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64/100BETHESDA Inspection Report, Violations & Safety Grade (WILLMAR, Minnesota)
901 SOUTHEAST WILLMAR AVENUE, WILLMAR, Minnesota 56201
Phone: 3202359532
CMS Overall:2/5
Overview & Bed Count
Certified Beds
248
Avg Residents/Day
220.6
Ownership
Non profit - Church related
Provider Type
Medicare and Medicaid
County
Kandiyohi
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall2/5
Health3/5
Staffing1/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | Minnesota Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.62 | 1.08 | -0.47 |
| Total Nurse Hours per Resident per Day | 3.44 | 4.27 | -0.83 |
| CMS Staffing Rating | 1/5 | 4.2/5 | - |
| Nursing Staff Turnover | 38.5% | 42.1% | - |
Health Citation History
19 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-12-10 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2025-12-10 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2025-12-10 | Resident Rights Deficiencies | Allow residents to self-administer drugs if determined clinically appropriate. | D – Moderate Harm Potential |
| 2025-12-10 | Resident Rights Deficiencies | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | D – Moderate Harm Potential |
| 2025-12-10 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-11-05 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G – Actual Harm |
| 2024-11-05 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2024-11-05 | 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. | D – Moderate Harm Potential |
| 2024-10-25 | Resident Rights Deficiencies | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | D – Moderate Harm Potential |
| 2024-10-25 | 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. | D – Moderate Harm Potential |
| 2024-10-25 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2024-10-25 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2024-10-25 | 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. | D – Moderate Harm Potential |
| 2024-10-25 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D – Moderate Harm Potential |
| 2024-05-03 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2024-01-24 | Administration Deficiencies | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | F – Moderate Harm Potential |
| 2024-01-24 | Environmental Deficiencies | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | F – Moderate Harm Potential |
| 2024-01-24 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-01-24 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D – Moderate Harm Potential |
Fire Safety Citation History
18 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-12-10 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2025-12-10 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-12-10 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2025-12-10 | 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. | E – Moderate Harm Potential |
| 2025-12-10 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | E – Moderate Harm Potential |
| 2025-12-10 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2025-12-10 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2025-12-10 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | D – Moderate Harm Potential |
| 2025-12-10 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | D – Moderate Harm Potential |
| 2024-10-25 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2024-10-25 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | F – Moderate Harm Potential |
| 2024-10-25 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2024-10-25 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2024-01-24 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | F – Moderate Harm Potential |
| 2024-01-24 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | E – Moderate Harm Potential |
| 2024-01-24 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
| 2024-01-24 | Emergency Preparedness Deficiencies | Implement emergency and standby power systems. | C – Minimal Harm Potential |
| 2024-01-24 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | B – Minimal Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties
No penalty records found.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the WILLMAR area at no cost.
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the WILLMAR area at no cost.
Find Safe, Vetted Facilities Near WILLMAR
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.