Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethany On University during CMS and state inspections, most recent first.
A resident scheduled for surgery received warfarin (Coumadin) on two days when it should have been held, despite clear physician orders and documentation to withhold the medication. Facility staff confirmed the medication was not held as directed.
A facility failed to follow a physician's pre-operative medication orders for a resident, administering additional medications not approved for the day of surgery. This deviation from professional standards was identified during a review of the resident's medical records, highlighting a lapse in protocol adherence.
The facility failed to follow infection control standards for three residents with wounds, as staff did not use Enhanced Barrier Precautions (EBP) such as gowns during care activities. Observations showed a lack of EBP signage and improper gown use during dressing changes for residents with pressure ulcers and chronic wounds, leading to potential infection risks.
Failure to Hold Anticoagulant as Ordered Prior to Surgery
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not following physician's orders regarding the administration of warfarin (Coumadin). The resident had a surgical procedure scheduled, and preoperative orders directed staff to contact the Coumadin Clinic or prescribing provider about when to hold the medication. A progress note specified that Coumadin should be held from a certain date until after the procedure. Despite these orders, the resident received Coumadin on two days when it should have been withheld. An administrative nurse confirmed that staff did not hold the medication as ordered by the physician. Review of the resident's medical record and medication administration record confirmed the medication was administered contrary to the documented orders, and this was acknowledged by facility staff during an interview.
Failure to Follow Pre-Operative Medication Orders
Penalty
Summary
The facility failed to adhere to professional standards of practice by not following the physician's pre-operative medication orders for a resident scheduled for surgery. According to the physician's orders, certain medications were approved to be administered on the day of surgery, while all others were to be held. However, the facility staff administered additional medications that were not approved by the physician, including furosemide, Calcium plus Vitamin D, Cholecalciferol, and Acidophilus, on the morning of the surgery. This oversight was identified during a review of the resident's medical records, which included both electronic and paper documentation. The failure to hold these medications as per the physician's explicit instructions represents a departure from competent nursing practice, as outlined in the professional reference, Kozier & Erb's Fundamentals of Nursing. This incident highlights a critical lapse in following established protocols for medication administration prior to surgery, potentially compromising the resident's safety.
Infection Control Lapses in Wound Care
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for three residents receiving treatment for wounds or pressure ulcers. Resident #34 had an unstageable pressure ulcer on the coccyx, and observations revealed that staff did not use Enhanced Barrier Precautions (EBP) such as gowns during care activities. Despite the presence of a wound, there was no signage indicating EBP on the resident's door or in the room, and staff members were observed performing care without donning gowns. Resident #88 had multiple chronic ulcers on the lower extremities, and similar lapses in infection control were noted. A staff nurse was observed performing a dressing change without wearing a gown, despite the presence of open and weeping wounds. Again, there was no EBP signage on the resident's door or in the room, indicating a lack of adherence to infection control protocols. Resident #139 had a necrotic abdominal wound that had been debrided and was being packed twice daily. The resident reported that nurses wore gloves but not gowns during dressing changes. Observations confirmed the absence of EBP signage and the lack of gown use by staff. The nurse manager stated that the resident was not on precautions, which contributed to the failure to implement appropriate infection control measures.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fargo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Meadows On University | 0.8 mi | — | 2 | 0 |
| Smp Health - St Catherine South | 1.4 mi | — | 0 | 0 |
| Smp Health - St Catherine North | 1.6 mi | — | 4 | 0 |
| Eventide Lutheran Home | 1.6 mi | — | 1 | 0 |
| Bethany On 42nd | 3 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.