Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
BETHESDA
WILLMAR, MN · 248 certified beds · Last Life Safety survey December 10, 2025
CMS Certification Number 245427 · first certified February 1987
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Church related
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MN
18 citations — more than 77% of the 338 certified nursing homes in MN. Compared within MN 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 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens November 2026 — about 1 month from now. This facility’s last Life Safety survey was December 2025. Facilities in MN are typically surveyed 11–14 months after the last one (median 13), measured over 613 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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1 inspection-and-testing tag has 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
1 of the 18 citations on file is 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)
3 physical-environment citations 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 18 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0584 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.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in MN, and nationally. Surveyors differ markedly between states, so the MN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 18 |
| Median facility in MN | 12 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 24, 2024 | 5 |
| October 25, 2024 | 4 |
| December 10, 2025 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2025-12-10 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2025-12-10 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2 | 2025-12-10 |
| 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. | 1 | 2025-12-10 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-12-10 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2025-12-10 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 1 | 2024-01-24 |
| E-0041 | Implement emergency and standby power systems. | 1 | 2024-01-24 |
What the citations cover
- Smoke Deficiencies 9
- Egress Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Services Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Egress Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Services Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 10, 2025 — 9 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 (February 2, 2026) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (February 2, 2026) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (February 2, 2026) |
| 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 (February 2, 2026) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (February 2, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 2, 2026) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (February 2, 2026) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (February 2, 2026) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (February 2, 2026) |
October 25, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| 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 (November 27, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 27, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 27, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (November 27, 2024) |
January 24, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (February 23, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (February 23, 2024) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (February 23, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (February 23, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (March 1, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.