Cycle 1
Health 2025-12-10 · Fire 2025-12-10
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Willmar, MN
Bethesda
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
901 Southeast Willmar Avenue, Willmar, MN
(320) 262-5376
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
248
Certified beds
Average residents
223
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1987-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.74
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
3.46
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.93
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.47
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.40
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
5.81
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
16%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,428
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.83
Composite VBP score used to determine payment impact.
Payment multiplier
1.0039
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.59% · Performance 21.50% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.72
Baseline 5.33% · Performance 6.42% · Measure score 4.72 · Achievement 4.72 · Improvement 0
Total nurse turnover
5.21
Baseline 40.68% · Performance 42.39% · Measure score 5.21 · Achievement 5.21 · Improvement 0
Adjusted total nurse staffing
10
Baseline 5.65 hours · Performance 5.81 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.06% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 193 · Observed rate 8.81% · Lower 95% interval 7.23% |
| Discharge to community | 52.45% |
50.57%
1.9 pts better
|
No Different than the National Rate · Eligible stays 181 · Observed rate 48.07% · Lower 95% interval 44.1% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 176 · Denominator 176 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 176 |
| Discharge self-care score | 47.3% |
53.69%
6.4 pts worse
|
Numerator 70 · Denominator 148 |
| Discharge mobility score | 51.35% |
50.94%
0.4 pts better
|
Numerator 76 · Denominator 148 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 176 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.42% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 4.76% · Lower 95% interval 4.14% |
| Staff COVID-19 vaccination coverage | 13.41% |
8.2%
5.2 pts better
|
Numerator 68 · Denominator 507 |
| Staff flu vaccination coverage | 46.55% |
42%
4.5 pts better
|
Numerator 270 · Denominator 580 |
| Discharge function score | 56.76% |
56.45%
0.3 pts better
|
Numerator 84 · Denominator 148 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 67 · Denominator 67 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 52 · Denominator 52 |
| Resident COVID-19 vaccinations up to date | 55.29% |
25.2%
30.1 pts better
|
Numerator 47 · Denominator 85 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.0
0.7 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
97.3%
2.6 pts better
|
93.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.1% |
3.9%
5.2 pts worse
|
3.3%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 11.4% · Q3 7.9% · Q4 7.4% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
4.3%
2 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.8% · Q3 1.7% · Q4 2.9% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
4.1%
1.6 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.8% · Q3 5.1% · Q4 0.0% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.3% |
12.4%
2.1 pts better
|
19.6%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 10.8% · Q3 10.2% · Q4 10.4% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.2% |
17.5%
4.3 pts better
|
16.7%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 14.3% · Q3 11.4% · Q4 13.3% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.5% |
22.5%
About the same
|
16.3%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 22.0% · Q3 23.0% · Q4 16.9% · 4Q avg 22.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.4% |
18.6%
3.8 pts worse
|
14.9%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 24.2% · Q3 26.7% · Q4 21.2% · 4Q avg 22.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
2.3%
0.1 pts better
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.5% · Q3 1.9% · Q4 1.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
2.6%
0.7 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.1% · Q3 3.2% · Q4 3.2% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.7% |
24.8%
2.9 pts worse
|
19.8%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 27.2% · Q3 31.2% · Q4 21.3% · 4Q avg 27.7% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.4%
0.1 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.2% · Q3 6.0% · Q4 5.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
88.6%
10.8 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 99.5% · Q3 100.0% · Q4 98.6% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
14.0%
0.2 pts better
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 12.1% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.9%
1 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.7% · Q3 0.7% · Q4 0.7% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.1% |
82.7%
16.4 pts better
|
79.7%
19.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
23.1%
2.3 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 16.2% · Expected 18.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-25 · Fire 2024-10-25
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2024-01-24 · Fire 2024-01-24
4 health deficiencies
Top issue: Administration (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-02-02
F · Potential for more than minimal harm
2025-12-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-02-02
F · Potential for more than minimal harm
2025-12-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2026-02-02
E · Potential for more than minimal harm
2025-12-10
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2026-02-02
E · Potential for more than minimal harm
2025-12-10
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2026-02-02
E · Potential for more than minimal harm
2025-12-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2026-02-02
E · Potential for more than minimal harm
2025-12-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-02-02
D · Potential for more than minimal harm
2025-12-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-02-02
D · Potential for more than minimal harm
2025-12-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2026-02-02
F · Potential for more than minimal harm
2024-10-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-27
F · Potential for more than minimal harm
2024-10-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-27
E · Potential for more than minimal harm
2024-10-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-10-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-27
F · Potential for more than minimal harm
2024-01-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-23
E · Potential for more than minimal harm
2024-01-24
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-01
C · Minimal harm
2024-01-24
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-02-23
B · Minimal harm
2024-01-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-23
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-23
E · Potential for more than minimal harm
2025-12-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-12-10
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-12-10
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-12-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-23
G · Actual harm
2024-11-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-11-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-11-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-10-25
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-25
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-25
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-05-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-19
F · Potential for more than minimal harm
2024-01-24
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-02-23
F · Potential for more than minimal harm
2024-01-24
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-24
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-24
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-02-23
Penalties and ownership
What sits behind the stars
Ownership
Ahrenholz, Roger
Corporate Officer · Individual
Behm, Myron
Corporate Officer · Individual
Blonigan-Christianson, Joan
Corporate Director · Individual
Dykema, Luther
Corporate Officer · Individual
Gehant, David
Corporate Director · Individual
Gilson, Michael
Corporate Director · Individual
Gjerde, Tamala
Corporate Officer · Individual
Haefner, Michelle
Corporate Officer · Individual
Johnson, Cheryl
Corporate Director · Individual
Johnson, Dean
Corporate Director · Individual
Krieger, Baillee
Operational/Managerial Control · Individual
Kveene, Julie
Corporate Director · Individual
Pool, Cheryl
Corporate Officer · Individual
Quam, Samuel
Corporate Officer · Individual
Roiseland, Alan
Operational/Managerial Control · Individual
Strehlow, Betty
Corporate Officer · Individual
Tusha-Mohlin, Karen
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Cura Of Willmar
Willmar, MN
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Glenoaks Senior Living Campus
New London, MN
1-star overall rating with 1-star inspections with $43,219 in total fines with 18 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Clara City Care Center
Clara City, MN
2-star overall rating with 1-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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