Public Record
Mitchell County Hospital Health Systems Ltcu
From CMS
Facility profile
- CMS overall rating
- 4 / 5
- Certified beds
- 36
- Avg. residents per day
- 34.2
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 38
- Inspections on file
- 6
- Last inspection
- 2025-02-06
*CMS
*CMS
*CMS
Citations
38 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0700Generalpotential for harm
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.
- 0882Generalpotential for harm
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
- 0293Generalpotential for harm
Have properly located and lighted "Exit" signs.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0343Generalpotential for harm
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0771Generalpotential for harm
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0744Generalpotential for harm
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0758Generalpotential for harm
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.
- 0911Generalpotential for harm
Meet requirements for the installation and maintenance of electrical systems.
- 0914Generalpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0761Generalpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0222Generalpotential for harm
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.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0372Generalpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0753Generalpotential for harm
Have restrictions on the use of highly flammable decorations.
- 0625Generalpotential for harm
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.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0758Generalpotential for harm
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.
- 0023Generalpotential for harm
Establish policies and procedures for medical documentation.
- 0024Generalpotential for harm
Establish policies and procedures for volunteers.
- 0225Generalpotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ
Questions and answers
- What is Mitchell County Hospital Health Systems Ltcu?
- Mitchell County Hospital Health Systems Ltcu is a Medicare- and Medicaid-certified nursing home in Beloit, KS, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 175505.
- What is the CMS rating for Mitchell County Hospital Health Systems Ltcu?
- Mitchell County Hospital Health Systems Ltcu has a CMS overall rating of 4 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Mitchell County Hospital Health Systems Ltcu have?
- Mitchell County Hospital Health Systems Ltcu is certified for 36 beds. It serves an average of 34.2 residents per day.
- How many citations does Mitchell County Hospital Health Systems Ltcu have?
- Mitchell County Hospital Health Systems Ltcu has 38 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Mitchell County Hospital Health Systems Ltcu last inspected?
- Mitchell County Hospital Health Systems Ltcu was last inspected on February 6, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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