Bethel Home
300 S Aztec St, Montezuma, KS 67867 · Gray County · 56 certified beds · avg 54 residents/day · certified since Aug 28, 2012
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Feb 1, 2023 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 4, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (15)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 16, 2025 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jan 16, 2025 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jan 16, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jan 16, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jan 16, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jan 16, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 16, 2025 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Aug 16, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 1, 2023 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Feb 1, 2023 | F · Potential for harm, facility-wide | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Feb 1, 2023 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Feb 1, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Feb 1, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Feb 1, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Mar 24, 2021 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (6 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 1 | 0 | D |
| 2023 | 7 | 1 | G ▲ |
| 2025 | 7 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Kansas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 6.40 | 4.58 | 3.95 | top 8% in Kansas; top 3% in the U.S. |
| Registered Nurse hours | 0.77 | 0.81 | 0.69 | top 43% in Kansas; top 30% in the U.S. |
| Weekend total nurse staffing | 5.59 | 4.05 | 3.50 | top 8% in Kansas; top 3% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.30 | 0.49 | 0.48 | bottom 18% in Kansas; bottom 32% in the U.S. |
| Total nursing staff turnover (%) | 28.6 | 48.1 | 45.8 | top 8% in Kansas; top 12% in the U.S. |
| RN turnover (%) | 16.7 | 42.0 | 42.9 | top 13% in Kansas; top 9% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.58, RN 0.55, weekend 4.00. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ensz, Terry | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2021 |
| Isaac, Travis | Individual | Corporate Director | NOT APPLICABLE | 01/01/2022 |
| Johnson, Lance | Individual | Corporate Director | NOT APPLICABLE | 01/01/2023 |
| Koehn, Brian | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/13/2018 |
| Koehn, Brian | Individual | ADP of the SNF | NOT APPLICABLE | 03/13/2018 |
| Koehn, Don | Individual | Corporate Director | NOT APPLICABLE | 01/01/2021 |
| Koehn, Eugene | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2018 |
| Koehn, Lennis | Individual | Corporate Director | NOT APPLICABLE | 01/01/2018 |
| Koehn, Presley | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Nickel, Brenton | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Schowengerdt, Andrew | Individual | Corporate Director | NOT APPLICABLE | 08/01/1991 |
| Schowengerdt, Andrew | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/1991 |
| Schowengerdt, Andrew | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/1991 |
| Smith, James | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2021 |
| Unruh, Brandon | Individual | Corporate Director | NOT APPLICABLE | 01/01/2023 |
| Unruh, David | Individual | Corporate Director | NOT APPLICABLE | 01/01/2019 |
| Yost, Chris | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who oversees antibiotic use here, and how do you decide when an antibiotic is really needed?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| The Shepherd's Center | 16.3 mi | Cimarron, KS | ★★☆☆☆ | 1/5 | SFF |
Compare this facility with the 1 closest →
Facility data as of CMS processing date 2026-08-01. CCN 175528.