents who lose too much weight | 8.1% |
5.5%
2.6 pts worse
|
5.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 9.1% · Q3 5.1% · Q4 12.3% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.6% |
17.4%
5.8 pts better
|
19.6%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 13.0% · Q3 11.5% · Q4 12.3% · 4Q avg 11.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.1% |
23.4%
7.3 pts better
|
16.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 15.0% · Q3 15.0% · Q4 11.7% · 4Q avg 16.1% · 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 | 17.2% |
19.0%
1.8 pts better
|
16.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 15.5% · Q3 11.0% · Q4 18.9% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.1% |
20.1%
4 pts worse
|
14.9%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 18.6% · Q3 26.8% · Q4 19.7% · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.8%
0.8 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 3.2% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
3.1%
About the same
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 6.4% · Q3 2.5% · Q4 2.6% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.8% |
25.2%
5.6 pts worse
|
19.8%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 28.2% · Q3 37.2% · Q4 31.2% · 4Q avg 30.8% |
| Percentage of long-stay residents with pressure ulcers | 12.5% |
5.3%
7.2 pts worse
|
5.1%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 12.0% · Q3 12.7% · Q4 11.8% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.0% |
93.6%
1.6 pts worse
|
81.7%
10.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 93.1% · Q3 100.0% · Q4 90.9% · 4Q avg 92.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
10.7%
1.1 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 9.1% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.8% |
88.3%
5.5 pts worse
|
79.7%
3.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.1% |
20.5%
3.4 pts better
|
23.9%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 13.6% · Expected 19.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-07 · Fire 2023-12-07
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-17 · Fire 2022-11-17
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-02-05
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-02-24
G · Actual harm
2024-02-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-07
E · Potential for more than minimal harm
2023-12-07
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 2024-01-08
D · Potential for more than minimal harm
2023-12-07
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-07
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-07
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-07
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-08
L · Immediate jeopardy
2022-11-17
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 2022-12-27
E · Potential for more than minimal harm
2022-11-17
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-12-23
E · Potential for more than minimal harm
2022-11-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-12-23
E · Potential for more than minimal harm
2022-11-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-23
D · Potential for more than minimal harm
2022-11-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-12-27
D · Potential for more than minimal harm
2022-11-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-27
D · Potential for more than minimal harm
2022-11-17
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2022-12-23
D · Potential for more than minimal harm
2022-11-17
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-12-23
D · Potential for more than minimal harm
2022-11-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-12-23
D · Potential for more than minimal harm
2022-11-17
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 2022-12-23
Penalties and ownership
What sits behind the stars
Ownership
Furuseth, Peter
Corporate Director · Individual
Hahn, Lori
Corporate Director · Individual
Haug, Arlis
Corporate Director · Individual
Kjos, Kenneth
Corporate Director · Individual
Kjos, Kenneth
Corporate Officer · Individual
Kuester, Lyle
Corporate Director · Individual
Peterson, Tammra
W-2 Managing Employee · Individual
Schmit, Aaron
Corporate Director · Individual
Schmit, Aaron
Corporate Officer · Individual
Skogen, Alvina
Corporate Director · Individual
Sorenson, Cindy
W-2 Managing Employee · Individual
Sundet, Margaret
Corporate Director · Individual
Sundet, Margaret
Corporate Officer · Individual
Wilt, Joel
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Mckenzie County Healthcare Systems Long Term Care
Watford City, ND
4-star overall rating with 3-star inspections with $6,300 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Tioga Medical Center Ltc
Tioga, ND
2-star overall rating with 3-star inspections with $11,408 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Sidney Health Center Extended Care
Sidney, MT
1-star overall rating with 1-star inspections with $92,925 in total fines with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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