Bethel Lutheran Nursing & Rehabilitation Center

Inspectors wrote1. Based on record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for 1 of 1 closed record (Resident #85) with an identified breast lump. Failure to ensure follow up on the identified breast abnormality prevented timely treatment interventions.

Inspectors wroteBased on observation, record review, review of facility policies, and staff interviews, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's dignity for 2 of 2 sampled residents (Resident #18 and #47) and 2 supplemental residents (Resident #74 and #76) observed during meals and 1 of 1 sampled resident (Resident #56) who requested assistance in their room. Failure to treat residents with dignity and respect has the potential to affect the residents' psychosocial wellbeing and does not enhance their quality of life.

Inspectors wroteBased on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 3 of 6 residents (Resident #3, #12 and #77) observed during medication administration. Four medication errors occurred during staff administration of 27 medications, resulting in a 14 percent error rate. Failure to follow physician's orders and/or pharmacy recommendations may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 4 of 18 sampled residents (Resident #1, #3, #12, #34, and #56) and 1 supplemental resident (Resident #77) observed during toileting cares and medication preparation and administration. Failure to practice infection control standards related to hand hygiene, glove use, and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to notify the physician or resident's representative for 1 of 1 closed records (Resident # 85) reviewed for change in breast tissue. Failure to notify the resident's representative and physician of an identified breast abnormality does not allow the representative or physician to be fully informed of the resident's care, current status, and to make informed decisions regarding medical care. Findings Include:Review of the facility policy titled Change in a Resident's Condition or Status occurred on 04/16/26. This policy, reviewed March 2026, stated, 2. Unless otherwise instructed by the resident. the Neighborhood Nurse Manager (or designee) or Social Worker will notify the resident's next of kin or representative (sponsor) when: . b. [...]

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #48) reviewed for abuse. Failure to provide the necessary services to protect residents from physical abuse resulted in a bruise to Resident #48's arm. Failure to protect all residents from physical abuse placed all residents at risk for psychosocial harm and/or injury.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from restraints for 1 of 1 sampled resident (Resident #9) reviewed for restraints. Failure to ensure staff refrained from using a manual method of restraining a resident placed Resident #9 at risk for increased behaviors, fear, anxiety, and injury. Findings Include:Review of the facility policy titled Use of Physical Restraints occurred on 04/16/26. This policy, dated February 2026, stated, . all residents have the right to be free from any physical restraints . Within 72 hours the interdisciplinary team must be notified of the application of the restraint so that they may complete a follow-up evaluation and determine the need to initiate the non-emergency physical restraint procedure. Review of Resident #9's medical record occurred on all days of survey. [...]

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to report incidents of potential abuse to officials including the State Survey Agency (SSA) for 3 of 3 sampled residents (Resident #9, #42, and #48) with allegations of physical or sexual abuse. Failure to report incidents of potential physical or sexual abuse to the State agency placed all residents at risk of abuse, mental and emotional distress, and or physical injury.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to thoroughly investigate alleged violations of possible abuse for 3 of 3 sampled residents (Resident #9, #42, and #48) subjected to physical abuse, sexual abuse, and restraint use. Failure to thoroughly investigate allegations of abuse, implement corrective actions, and evaluate the effectiveness of those actions, placed all residents at risk of abuse, mental/emotional distress, and physical injury.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the State Long Term Care Ombudsman with a written notice of discharge for 1 of 1 closed record (Resident #81) reviewed for facility discharge. Failure to notify the State Ombudsman does not provide residents with access to an advocate who can inform them of their options and rights, and to provide them with protection from being discharged inappropriately.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 1 of 18 sampled residents (Resident #9). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observation, record review, review of facility policy, review of manufacturer's instruction manual, and staff interview, the facility failed to ensure staff used a mechanical lift appropriately for 1 of 4 sampled residents (Resident #48) observed during sit-to-stand lift transfers. Failure to ensure staff used the mechanical lift according to manufacturer's instructions placed Resident #48 at risk for pain/discomfort and/or injury.

