Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethany Home during CMS and state inspections, most recent first.
A resident who required two-person assistance for transfers was transferred by a single agency CNA, resulting in a clavicle fracture. The resident's care plan and shift report specified the need for two staff, but the CNA proceeded alone after being unable to find help. The resident requested ER transfer due to pain, but the agency RN delayed the transfer due to unfamiliarity with paperwork. The facility did not ensure all agency staff received or acknowledged required training on transfer procedures and care plan adherence.
A CNA who had lived outside the state in the past three years began working at the facility without the required out-of-state background check being completed. The facility relied on the agency to handle background checks, but neither the Director of Nursing nor the Director of Human Resources ensured that the necessary documentation was obtained before the CNA started work.
The facility failed to document vital signs every shift for 24 hours post-fall for two residents, as required by policy. One resident's medical record lacked vital signs after a fall, with inconsistencies noted in 24-hour report sheets. Another resident's record was missing vital signs for two shifts post-fall. The ADON confirmed these deficiencies in documentation.
A resident with severe cognitive impairment and significant weight loss did not receive the required one-to-one assistance during meals, as per their care plan. Observations showed the resident was left unassisted, leading to minimal food intake, and meal documentation was inaccurate.
A resident receiving oxygen therapy did not have a care plan that included necessary instructions for cleaning and changing their oxygen equipment, as required by the facility's policy. The resident reported that the equipment had not been maintained since their admission, a fact confirmed by the Director of Nursing.
The facility failed to provide accurate pharmaceutical services, leading to medication administration errors for two residents. One resident's medication card labels were not updated, and the LPN did not check BP before administering medications. Another resident received a crushed extended-release medication, contrary to policy. The errors were identified through staff interviews, record reviews, and direct observation.
The facility failed to adequately monitor a high-risk medication for a resident prescribed digoxin. Staff did not take the resident's apical pulse before administration and did not check digoxin levels as required by the care plan. Interviews revealed a lack of proper orders and policies for high-risk medication monitoring.
Failure to Follow Transfer Protocols and Ensure Agency Staff Training
Penalty
Summary
A deficiency occurred when a resident who required an EZ stand mechanical lift with the assistance of two staff for transfers was transferred by a single agency CNA, contrary to the resident's care plan. The CNA was aware from shift report and the care plan that two staff were needed for all transfers due to the resident's weakness, but attempted to transfer the resident alone after being unable to find another staff member. During the transfer, the resident's leg gave out, resulting in the resident slipping from the lift and being lowered to the floor, which led to a non-displaced left clavicle fracture. The resident, who had a history of left below-the-knee amputation, type 2 diabetes, hypertensive heart disease with CHF, and was cognitively intact, requested to be sent to the emergency room due to pain and decreased range of motion following the incident. However, the agency RN on duty did not transfer the resident immediately because the RN did not know how to complete the necessary paperwork. The resident was eventually sent to the ER approximately two hours later when the night shift nurse arrived. The facility's policies required that staff follow the resident's care plan for transfer assistance and that training occur after transfer-related incidents. Despite identifying the deficient practices, the facility did not ensure that all agency staff who had worked since the incident received or acknowledged the required education regarding transfer procedures and care plan adherence. The process for ensuring agency staff received and signed off on education was not effective, as most agency staff did not know to check the clipboard where such information was posted.
Failure to Complete Required Out-of-State Background Check for CNA
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse by not ensuring that a required out-of-state background check was completed for a certified nursing assistant (CNA) who had lived outside Wisconsin in the previous three years. The CNA began working at the facility through an agency, and the background information disclosure form indicated the need for an out-of-state check. However, the facility's records did not show that this check was completed prior to the CNA starting work. The Director of Nursing stated that the facility relies on the agency to complete background checks, while the Director of Human Resources confirmed that the necessary out-of-state background check was neither provided nor completed before the CNA began employment.
