Cycle 1
Health 2025-03-12 · Fire 2025-03-12
2 health deficiencies
Top issue: Infection Control (1 deficiency)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Goessel, KS
Bethesda Home
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
408 E Main, Goessel, KS
(620) 367-2291
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
57
Certified beds
Average residents
30
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-01-01
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
0.79
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.72
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.52
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.79
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.74
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
5.16
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
63
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
90.26
Composite VBP score used to determine payment impact.
Payment multiplier
1.0273
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
8.05
Baseline 32.50% · Performance 30.77% · Measure score 8.05 · Achievement 8.05 · Improvement 1.76
Adjusted total nurse staffing
10
Baseline 5.61 hours · Performance 6.25 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 9 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5.36% |
8.2%
2.8 pts worse
|
Numerator 6 · Denominator 112 |
| Staff flu vaccination coverage | 32.52% |
42%
9.5 pts worse
|
Numerator 40 · Denominator 123 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.2
1.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
91.8%
7.2 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 96.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
95.5%
0.7 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
4.4%
4.4 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.6%
5.6 pts better
|
11.4%
11.4 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 who lose too much weight | 4.8% |
5.0%
0.2 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 5.0% · Q3 0.0% · Q4 4.5% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.3% |
23.2%
8.9 pts better
|
19.6%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 15.0% · Q3 15.0% · Q4 9.1% · 4Q avg 14.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.7% |
19.8%
4.1 pts better
|
16.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 12.3% |
18.4%
6.1 pts better
|
16.3%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.0% |
18.8%
2.8 pts better
|
14.9%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q4 19.0% · 4Q avg 16.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.3% |
3.1%
2.2 pts worse
|
1.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 8.3% · Q3 4.5% · Q4 4.2% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.4% |
23.2%
3.8 pts better
|
19.8%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 23.8% · Q3 15.8% · Q4 14.7% · 4Q avg 19.4% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
4.6%
2.1 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 13.6% · Q4 9.0% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.9% |
75.6%
15.3 pts better
|
81.7%
9.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 91.3% · Q3 90.5% · Q4 85.7% · 4Q avg 90.9% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.0% |
73.5%
10.5 pts better
|
79.7%
4.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-07 · Fire 2023-06-07
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-12-14 · Fire 2021-12-14
3 health deficiencies
Top issue: Infection Control (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-12
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-05-17
F · Potential for more than minimal harm
2025-03-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-05-17
F · Potential for more than minimal harm
2025-03-12
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 2025-05-17
F · Potential for more than minimal harm
2025-03-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-17
F · Potential for more than minimal harm
2025-03-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-17
F · Potential for more than minimal harm
2025-03-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-17
F · Potential for more than minimal harm
2025-03-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-17
F · Potential for more than minimal harm
2025-03-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-17
F · Potential for more than minimal harm
2025-03-12
K771 · Miscellaneous Deficiencies
Fire Safety
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
Corrected 2025-05-17
F · Potential for more than minimal harm
2025-03-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-17
D · Potential for more than minimal harm
2025-03-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-17
F · Potential for more than minimal harm
2023-06-07
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-07-27
F · Potential for more than minimal harm
2023-06-07
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 2023-07-27
F · Potential for more than minimal harm
2023-06-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-27
F · Potential for more than minimal harm
2023-06-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-27
F · Potential for more than minimal harm
2023-06-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-27
E · Potential for more than minimal harm
2023-06-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-27
E · Potential for more than minimal harm
2023-06-07
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-07-27
F · Potential for more than minimal harm
2021-12-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-01-11
F · Potential for more than minimal harm
2021-12-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-11
F · Potential for more than minimal harm
2021-12-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-01-11
F · Potential for more than minimal harm
2021-12-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-01-11
F · Potential for more than minimal harm
2021-12-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-14
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-14
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 2022-01-11
D · Potential for more than minimal harm
2021-12-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-01-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-01
E · Potential for more than minimal harm
2025-03-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-04
F · Potential for more than minimal harm
2021-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-14
F · Potential for more than minimal harm
2021-12-14
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-01-14
C · Minimal harm
2021-12-14
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-01-14
Penalties and ownership
What sits behind the stars
Ownership
Banman, Darla
Corporate Director · Individual
Brubaker, Karl
Corporate Director · Individual
Buller, Lindsey
Corporate Director · Individual
Duerksen, Lynette
Corporate Director · Individual
Heidebrecht, Marci
W-2 Managing Employee · Individual
Hiebert, Sara
Operational/Managerial Control · Individual
Hiebert, Sara
Corporate Officer · Individual
Nafziger, Brendon
Corporate Director · Individual
Nickel, Denise
Corporate Director · Individual
Peters, Nicholas
Corporate Director · Individual
Regier, Stephanie
Corporate Director · Individual
Schmidt, Eileen
Corporate Director · Individual
Stucky, Nancy
Corporate Director · Individual
Unruh, Elaine
Corporate Director · Individual
Valdois, Christina
Operational/Managerial Control · Individual
Valdois, Christina
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Schowalter Villa
Hesston, KS
5-star overall rating with 5-star inspections with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Moundridge Manor
Moundridge, KS
5-star overall rating with 4-star inspections with $20,295 in total fines with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Parkside Homes
Hillsboro, KS
1-star overall rating with 1-star inspections with $72,818 in total fines with 19 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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