Mitchell County Hospital Health Systems Ltcu
400 W 8th Street, Beloit, KS 67420 · Government - County · 36 certified beds · (785) 738-9590 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- its facility-reported quality-measure rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 37.4% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.1% | 4.9% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 5.3% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 11.9% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 6.5% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 7.5% | 4.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 25.2% | 16.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 37.1% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.5% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.1% | 22.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.2% | 18.1% | 17.1% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.23 | 1.80 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.10 | 2.13 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Staffing
How full it usually is: this home is certified for 36 beds and averages 32.7 residents a day — about 91% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.79 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.30 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.16 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.03 hrs/resident/day on weekends vs 5.09 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.52 to 0.77 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 28% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
14 citations, most serious first — scroll within the box to see all.
- Potential for harm · E2025-02-06 · tag F0882 — patternDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility had a census of 33 residents. Based on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This placed the residents at risk for lack of identification and treatment of infections. Findings included: - On 02/07 /25 at 01:30 PM, Administrative Nurse F stated she was responsible for the Infection Prevention and Control Program and lacked certification as an Infection Preventionist. Administrative Nurse E stated she had enrolled in the program, and completed the training modules, but had not received the certification. The Infection Prevention Plan policy dated 09/24/24, documented the infection prevention committee including the Infection Preventionist would implement, develop, and update the infection prevention policies and procedures, and educate and train faculty and staff. The Infection Preventionist would also assess competency of tasks, compliance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-06 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 33 residents. The sample included 12 residents with two reviewed for bed rail use. Based on observation, interview, and record review the facility failed to provide bed rails with gaps less than four and three-quarters inches per Food and Drug Administration (FDA) guidelines for safety. This deficient practice placed Resident (R) 2 and R13 at risk for injury. Findings included: - R2's Electronic Medical Record documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), delusional disorders (untrue persistent beliefs held by a person although evidence shows it was untrue), anxiety disorder (a mental or emotional disorder characterized by apprehension, uncertainty, and irrational fear), and insomnia (inability to sleep). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-31 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to thoroughly investigate two separate incidents of resident-to-resident incident between three sampled residents, Resident (R)26 and R8; R26 and R22 in another incident. This placed the residents at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record (EMR) for R26 documented diagnoses of dementia without behavioral disturbance, and delusional disorder (untrue persistent belief or perception healed by a person although evidence shows it was untrue). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R26 had severely impaired cognition and required limited assistance of one staff for bed mobility, transfers, toileting, and supervision and one staff assistance for ambulation. The MDS further documented R26 had verbal behaviors, other behaviors, and rejection of care one to three days, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-31 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan that included Resident (R)17's history of bowel obstruction (a gastrointestinal condition in which digested material is prevented from passing normally through the bowel) and interventions to prevent constipation (difficulty passing stool). This placed the resident at risk for impaction (the condition of being or process of becoming impacted, especially of feces in the intestine) and bowel obstruction. Findings included: -- The Electronic Medical Record (EMR) for R17 documented diagnoses of Alzheimer's disease (progressive mental deterioration due to generalized deterioration of the brain), anxiety (feeling of worry, nervousness, or unease), depression (persistent sadness and lack of interest or pleasure in previously rewarding or enjoyable activities), hypertension (high blood pressure) dementia without behavioral disturbance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-31 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to revise, with person centered interventions for falls, the care plan for two sampled residents, Resident (R) 17 and R26, and lacked direction in the plan of care to staff for anticoagulant (blood thinner) medication for R8. This placed the residents at risk for uncommunicated and unmet care needs. Findings included: - The Electronic Medical Record (EMR) for R17 documented diagnoses of Alzheimer's disease (progressive mental deterioration due to generalized deterioration of the brain), anxiety (feeling of worry, nervousness, or unease), depression (persistent sadness and lack of interest or pleasure in previously rewarding or enjoyable activities), hypertension (high blood pressure) and dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R17…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - R8's Electronic Medical Record documented diagnoses of osteoporosis (bone disease that develops when bone mineral density and bone mass decreases), cervicalgia (neck pain), hypertension (high blood pressure), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and atrial fibrillation (an irregular and often very rapid heart rhythm). