Mitchell County Hospital Health Systems Ltcu
400 W 8th Street, Beloit, KS 67420
Mitchell County Hospital Health Systems Ltcu is a nursing home in Beloit, Kansas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 4 of 5CMS overall star rating
- 5 of 5CMS health inspection star rating
- 5 of 5CMS staffing star rating
- 1 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (785) 738-9590
- Last standard health inspection
- February 6, 2025 (1 year ago)
- Certified beds
- 36
- Residents per day, on average
- 32.5
- Ownership type
- Government - County
- Legal business name
- Mitchell County Hospital Health Systems
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Kansas average (14 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of April 30, 2025
Star rating
The CMS health inspection star rating changed from 4 of 5 to 5 of 5.
2 citations
Health inspection on February 6, 2025
CMS lists this as a standard inspection.
Citation F0882. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS lists it as corrected on March 25, 2025.
Citation F0700. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Try 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.
CMS lists it as corrected on March 25, 2025.
9 citations
Fire safety inspection on February 6, 2025
CMS lists this as a standard inspection.
Citation K0293. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on April 11, 2025.
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on April 11, 2025.
Citation K0343. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
CMS lists it as corrected on April 11, 2025.
Citation K0511. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on April 11, 2025.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on April 11, 2025.
CMS has cited this home for K0712 2 times since 2023.
Citation K0771. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
CMS lists it as corrected on April 11, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on April 11, 2025.
CMS has cited this home for K0918 2 times since 2023.
Citation K0345. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on April 11, 2025.
CMS has cited this home for K0345 3 times since 2021.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 11, 2025.
CMS has cited this home for K0353 3 times since 2021.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.5 to 4.0 hours per resident per day.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 5 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
8 citations
Health inspection on May 31, 2023
CMS lists this as a standard inspection.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on June 29, 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on June 29, 2023.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on June 29, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 29, 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on June 29, 2023.
Citation F0744. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on June 29, 2023.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on June 29, 2023.
CMS has cited this home for F0756 2 times since 2021.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 29, 2023.
CMS has cited this home for F0758 2 times since 2021.
10 citations
Fire safety inspection on May 31, 2023
CMS lists this as a standard inspection.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on August 8, 2023.
Citation K0372. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on August 8, 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on August 8, 2023.
Citation K0753. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have restrictions on the use of highly flammable decorations.
CMS lists it as corrected on August 8, 2023.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on August 8, 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on August 8, 2023.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on August 8, 2023.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 8, 2023.
Citation K0914. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on August 8, 2023.
Citation K0911. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on August 8, 2023.
4 citations
Health inspection on November 22, 2021
CMS lists this as a standard inspection.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 16, 2021.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 16, 2021.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on December 16, 2021.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 16, 2021.
5 citations
Fire safety inspection on November 22, 2021
CMS lists this as a standard inspection.
Citation E0023. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures for medical documentation.
CMS lists it as corrected on December 22, 2021.
Citation E0024. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures for volunteers.
CMS lists it as corrected on December 22, 2021.
Citation K0225. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
CMS lists it as corrected on December 22, 2021.
Citation K0345. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on December 22, 2021.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on December 22, 2021.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- MITCHELL COUNTY HOSPITAL HEALTH SYSTEMSDirect ownership interest · not applicable · since 07/01/2005
- MITCHELL COUNTY HOSPITAL HEALTH SYSTEMSOperational/managerial control · not applicable · since 07/01/2005
- CLEVELAND, NICKIOperational/managerial control · not applicable · since 06/02/2015
- EILERT, LEANNEOperational/managerial control · not applicable · since 10/07/1999
- GAVINO, LUIGIOperational/managerial control · not applicable · since 06/26/2023
- KIRCHER, JANELLEOperational/managerial control · not applicable · since 02/07/2023
- MAROZAS, CHRISTINEOperational/managerial control · not applicable · since 01/01/2021
- SIMMONS, STEPHANIEOperational/managerial control · not applicable · since 11/18/2010
Questions
When was Mitchell County Hospital Health Systems Ltcu last inspected?
CMS lists February 6, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Mitchell County Hospital Health Systems Ltcu have?
CMS lists 14 health citations since November 22, 2021. CMS also calls these deficiencies.
Has Mitchell County Hospital Health Systems Ltcu been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Mitchell County Hospital Health Systems Ltcu?
Its CMS overall star rating is 4 of 5.
Is Mitchell County Hospital Health Systems Ltcu a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.