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
Staffing
Hours and turnover
RN hours / resident day
0.74
Registered nurse staffing
LPN hours / resident day
0.73
Licensed practical nurse staffing
Aide hours / resident day
3.46
Nurse aide staffing
Weekend hours
4.40
Weekend nurse staffing
RN turnover
16%
Annual RN turnover
Total nurse turnover
39%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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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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