Inspectors wroteBased on observation, record review, review of facility policy, review of the dialysis communications forms, and resident and staff interview, the facility failed to provide care and services consistent with professional standards of practice for 1 of 1 sampled resident (Resident #63) receiving hemodialysis. Failure to receive dialysis treatment communication on a consistent basis and complete post-dialysis assessments may result in an unidentified change in the resident's condition.

Inspectors wroteBased on observation, review of professional reference, and staff interview, the facility failed to ensure medication labels matched provider's orders for 1 of 2 residents (Resident #3) observed for insulin administration. Failure to ensure medication labels matched the provider's orders placed the resident at risk for medication errors.

Inspectors wroteBased on record review, review of facility policy, and resident and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 3 of 18 sampled residents (Residents #50, #55, and #63) and 1 supplemental resident (Resident #81). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment for 2 of 18 sampled residents (Resident #78 and Resident #285) reviewed for advanced directives. Failure to ensure all methods of communication and/or documentation of code status accurately reflected the resident/resident representative wishes has the potential to limit access to life-sustaining services or unwanted treatment.

Inspectors wroteBased on record review, review of facility investigation, review of the facility policies, and staff interviews, the facility failed to ensure adequate supervision and assistance for 1 of 3 sampled residents (Resident #3) who required staff assistance and sit to stand mechanical lift transfers. Failure to provide adequate assistance as care planned for transfers may have resulted in Resident #3's fracture and placed all residents requiring assistance for transfers at risk for injuries.

Inspectors wroteBased on observation, and review of facility policy, the facility failed to ensure safe and secure storage of narcotic medications for 2 of 4 medication carts (Harmony and Wheatland Units). Failure to store medications securely may result in unauthorized access to medications and/or medication errors.

Inspectors wroteBased on record review and staff interview, the facility failed to provide a bed hold notice to 2 of 5 sampled residents (Residents #15 and #79) reviewed with a hospital transfer. Failure to provide a bed hold notice does not allow the residents and/or their representatives to make an informed decision regarding their rights.

Inspectors wroteBased on record review, review of the North Dakota Provider Manual for Preadmission Screening and Resident Review (PASRR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 2 of 4 sampled residents (Resident #2 and Resident #63) reviewed for PASRR. Failure to complete a change in status assessment for a newly diagnosed mental illness may result in the delivery of care and services that are inconsistent with residents' needs.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the current status for 3 of 21 sampled residents (Resident #1, #43, and #89). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care and safety.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment/services to promote the healing of pressure ulcers for 1 of 3 sampled residents (Resident #64) identified with a pressure ulcer. Failure to routinely assess, monitor, and measure pressure ulcers may result in delayed healing of the pressure ulcer.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from unnecessary psychotropic medications for 1 of 3 sampled resident (Resident #9) who received an as needed (PRN) psychotropic. Failure to limit PRN psychotropic use to 14 days unless reevaluated by a practitioner placed the resident as risk of receiving unnecessary medications and experiencing adverse drug effects.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents records contained the hospice election form and the certification of a terminal illness for 1of 1 supplemental resident (Resident #74) receiving hospice services. Failure to obtain these documents limits staff's ability to ensure coordination of care between the facility and the hospice.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 3 of 6 sampled residents (Resident #32, #43 and #54) on precautions. Failure to practice infection control standards related to use of personal protective equipment (PPE) and perineal cares has the potential to spread infection throughout the facility. Findings Include: PERSONAL PROTECTIVE EQUIPMENT - Observation on 12/05/23 at 9:16 a.m. showed a sign outside Resident #43's room door that stated, Entering the room: Hand hygiene with sanitizer; Isolation gown; Use N-95 [type of mask]; Place tear away goggles on; gloves; enter room. Observation showed two certified nurse aides (CNAs) (#12 and #13) entered Resident #43's room without an isolation gown, N-95 mask, or goggles. Staff failed to wear PPE upon entering Resident #43's room. [...]