Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MITCHELL COUNTY HOSPITAL HEALTH SYSTEMS LTCU
BELOIT, KS · 36 certified beds · Last Life Safety survey February 6, 2025
CMS Certification Number 175505 · first certified September 2008
Ownership
Independently operated (no chain recorded by CMS) · Government - County
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within KS
24 citations — more than 38% of the 296 certified nursing homes in KS. Compared within KS rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 9 citations; the earlier surveys in the window averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens September 2026. This facility’s last Life Safety survey was February 2025. Facilities in KS are typically surveyed 20–22 months after the last one (median 21), measured over 298 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 24 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 24 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 24 |
| Median facility in KS | 27 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 22, 2021 | 5 |
| May 31, 2023 | 10 |
| February 6, 2025 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2025-02-06 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-02-06 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-02-06 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-02-06 |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | 1 | 2025-02-06 |
| K-0753 | Have restrictions on the use of highly flammable decorations. | 1 | 2023-05-31 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2023-05-31 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2025-02-06 |
What the citations cover
- Smoke Deficiencies 9
- Miscellaneous Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Egress Deficiencies 3
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Miscellaneous Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Egress Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 6, 2025 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0771 | Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 11, 2025) |
May 31, 2023 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (August 8, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 8, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 8, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 8, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 8, 2023) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (August 8, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 8, 2023) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (August 8, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (August 8, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 8, 2023) |
November 22, 2021 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0023 | Establish policies and procedures for medical documentation. | Deficient, Provider has date of correction (December 22, 2021) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (December 22, 2021) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (December 22, 2021) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 22, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 22, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.