01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-02-06 | 2 | 2025-02-06 | 9 |
| Cycle 2 | 2023-05-31 | 8 | 2023-05-31 | 10 |
| Cycle 3 | 2021-11-22 | 4 | 2021-11-22 | 5 |
CMS CCN 1755052026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Mitchell County Hospital Health Systems Ltcu
400 W 8Th Street · Beloit, KS 67420 · Mitchell County
Certified beds36CMS provider file
Recent citation rows38current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
38 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-02-06 · HEALTHF0700Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-03-252025-02-06 · HEALTHF0882Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Correction field: Deficient, Provider has date of correction · 2025-03-252025-02-06 · FIREK0293Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-02-06 · FIREK0321Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-02-06 · FIREK0343Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-02-06 · FIREK0345Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-02-06 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-02-06 · FIREK0511Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-02-06 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-02-06 · FIREK0771Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-02-06 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-04-112023-05-31 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2023-06-292023-05-31 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2023-06-292023-05-31 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2023-06-292023-05-31 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2023-06-292023-05-31 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2023-06-292023-05-31 · HEALTHF0744Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Correction field: Deficient, Provider has date of correction · 2023-06-292023-05-31 · HEALTHF0756Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2023-06-292023-05-31 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-06-292023-05-31 · FIREK0222Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-08-082023-05-31 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2023-08-082023-05-31 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2023-08-082023-05-31 · FIREK0372Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2023-08-082023-05-31 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2023-08-0803 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- MITCHELL COUNTY HOSPITAL HEALTH SYSTEMSOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 07/01/2005
- KIRCHER, JANELLEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 02/07/2023
- MAROZAS, CHRISTINEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2021
- MITCHELL COUNTY HOSPITAL HEALTH SYSTEMSOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2005
- CLEVELAND, NICKIIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/02/2015
- EILERT, LEANNEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/07/1999
- GAVINO, LUIGIIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/26/2023
- KIRCHER, JANELLEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/07/2023
- MAROZAS, CHRISTINEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/2021
- SIMMONS, STEPHANIEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/18/2010
- MITCHELL COUNTY HOSPITAL HEALTH SYSTEMSOrganization · TRUSTEE OF THE SNFNOT APPLICABLE · since 07/01/2005
- MAROZAS, CHRISTINEIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 01/01/2021
- MITCHELL COUNTY HOSPITAL HEALTH SYSTEMSOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/01/2005
- KIRCHER, JANELLEIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/13/2025
- MAROZAS, CHRISTINEIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/13/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.79per resident day
RN hours1.30per resident day
Weekend nurse hours4.03per resident day
Staff turnover27.8%CMS reported field
06 / LOCAL RECORDS
Open the Beloit ledger →