Bethesda
Open-data reference.
Bethesda is a non profit - church related facility in WILLMAR, MN with 248 certified beds and a 4-star overall CMS rating. The facility has 19 deficiency records on file.
901 SOUTHEAST WILLMAR AVENUE, WILLMAR, MN 56201
Phone: 3202625376
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 245427
- Ownership
- Non profit - Church related
- Provider Type
- Medicare and Medicaid
- Beds
- 248
- Residents
- 223
- In Hospital
- No
- County
- Kandiyohi
- Last Inspection
- Dec 10, 2025
Staffing Data
- RN Hours
- 0.74 (nat'l avg: 0.68)
- LPN Hours
- 0.73
- CNA Hours
- 3.46
- Total Nursing Hours
- 4.93 (nat'l avg: 3.89)
- PT Hours
- 0.03
- Nursing Turnover
- 39.4%
- RN Turnover
- 16.2%
What the CMS Record Reveals About Bethesda
Bethesda operates 248 certified beds in WILLMAR, MN with approximately 223 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (5★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 19 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 4.93 total nursing hours per resident day (national average 3.89), with RN coverage at 0.74 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Church related" ownership and operating as a "Medicare and Medicaid" provider, Bethesda falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 39.4%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (19 most recent)
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 23, 2026
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jan 23, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jan 23, 2026
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Category: Resident Rights Deficiencies
Corrected: Jan 23, 2026
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Jan 23, 2026
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 12, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 12, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Dec 12, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Dec 6, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Dec 6, 2024
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 6, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 6, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 6, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Dec 6, 2024
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Jun 19, 2024
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: Feb 23, 2024
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Category: Administration Deficiencies
Corrected: Feb 23, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Feb 23, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 23, 2024
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 22.4% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 2.5% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 2.2% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 3.3% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 2.3% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 9.1% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 99.9% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 99.4% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.9% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 22.5% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 10.3% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 99.1% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 5.3% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 27.7% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 13.2% | Yes |
Penalty History
No penalties on record.
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County Health Data
Health outcomes, access, and quality metrics for Kandiyohi on PlainHealth
Frequently Asked Questions
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.