Bethany on University

In the surveyor’s words

From the most serious findings on record at Bethany on University, in the surveyor’s own words.

• Actual harm, isolatedF563Oct 26, 2023

  Based on observation, record review, review of the North Dakota Resident Rights Resident Guide, and resident, staff, and family interviews, the facility failed to respect the resident right to have visitors of their choosing and at the time of their choosing for 1 of 1 sampled resident (Resident #136) and 1 supplemental resident (Resident #96), a married couple whose visitation was discontinued due to behaviors and ended in one resident transferred to another facility. Failure to ensure visitation rights are respected may have been the cause and/or increase of behaviors and/or emotional distress, which negatively impacted the psychosocial well-being of both residents. […]

• No harm, potential for more than minimal, patternF689Aug 5, 2021

  Based on observation, record review, review of a professional reference, and staff interview, the facility failed to ensure resident safety for 1 of 2 locked memory care units (Third floor Willow) with unsecured electrical cords. Failure to secure electrical cords has the potential to affect 28 residents on the unit at risk for injury. Findings include: The facility failed to provide a copy of their policy addressing potential fall hazards for residents as requested. Kozier and Erb's Fundamental of Nursing Concepts, Process, and Practice, 11th edition, 2020, page 703, stated, . causes of falls . presence of electrical cords unsecured . people with impaired cognition . vision deficits . […]

• No harm, potential for more than minimal, isolatedF627Feb 12, 2026

  Based on record review and review of facility policy the facility failed to provide the resident or resident representative with written discharge instructions for 1 of 2 sampled residents (Resident #190) who were discharged . Failure to provide written discharge instructions to residents leaving the facility may affect the continued health and safety of the residents discharged to the community.Findings include:Review of the facility policy titled TRANSFER AND DISCHARGE POLICY (including AMA [against medical advice) occurred on 02/12/26. This policy, revised February 2020, stated, . […]

• No harm, potential for more than minimal, isolatedF628Feb 12, 2026

  Based on record review, review of facility policy, and staff interview, the facility failed to provide the State Long Term Care Ombudsman a written notice of transfer/discharge for 1 of 5 closed records (Resident #177) reviewed for discharge. Failure to notify the State Ombudsman of resident discharges does not allow the State Ombudsman to advocate for the resident and/or their representative regarding their options and rights. Findings include:Review of the facility policy titled Transfer And Discharge Policy occurred on 02/12/26. This policy, dated February 2020, stated, . Contents of the notice must include: The reason for transfer or discharge; The effective date of transfer or discharge; . […]

• No harm, potential for more than minimal, isolatedF880Feb 12, 2026

  Based on observation, record review, review of facility policy, and staff interviews, the facility failed to follow infection control standards for 3 of 8 sampled residents (Residents #11, #94, and #118) on enhanced barrier precautions (EBP). Failure to follow infection control practices has the potential to spread infection throughout the facility. Findings Include: Review of the facility policy titled, Hand Hygiene occurred on 02/12/26. This policy revised February 2021, stated, . Hand Hygiene Table . after removing personal protective equipment (PPE), including gloves . [cleanse hands with] Either Soap and Water or Alcohol Based Hand Rub . Review of the facility policy titled, Infection Control - Enhanced Barrier Precautions occurred on 02/12/26. This policy revised May 2025, stated, . […]