BETHESDA

Nursing Home Inspector

901 SOUTHEAST WILLMAR AVENUE
WILLMAR, MN 56201
Kandiyohi County
Phone: 320-262-5376
Provider Number: 245427
Last Inspection: 01/12/2017

About the Nursing Home

Number of Beds: 248
Number of Residents: 203
Beds Available: 45
Percent Occupancy: 82%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: Non profit - Church related
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

18

Facility
25

County
19

MN
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

18

2017
21

2015
28

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

1/12/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Try to resolve each resident's complaints quickly. Isolated : Minimal 3 2/17/2017
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 2/17/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 2/17/2017
 
Failed To: Make sure that doctors visit residents regularly, as required. Pattern : Minimal 4 2/17/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 2/17/2017
 

12/10/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep residents' personal and medical records private and confidential. Pattern : Minimal 4 1/13/2016
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 1/13/2016
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 1/13/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 1/13/2016
 
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Potential 4 1/13/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 1/13/2016
 

10/2/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Isolated : Minimal 3 10/24/2014
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 10/24/2014
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated : Minimal 3 10/24/2014
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 10/24/2014
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 10/24/2014
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 10/24/2014
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 10/24/2014
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 10/24/2014
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Potential 4 10/24/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MN State Avg
Number of Residents 203 107.00 65.71
Registered Nurses 0.48 0.69 0.93
Licensed Practical / Vocational Nurses 0.77 0.74 0.68
Certified Nursing Assistants 4.08 2.98 2.53
Total Staff Hours 5.33 4.41 4.14

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MN State Avg%
of high risk long-stay residents with pressure ulcers 5 4 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 99 99 95
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 99 96
of long-stay residents experiencing one or more falls with major injury 5 3 4
of long-stay residents who have depressive symptoms 3 2 4
of long-stay residents who lose too much weight 4 4 7
of long-stay residents who received an antianxiety or hypnotic medication 12 11 13
of long-stay residents who received an antipsychotic medication 15 11 13
of long-stay residents who self-report moderate to severe pain 6 6 9
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 18 14 17
of long-stay residents whose need for help with daily activities has increased 17 13 14
of long-stay residents with a catheter inserted and left in their bladder 3 1 2
of long-stay residents with a urinary tract infection 7 5 3
of low risk long-stay residents who lose control of their bowels or bladder 36 44 51
of short-stay residents assessed and appropriately given the pneumococcal vaccine 90 90 84
of short-stay residents who had an outpatient emergency department visit 5 7 12
of short-stay residents who made improvements in function 88 76 75
of short-stay residents who newly received an antipsychotic medication 2 0 1
of short-stay residents who self-report moderate to severe pain 22 22 20
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 84 84 82
of short-stay residents who were rehospitalized after a nursing home admission 9 10 19
of short-stay residents who were successfully discharged to the community 76 80 64
of short-stay residents with pressure ulcers that are new or worsened 1 0 0