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Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 58 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
No Medicare penalties on record
This facility has areas of concern that warrant careful consideration. The latest standard survey recorded 14 findings, above the ND average of 5.4. We recommend asking the administrator directly: "How are you addressing recent staffing shortfalls?" These are not reasons to panic, but they are reasons to ask tough questions and visit in person.
Bethel Lutheran Nursing & Rehabilitation Center receives a high volume of positive feedback regarding the friendliness of the staff and the cleanliness of the facility. However, families should be aware of serious concerns regarding the security of personal belongings and communication issues with management during sensitive times like end-of-life care.
Quality Themes
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Concerns
Rating Trends
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Distribution · 62 analyzed
Personalized based on this facility's data
Key Review Excerpts
“My mother is in there and the ladies that take care of her are angels she loves it there in the Nelson Manor part”
“Staff is friendly, the residents are treated with respect, there are activities. The place was very clean and inviting.”
“My friends mother just passed and only 2 of the 7 rings she moved in with where given back the rest were stolen from her.”
This facility meets both EveryPlace staffing reference benchmarks. Higher staffing is generally associated with stronger day-to-day care.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
8
measures
7
measures
2
measures
Residents whose bladder or bowel control got worse
Residents needing more daily help over time
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on antipsychotic medication
Residents with pressure sores (bedsores)
Residents on anti-anxiety or sleep medication
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
Families have filed reports that triggered three inspections, indicating ongoing concerns at this facility. The most recurring issues involve medication management, care planning, and resident rights violations. While all deficiencies show correction dates, problems persist across multiple surveys from 2022 to 2025, suggesting systemic challenges that may require careful evaluation during any visit.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Pharmacy Service Deficiencies
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.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Rights Deficiencies
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.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Pharmacy Service Deficiencies
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.
Resident Rights Deficiencies
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.
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Pharmacy Service Deficiencies
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.
Administration Deficiencies
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.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Bethel Lutheran Nursing & Rehabilitation Center
nonprofit
Key personnel
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