MITCHELL COUNTY HOSPITAL HEALTH SYSTEMS LTCU

BELOIT, KS · 36 beds · Government - County

100 Trust Score
Grade: A+ LOW Risk → Stable

Red Flags

No red flags identified.

Green Flags

  • 5-star health inspection rating
  • 5-star staffing rating
  • Below-average deficiency count (2 vs 10 state avg)
  • No fines or penalties on record
  • Above-average RN staffing (1.26 hrs vs 0.80 state avg)

Quick Facts

★★★★☆
CMS Overall
★★★★★
Health Inspection
2
0.2x state avg
Deficiencies
$0
Fines (3-yr)
★★★★★
Staffing

Violation Timeline

February 5, 2025

6 deficiencyies
F0700 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

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.

F0882 Potential Harm Scope/Severity: E

Infection Control Deficiencies

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Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

F0700 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

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.

F0882 Potential Harm Scope/Severity: E

Infection Control Deficiencies

Show details

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

F0700 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

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.

F0882 Potential Harm Scope/Severity: E

Infection Control Deficiencies

Show details

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

May 30, 2023

14 deficiencyies
F0610 Potential Harm Scope/Severity: D

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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Respond appropriately to all alleged violations.

F0656 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

F0657 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

F0689 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

F0692 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

Provide enough food/fluids to maintain a resident's health.

F0744 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

F0756 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

F0758 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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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.

F0610 Potential Harm Scope/Severity: D

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Show details

Respond appropriately to all alleged violations.

F0656 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

Show details

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

F0657 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

Show details

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

F0689 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

F0692 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

Provide enough food/fluids to maintain a resident's health.

F0744 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

See full violation history →

Staffing

1.26
RN hrs/res/day
0.66
LPN hrs/res/day
3.35
CNA hrs/res/day
4.30
Weekend hrs/res/day
42%
Total nurse turnover
33%
RN turnover

A nurse checks on each resident roughly every 4.5 hours on average.

Fines & Penalties

No fines or penalties on record.

Ownership

Government - County Independent (not part of a chain)
  • MITCHELL COUNTY HOSPITAL HEALTH SYSTEMS

    5% OR GREATER DIRECT OWNERSHIP INTEREST

    Since since 07/01/2005

    100% Organization
  • MITCHELL COUNTY HOSPITAL HEALTH SYSTEMS

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 07/01/2005

    Organization
  • CLEVELAND, NICKI

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 06/02/2015

    Individual
  • EILERT, LEANNE

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 10/07/1999

    Individual
  • GAVINO, LUIGI

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 06/26/2023

    Individual
  • KIRCHER, JANELLE

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 02/07/2023

    Individual
  • MAROZAS, CHRISTINE

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 01/01/2021

    Individual
  • SIMMONS, STEPHANIE

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 11/18/2010

    Individual

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