Bethany On 42nd
4255 30th Ave S, Fargo, ND 58104


Bethany On 42nd is nursing home registered in the Centers for Medicare & Medicaid Services (CMS). The Provider Number is 355123. The address is 4255 30th Ave S, Fargo, ND 58104. The zip code is 58104. The phone number is 7014788900.


Bethany On 42nd · 4255 30th Ave S, Fargo, ND 58104

Federal Provider Number 355123
Provider Name BETHANY ON 42ND
Address 4255 30TH AVE S
FARGO, ND 58104
Phone Number 7014788900
SSA County Code 80
County Name Cass
Ownership Type Non profit - Corporation
Certified Beds 116
Certified Beds Residents 111
Provider Type Medicare and Medicaid
Resides in Hospital false
Legal Business Name BETHANY ON 42ND
Date First Approved to Provide Medicare Medicaid Services 01/20/2010
Continuing Care Retirement Community false
Special Focus Facility false
Most Recent Health Inspection More Than 2 Years Ago false
Changed Ownership Last 12 Months false
With Resident Family Council Resident
Automatic Sprinkler Systems in All Required Areas Yes
Overall Rating 5
Health Inspection Rating 4
Quality Measure Rating 5
Staffing Rating 5
RN Staffing Rating 5
Reported CNA Staffing Hours per Resident per Day 3.60811
Reported LPN Staffing Hours per Resident per Day 0.86802
Reported RN Staffing Hours per Resident per Day 0.98288
Reported Licensed Staffing Hours per Resident per Day 1.8509
Reported Total Nurse Staffing Hours per Resident per Day 5.45901
Reported Physical Therapist Staffing Hours per Resident Per Day 0.08604
Expected CNA Staffing Hours per Resident per Day 2.52915
Expected LPN Staffing Hours per Resident per Day 0.61076
Expected RN Staffing Hours per Resident per Day 0.99188
Expected Total Nurse Staffing Hours per Resident per Day 4.13179
Adjusted CNA Staffing Hours per Resident per Day 3.50048
Adjusted LPN Staffing Hours per Resident per Day 1.17961
Adjusted RN Staffing Hours per Resident per Day 0.74042
Adjusted Total Nurse Staffing Hours per Resident per Day 5.32572
Cycle 1 Total Number of Health Deficiencies 2
Cycle 1 Number of Standard Health Deficiencies 2
Cycle 1 Health Deficiency Score 12
Cycle 1 Standard Survey Health Date 01/26/2017
Cycle 1 Number of Health Revisits 1
Cycle 1 Total Health Score 12
Cycle 2 Total Number of Health Deficiencies 5
Cycle 2 Number of Standard Health Deficiencies 5
Cycle 2 Health Deficiency Score 36
Cycle 2 Standard Health Survey Date 02/04/2016
Cycle 2 Number of Health Revisits 1
Cycle 2 Total Health Score 36
Cycle 3 Total Number of Health Deficiencies 9
Cycle 3 Number of Standard Health Deficiencies 9
Cycle 3 Number of Complaint Health Deficiencies 9
Cycle 3 Health Deficiency Score 48
Cycle 3 Standard Health Survey Date 12/18/2014
Cycle 3 Number of Health Revisits 1
Cycle 3 Total Health Score 48
Total Weighted Health Survey Score 26
Number of Substantiated Complaints 1
Total Amount of Fines in Dollars $0.00
Processing Date 08/01/2017

Owner or Manager · Bethany On 42nd

Owner Name Role Association Date
BETHANY HOMES, INC (Organization) 5% OR GREATER DIRECT OWNERSHIP INTEREST
100%
since 08/20/2007
BETHANY ON 42ND (Organization) OPERATIONAL/MANAGERIAL CONTROL since 01/14/2010
BOKINSKIE, JEAN (Individual) OFFICER since 04/01/2012
BRANTNER-ADAMS, JERILYNN (Individual) DIRECTOR since 04/01/2011
ERICKSON, ALLAN (Individual) DIRECTOR since 04/01/2013
GLATT, DAVID (Individual) DIRECTOR since 06/23/2009
HEIDEN, STACIE (Individual) DIRECTOR since 04/01/2013
HERTSGAARD, JOHN (Individual) DIRECTOR since 04/01/2012
HERTSGAARD, JOHN (Individual) OFFICER since 04/01/2014
HOVLAND SHERIDAN, ANNE (Individual) DIRECTOR since 09/01/2014
MCCAUL, HARRIETTE (Individual) DIRECTOR since 04/01/2010
OHALLORAN, LINDA (Individual) DIRECTOR since 04/01/2013
OLSON, ROGER (Individual) DIRECTOR since 04/01/2012
OLSON, ROGER (Individual) OFFICER since 04/01/2014
SMITH, LLOYD (Individual) DIRECTOR since 06/23/2009
SMITH, LLOYD (Individual) OFFICER since 04/01/2013
STUHAUG, SHAWN (Individual) MANAGING EMPLOYEE since 06/23/2009

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