Bethel Lutheran Nursing & Rehabilitation Center
1515 2nd Ave West, Williston, ND 58801 · Williams County · 90 certified beds · avg 75 residents/day · certified since Aug 1, 1978
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Apr 16, 2026 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 18, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 7, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 7, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (25)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 16, 2026 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 16, 2026 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Apr 16, 2026 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Apr 16, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 16, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Apr 16, 2026 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Apr 16, 2026 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Apr 16, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Apr 16, 2026 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Apr 16, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Apr 16, 2026 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Apr 16, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 16, 2026 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Apr 16, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 5, 2025 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Feb 5, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint |
| Feb 7, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 7, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Dec 7, 2023 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Dec 7, 2023 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Dec 7, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Dec 7, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Dec 7, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Dec 7, 2023 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Dec 7, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 14).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 8 | 0 | E |
| 2024 | 1 | 1 | G ▲ |
| 2025 | 2 | 0 | E |
| 2026 | 14 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | North Dakota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.18 | 5.15 | 3.95 | top 47% in North Dakota; top 11% in the U.S. |
| Registered Nurse hours | 1.17 | 1.09 | 0.69 | top 33% in North Dakota; top 10% in the U.S. |
| Weekend total nurse staffing | 4.25 | 4.43 | 3.50 | bottom 37% in North Dakota; top 17% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.78 | 0.59 | 0.48 | top 17% in North Dakota; top 12% in the U.S. |
| Total nursing staff turnover (%) | 63.0 | 48.8 | 45.8 | bottom 17% in North Dakota; bottom 12% in the U.S. |
| RN turnover (%) | 50.0 | 40.3 | 42.9 | bottom 31% in North Dakota; bottom 39% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.81, RN 1.09, weekend 3.95. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 2/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bethel Lutheran Nursing & Rehabilitation Center | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/1966 |
| Axtman, Pat | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/01/2024 |
| Bethel Lutheran Nursing & Rehabilitation Center | Organization | Operational/Managerial Control | NOT APPLICABLE | 09/21/2021 |
| Braaten, Richard | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/01/2021 |
| Geltel, Kelsey | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/01/2021 |
| Hanson, Tina | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/01/2021 |
| Harper, John | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/01/2023 |
| Jorgenson, Jenny | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/01/2025 |
| McKenzie, James | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/01/2022 |
| Moen, Belinda | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/21/2021 |
| Moen, Belinda | Individual | ADP of the SNF | NOT APPLICABLE | 09/21/2021 |
| Osborn, Robert | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/01/2022 |
| Sickinger, Tiffany | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2021 |
| Sickinger, Tiffany | Individual | ADP of the SNF | NOT APPLICABLE | 11/01/2021 |
| Siewert, Ryan | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/19/2025 |
| Siewert, Ryan | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2023 |
| Weyrauch, Denise | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/01/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your policy on physical restraints, and what alternatives do you try first?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| McKenzie County Healthcare Systems Long Term Care | 29.6 mi | Watford City, ND | ★★★☆☆ | 3/5 | |
| Tioga Medical Center LTC | 36.3 mi | Tioga, ND | ★★★☆☆ | 4/5 | |
| Sidney Health Center Extended Care | 39.4 mi | Sidney, MT | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 355070.