BETHESDA HERITAGE CENTER
Address
1012 EAST THIRD STREET
WILLMAR, MN 56201
(320) 235-3924
Nursing Home Ratings
| Health Inspections | |
| Quality Measures | |
| Nursing Staff | |
| R.N. Staff Only | |
| Overall Rating | |
Percent of Beds Occupied
88%Number of Residents and Certified Beds
- Residents: 112
- Certified Beds: 128
This Facility Accepts
- Medicare
- Medicaid
Operational Details
- Operated By Non Profit - Church Related
- Offers Both Resident and Family Counseling Services
- This Facility is Not Part of a Chain or Franchise
Resident Services
The information below lists services this facility has provided for residents from October through December 2010. During this period, the most common type of service provided was "Very High Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by Bethesda Heritage Center. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.
| Resident Services | Resident Conditions | Percent of Service Days |
Ultra-High Rehabilitation
- At least one rehabilitation discipline five days/week
- A second rehabilitation discipline three days/week
| ADL Index Range: 11-16 | 5.7% |
| Total Percent: | 5.7% |
Very High Rehabilitation
- At least one rehabilitation discipline five days/week
| ADL Index Range: 11-16 | 5.2% |
| ADL Index Range: 6-10 | 18.4% |
| ADL Index Range: 0-5 | 17.2% |
| Total Percent: | 40.8% |
High Rehabilitation
- At least one rehabilitation discipline five days/week
| ADL Index Range: 6-10 | 4.7% |
| ADL Index Range: 0-5 | 26.9% |
| Total Percent: | 31.6% |
Medium Rehabilitation
- Five days any combination of three rehabilitation disciplines
| ADL Index Range: 11-16 | 11.3% |
| ADL Index Range: 6-10 | 1.2% |
| ADL Index Range: 0-5 | 3.5% |
| Total Percent: | 16.0% |
Special Care High
- Comatose
- Septicemia
- Diabetes with daily injections and a change of order two or more days
- Quadriplegia with ADL score greater or equal to 5
- Chronic Obstructive Pulmonary Disease (COPD) and shortness of breath when lying flat
- Fever with pneumonia, or vomiting, or weight loss, or feeding tube
- Parenteral/IV feedings
- Respiratory therapy for 7 days
- Activities of Daily Living (ADL) score of 2 or more
| ADL Index Range: 11-14 - No Signs of depression | 3.3% |
| Total Percent: | 3.3% |
Clinically Complex
- Pneumonia, hemiplegia with ADL score >=5
- Surgical wounds or open lesions with treatment
- Burns
- Chemotherapy while a resident
- Oxygen therapy while a resident
- IV medications or transfusions while a resident
- Extensive Services, Special Care High or Special Care Low qualifier and ADL score of 0 or 1
| ADL Index Range: 11-14 - No Signs of depression | 1.7% |
| ADL Index Range: 6-10 - No Signs of depression | 0.9% |
| Total Percent: | 2.6% |
Rating Details For Bethesda Heritage Center
Nursing Staff - 
The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.
| Nursing Hours Per Resident Per Day | Reported | Expected |
| Registered Nurse (RN) Hours | 43 Minutes | 54 Minutes |
| Licensed Practical/Vocational Nurse (LPN/LVN) Hours | 58 Minutes | 38 Minutes |
| Certified Nursing Assistant (CNA) Hours | 2 Hours and 35 Minutes | 2 Hours and 23 Minutes |
| Total Licensed Nurse Hours | 1 Hour and 40 Minutes | 1 Hour and 32 Minutes |
| Total Nurse Hours | 4 Hours and 16 Minutes | 3 Hours and 55 Minutes |
Quality of Care -
Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Minnesota are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.
| This Facility | Minnesota Average |
Long-Term Stay Preventive Actions
| Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 90-100% | 93% |
| Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season | 90-100% | 94% |
Long-Term Stay Deficiencies
| Percent of Low-Risk Long-Stay Residents Who Have Pressure Sores | 1% | 3% |
| Percent of Long-Stay Residents Who Are More Depressed or Anxious | 34% | 23% |
| Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder | 1% | 6% |
| Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair | - | 2% |
| Percent of Long-Stay Residents Who Were Physically Restrained | - | 3% |
| Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder | 52% | 53% |
| Percent of Long-Stay Residents Who Lose Too Much Weight | 5% | 7% |
| Percent of Long-Stay Residents Who Had a Urinary Tract Infection | 6% | 7% |
| Percent of High-Risk Long-Stay Residents Who Have Pressure Sores | 6% | 7% |
| Percent of Long-Stay Residents Who Have Moderate to Severe Pain | 2% | 4% |
| Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse | 9% | 11% |
| Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased | 16% | 14% |
Short-Term Stay Preventive Actions
| Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 90-100% | 88% |
| Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season | 90-100% | 90% |
Short-Term Stay Deficiencies
| Percent of Short-Stay Residents Who Had Moderate to Severe Pain | 31% | 23% |
| Percent of Short-Stay Residents Who Have Pressure Sores | 7% | 9% |
| Percent of Short-Stay Residents Who Have Delirium | 2% | 3% |
Health Inspection Details - 
All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 07/22/2010.
Degree of Harm
- Potential for Minimal Harm
- Minimal Harm or Potential for Harm
- Resident Harmed
- Immediate Jeopardy to Resident Health
Residents Affected
- Isolated
- Some Residents
- Many Residents
| Deficiencies Found By Inspectors | Degree of Harm | Residents Affected |
Environmental
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Have a Program to Keep Infection from Spreading.
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Make Sure There is a Program to Prevent/Deal with Mice, Insects, or Other Pests.
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Nutrition and Dietary
Store, Cook, and Give out Food in a Safe and Clean Way.
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Pharmacy Service
1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects.
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1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects.
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At Least Once a Month, Have a Licensed Pharmacist Check the Drugs That Each Resident Takes.
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Quality Care
Provide Social Services for Related Medical Problems to Help Each Resident Achieve the Highest Possible Quality of Life.
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Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
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Give or Get Dental Care for Each Resident.
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Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
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Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
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Resident Assessment
Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
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Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
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Resident Rights
Let Residents Give Themselves Their Drugs if They Are Able.
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Deficiencies from Complaints and Incidents
The table below lists incident reports by the nursing staff or administration for Bethesda Heritage Center, as well as complaints by residents or their family in the previous three years.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
| Formal Complaints | Degree of Harm | Residents Affected |
Mistreatment
1) Hire Only People Who Have 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.
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Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property.
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Quality Care
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
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Fire Safety
Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Bethesda Heritage Center had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 07/22/2010.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
| Deficiencies Found By Inspectors | Degree of Harm | Residents Affected |
Automatic Sprinkler Systems
Automatic Sprinkler Systems That Have Been Maintained in Working Order.
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Building Service Equipment
Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions.
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Properly Constructed Linen or Trash Chutes.
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Fire Alarm Systems
An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems.
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