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six, indicating severely impaired cognition. The MDS documented R8 required supervision for eating and extensive assistance of two staff for all other activities of daily living (ADL). The MDS documented R8 had range of motion (ROM) impairment in both legs, unsteady balance requiring assistance, used a wheelchair and had no falls in the lookback period. The MDS documented R8 had frequent severe pain, received scheduled pain medication, anticoagulant (blood thinning)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-31 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 12 residents with one reviewed for weight loss. Based on observation, interview, and record review the facility failed to implement interventions to prevent further weight loss after Resident (R)8 had a weight loss in February 2023 and continued to lose weight. This deficient practice placed R8 at risk for continued weight loss and malnutrition. Findings included: - R8's Electronic Medical Record documented diagnoses of osteoporosis (bone disease that develops when bone mineral density and bone mass decreases), cervicalgia (neck pain), hypertension (high blood pressure), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), gastro-esophageal reflux disease (occurs when stomach acid or bile flows into the food pipe and irritates the lining), atrial fibrillation (an irregular and often very rapid heart rhythm) and a history of Covid-19 (respiratory…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-31 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 12 residents, with two reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Based on observation, record review, and interview, the facility failed to provide the necessary dementia care and services for one sampled resident, Resident (R) 26, who had dementia related behaviors which significantly impacted R26 and other resident's quality of life. This placed the resident at risk for injury and unmet needs. Findings included: - The Electronic Medical Record (EMR) for R26 documented diagnoses of dementia without behavioral disturbance, and delusional disorder (untrue persistent belief or perception healed by a person although evidence shows it was untrue). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R26 had severely impaired cognition and required limited assistance of one staff for bed mobility, transfers, toileting, and supervision and one staff assistance for ambulation. The MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-31 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 12 residents with five residents reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure the consultant pharmacist identified and reported Resident (R) 16's as needed (prn) lorazepam (an antianxiety medication) lacked a stop date as required by Center for Medicare and Medicaid Services (CMS). This deficient practice placed R16 at risk for unnecessary medications. Findings included: - R16's Electronic Medical Record documented diagnoses including cervicalgia (neck pain), hypertension (high blood pressure), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and atrial fibrillation (an irregular and often very rapid heart rhythm). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-31 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 31 residents. The sample included 12 residents with five residents reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure Resident (R) 16's as needed (prn) lorazepam (an antianxiety medication) had a stop date as required by Center for Medicare and Medicaid Services (CMS). This deficient practice placed R16 at risk for adverse side effects related to psychotropic (altering mood or mind) medication use. Findings included: - R16's Electronic Medical Record documented diagnoses including cervicalgia (neck pain), hypertension (high blood pressure), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and atrial fibrillation (an irregular and often very rapid heart rhythm). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-11-22 · tag F0625 — isolatedNotify 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 27 residents. The sample included 12 residents of which one was reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide a copy of the facility bed hold policy to Resident (R) 10 or her representative for her facility-initiated hospitalization. Findings included: - The Quarterly Minimum Data Assessment (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) of eight, which indicated moderate cognitive impairment. The MDS documented the resident required extensive staff assistance with activities of daily living (ADLs) except supervision with eating. The ADL Care Plan, revised on 10/08/21, documented the resident required staff assistance with ADLs except set up assistance with eating. The Nurse's Note, dated 09/14/21 at 12:55 PM, documented the facility received a call from the physician and the resident was admitted to the hospital. The note documented the resident's family member was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-11-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 27 residents. The sample included 12 residents. Based on observation, interview and record review, the facility failed to assess one sampled Resident (R) 23, for bowel problems when the resident had no bowel movement (BM) for more than three days. Findings included: - R23's Physician's Orders, dated 09/29/21, included diagnoses of hypertension (high blood pressure), Parkinson's Disease (progressive nervous system disorder that affects movement), and Alzheimer's Disease (progressive disease that destroys memory and other important mental functions). The Quarterly Minimum Data Set (MDS), dated [DATE], documented Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS documented the resident required extensive staff assistance with all activities of daily living (ADLs) including toileting. The MDS documented the resident did not walk and was always incontinent of bowel. The ADL Care Plan, dated 09/28/21, directed staff to provide assistance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-11-22 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 27 residents. The sample included 12 residents with six reviewed for unnecessary medications. Based on observation, interview, and record review, the consultant pharmacist failed to notify the Director of Nursing, physician, and medical director of the requirement for a stop date for psychotropic medication (drug that affects behavior, mood, thoughts, or perception) ordered for Resident (R) 9. Findings included: - R9's Physician Orders documented a diagnosis of recurrent depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and did not include a diagnosis of anxiety (feeling of worry, nervousness, or unease). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS documented the resident was independent with most activities of daily living (ADLs) and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-11-22 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 27 residents. The sample included 12 residents with six reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure one sampled Resident (R) 9 did not receive psychotropic medication (drug that affects behavior, mood, thoughts, or perception) without a stop date. Findings included: - R9's Physician Orders, documented a diagnosis of recurrent depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and did not include a diagnosis of anxiety (feeling of worry, nervousness, or unease). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS documented the resident was independent with most activities of daily living (ADLs) and required supervision for eating and walking. The MDS further documented the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MITCHELL COUNTY HOSPITAL HEALTH SYSTEMS | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF | since 07/01/2005 |
| KIRCHER, JANELLE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2023 |
| MAROZAS, CHRISTINE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF | since 01/01/2021 |
| CLEVELAND, NICKI | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 06/02/2015 |
| EILERT, LEANNE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 10/07/1999 |
| GAVINO, LUIGI | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 06/26/2023 |
| SIMMONS, STEPHANIE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 11/18/2010 |
CMS files one row per role, so the 15 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
What families pay in KS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175505. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-06, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.