Federal inspection record · CMS data as of October 1, 2026
Mitchell County Hospital Health Systems Ltcu
400 W 8th Street, Beloit, KS · (785) 738-9590
- Certified beds
- 36
- Residents per day
- 33
- Ownership
- Government
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- September 1, 2008
1
How this home got 4 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Kansas.
-
Staffing
★★★★★no change (already 5)
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★−1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★4 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Kansas homes
Mitchell County Hospital Health Systems Ltcu carries 17 inspection points. That is fewer than 97% of Kansas's 293 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Kansas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–27 pts
- 4★ 27–49 pts
- 3★ 49–71 pts
- 2★ 71–114.38 pts
- 1★ over 114.38 pts
Bars show every rated home in Kansas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
14 health citations on record since 2021. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Quality of Life and Care5D
- D
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.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Pharmacy Service4D
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- D
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.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- D
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.
Resident Assessment and Care Planning2D
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Infection Control1E
- E
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Freedom from Abuse, Neglect, and Exploitation1D
- D
Respond appropriately to all alleged violations.
Resident Rights1D
- D
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.
Inspection history
2025-02-06
2 health deficiencies · 9 fire-safety deficiencies
Top issue: Infection Control (1 deficiency)
2023-05-31
8 health deficiencies · 10 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2021-11-22
4 health deficiencies · 5 fire-safety deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 37 min of nursing staff time a day, 1 h 5 min of it from a registered nurse.
This home
4 h 37 min
Kansas average
4 h 8 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 31% of nursing staff and 14% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days1.3 pts worse | 3.0 | 1.7 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days2 pts worse | 4.0 | 2.0 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine7.1 pts better | 100.0% | 92.9% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine5.1 pts better | 100.0% | 94.9% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.1 pts worse | 5.3% | 4.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms6.6 pts better | 0.0% | 6.6% | 13.5% |
| Percentage of long-stay residents who lose too much weight4.4 pts worse | 9.2% | 4.8% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication22 pts worse | 45.4% | 23.4% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication2.3 pts better | 15.4% | 17.7% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened11.2 pts worse | 25.7% | 14.5% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased23 pts worse | 40.4% | 17.4% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder3.8 pts worse | 5.2% | 1.4% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection10 pts worse | 12.8% | 2.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence2.5 pts worse | 24.1% | 21.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.8 pts worse | 6.2% | 4.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine14.2 pts better | 91.3% | 77.1% | 82.3% |
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Who owns and runs it
15 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Cleveland, Nicki | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Eilert, Leanne | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Gavino, Luigi | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Kircher, Janelle | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Kircher, Janelle | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Kircher, Janelle | Adp Of The SNF · Individual | 0% | 1 facilities |
| Marozas, Christine | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Marozas, Christine | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Marozas, Christine | Trustee Of The SNF · Individual | 0% | 1 facilities |
| Marozas, Christine | Adp Of The SNF · Individual | 0% | 1 facilities |
| Mitchell County Hospital Health Systems | Direct Ownership Interest · Organization | 0% | 1 facilities |
| Mitchell County Hospital Health Systems | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Mitchell County Hospital Health Systems | Trustee Of The SNF · Organization | 0% | 1 facilities |
| Mitchell County Hospital Health Systems | Adp Of The SNF · Organization | 0% | 1 facilities |
| Simmons, Stephanie | Operational/Managerial Control · Individual | 0% | 2 facilities |
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Fire safety
24 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke9F
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- F
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
- E
Have approved installation, maintenance and testing program for fire alarm systems.
- D
Inspect, test, and maintain automatic sprinkler systems.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E
Inspect, test, and maintain automatic sprinkler systems.
- E
Have approved installation, maintenance and testing program for fire alarm systems.
- E
Inspect, test, and maintain automatic sprinkler systems.
Miscellaneous5F
- F
Have simulated fire drills held at unexpected times.
- F
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
- F
Have simulated fire drills held at unexpected times.
- F
Have restrictions on the use of highly flammable decorations.
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Gas, Vacuum, and Electrical Systems4F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- D
Meet requirements for the installation and maintenance of electrical systems.
Egress3F
- F
Have properly located and lighted "Exit" signs.
- E
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.
- F
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Emergency Preparedness2F
- F
Establish policies and procedures for medical documentation.
- F
Establish policies and procedures for volunteers.
Services1F
- F
Have properly installed electrical wiring and gas equipment.
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Other homes nearby
-
Hilltop Lodge Health And Rehabilitation Center
Beloit, KS · Recover-Care Healthcare
★★★★★- Worst citation, 3 yrs
- K
- Nursing / resident / day
- 3 h 28 min
- Fines
- $28,937
-
The Nicol Home
Glasco, KS
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 4 h 40 min
- Fines
- $0
-
Downs Care And Rehab
Downs, KS · Mission Health Communities
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 3 h 39 min
- Fines
- $0