Cycle 1
Health 2025-02-06 · Fire 2025-02-06
2 health deficiencies
Top issue: Infection Control (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Beloit, KS
Mitchell County Hospital Health Systems Ltcu
4-star overall rating with 5-star inspections with 2 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
400 W 8th Street, Beloit, KS
(785) 738-9590
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
36
Certified beds
Average residents
33
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-09-01
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.05
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.78
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.38
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.58
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.26
CMS adjusted RN staffing hours
Adjusted total hours
5.28
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
951
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.79
Composite VBP score used to determine payment impact.
Payment multiplier
1.0168
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
3.99
Baseline 42.55% · Performance 47.37% · Measure score 3.99 · Achievement 3.99 · Improvement 0
Adjusted total nurse staffing
8.37
Baseline 5.75 hours · Performance 5.46 hours · Measure score 8.37 · Achievement 8.37 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 74 |
| Staff flu vaccination coverage | 25% |
42%
17 pts worse
|
Numerator 22 · Denominator 88 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.4 |
1.8
1.6 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 2.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.6 |
2.2
1.4 pts worse
|
1.8
1.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 3.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.8%
8.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.5%
4.5 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 | 12.0% |
4.4%
7.6 pts worse
|
3.3%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 13.3% · Q3 12.1% · Q4 9.4% · 4Q avg 12.0% · 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 | 4.0% |
5.0%
1 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.7% · Q3 6.1% · Q4 3.2% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.2% |
23.2%
1 pts worse
|
19.6%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 20.0% · Q3 21.2% · Q4 38.7% · 4Q avg 24.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.5% |
19.8%
4.3 pts better
|
16.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 12.5% · Q3 15.4% · Q4 13.3% · 4Q avg 15.5% · 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 | 19.2% |
18.4%
0.8 pts worse
|
16.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 28.1% · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.7% |
18.8%
13.9 pts worse
|
14.9%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 25.9% · Q3 18.5% · Q4 53.6% · 4Q avg 32.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.9% |
1.8%
4.1 pts worse
|
1.0%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 9.6% · Q3 3.8% · Q4 5.0% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.6% |
3.1%
6.5 pts worse
|
1.7%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 16.7% · Q3 12.1% · Q4 9.4% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.4% |
23.2%
1.2 pts worse
|
19.8%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 23.6% · Q3 20.0% · Q4 34.6% · 4Q avg 24.4% |
| Percentage of long-stay residents with pressure ulcers | 7.2% |
4.6%
2.6 pts worse
|
5.1%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 14.6% · Q3 3.6% · Q4 6.4% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
75.6%
21 pts better
|
81.7%
14.9 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 96.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-31 · Fire 2023-05-31
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2021-11-22 · Fire 2021-11-22
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-04-11
F · Potential for more than minimal harm
2025-02-06
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 2025-04-11
F · Potential for more than minimal harm
2025-02-06
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2025-04-11
F · Potential for more than minimal harm
2025-02-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-11
F · Potential for more than minimal harm
2025-02-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-11
F · Potential for more than minimal harm
2025-02-06
K771 · Miscellaneous Deficiencies
Fire Safety
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
Corrected 2025-04-11
F · Potential for more than minimal harm
2025-02-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-02-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-11
F · Potential for more than minimal harm
2023-05-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-08
F · Potential for more than minimal harm
2023-05-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-08
F · Potential for more than minimal harm
2023-05-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-08
F · Potential for more than minimal harm
2023-05-31
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-08-08
F · Potential for more than minimal harm
2023-05-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-08
F · Potential for more than minimal harm
2023-05-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-08
E · Potential for more than minimal harm
2023-05-31
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 2023-08-08
E · Potential for more than minimal harm
2023-05-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-08
E · Potential for more than minimal harm
2023-05-31
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-08-08
D · Potential for more than minimal harm
2023-05-31
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-08-08
F · Potential for more than minimal harm
2021-11-22
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2021-12-22
F · Potential for more than minimal harm
2021-11-22
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2021-12-22
F · Potential for more than minimal harm
2021-11-22
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2021-12-22
E · Potential for more than minimal harm
2021-11-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-12-22
E · Potential for more than minimal harm
2021-11-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-06
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-06
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-03-25
D · Potential for more than minimal harm
2023-05-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-05-31
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 2023-06-29
D · Potential for more than minimal harm
2023-05-31
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-05-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-05-31
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-05-31
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-05-31
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-05-31
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 2023-06-29
D · Potential for more than minimal harm
2021-11-22
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2021-12-16
D · Potential for more than minimal harm
2021-11-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-12-16
D · Potential for more than minimal harm
2021-11-22
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-12-16
D · Potential for more than minimal harm
2021-11-22
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 2021-12-16
Penalties and ownership
What sits behind the stars
Ownership
Mitchell County Hospital Health Systems
5% Or Greater Direct Ownership Interest · Organization
Cleveland, Nicki
Operational/Managerial Control · Individual
Eilert, Leanne
Operational/Managerial Control · Individual
Gavino, Luigi
Operational/Managerial Control · Individual
Kircher, Janelle
Operational/Managerial Control · Individual
Marozas, Christine
Operational/Managerial Control · Individual
Mitchell County Hospital Health Systems
Operational/Managerial Control · Organization
Simmons, Stephanie
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Hilltop Lodge Health And Rehabilitation Center
Beloit, KS
2-star overall rating with 2-star inspections with $51,652 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
The Nicol Home
Glasco, KS
3-star overall rating with 4-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Downs Care And Rehab
Downs, KS
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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