Failure to Document Vital Signs Post-Fall
Penalty
Summary
The facility failed to ensure thorough assessments were completed post-fall for two residents, R1 and R2, as per the facility's Neurological Assessment policy. This policy requires vital signs to be documented every shift for 24 hours following a fall. For R1, who had an unwitnessed fall on 9/5/24, the medical record did not contain vital signs after 7/21/24, except for one set documented on the Fall Review. The 24-hour report sheets, which were not part of the medical record, showed inconsistencies in the documentation of vital signs, with missing entries for the 9/6/24 night and PM shifts. The Assistant Director of Nursing (ADON) confirmed these discrepancies and the absence of vital signs in the medical record. Similarly, for R2, who experienced an unwitnessed fall on 7/19/24, the medical record lacked vital signs documentation for the second and third shifts post-fall. The 24-hour report sheets indicated that only one set of vital signs was documented for the 7/19/24 AM shift, with no entries for the subsequent PM and night shifts. The ADON verified that the medical records for both residents should have included a set of vital signs at the time of the fall and three additional sets for each shift post-fall over a 24-hour period. The failure to document these vital signs as per policy constitutes a deficiency in the facility's care practices.
Failure to Provide Required Mealtime Assistance
Penalty
Summary
The facility did not ensure the necessary treatment and services were provided to prevent weight loss for a resident (R17) who experienced a significant weight loss of 22 pounds over six months. Despite R17's care plan indicating the need for one-to-one (1:1) assistance with meals due to severe cognitive impairment and risk of aspiration, observations on 4/15/24 and 4/16/24 revealed that R17 was left unassisted during meals. R17's medical record and care plan included specific interventions such as 1:1 assistance, small bites/sips, and monitoring of meal intake, which were not followed during the observed meals. During the lunch meal observations, R17 was seated alone without staff assistance, and attempts to eat independently were largely unsuccessful, resulting in minimal food intake. Interviews with staff confirmed that R17 required mealtime assistance, yet the necessary supervision was not provided. The documentation of R17's meal intake was also inaccurate, as it indicated a higher consumption than what was observed. The Director of Nursing verified that R17 should have received 1:1 assistance as per the care plan, highlighting a failure in adhering to the established care protocols.
Deficiency in Respiratory Care for Resident
Penalty
Summary
The facility did not ensure that a resident received the necessary care and treatment for respiratory therapy. The resident, who was receiving oxygen therapy via an oxygen concentrator and nasal cannula, had a care plan that lacked orders for staff to clean or change the equipment in accordance with the facility's policy. The facility's Oxygen Therapy policy required that oxygen tubing be changed and the concentrator filter cleaned every 7 days, but these instructions were not included in the resident's Plan of Service or Treatment Administration Record. Upon review, it was found that the resident's medical record and care plan did not contain a schedule for cleaning or replacing the oxygen equipment. The Director of Nursing confirmed that the care plan and physician orders should have included these instructions. Additionally, the resident reported that the oxygen tubing and filter had not been changed or cleaned since their admission to the facility. This oversight was verified through observation and interviews with both the resident and the Director of Nursing.
Medication Administration Errors
Penalty
Summary
The facility failed to provide accurate pharmaceutical services for two residents, leading to medication administration errors. For one resident, the medication card labels for diltiazem, carvedilol, and spironolactone were not updated to reflect the current orders in the Medication Administration Record (MAR). The Licensed Practical Nurse (LPN) administering the medications did not check the resident's blood pressure (BP) before administration, as required by the outdated medication card instructions. The facility's Consultant Pharmacist confirmed that the pharmacy did not receive an order to discontinue the BP parameters, and the facility failed to provide a copy of the faxed order to the surveyor. The Director of Nursing (DON) acknowledged that the discrepancy should have been clarified with the pharmacy earlier. For another resident, the LPN crushed a potassium chloride extended-release (ER) medication, which should not have been crushed according to the facility's Crushed Medication policy. The LPN confirmed the error upon review of the Medication Administration Record (MAR). The Director of Nursing (DON) reiterated that staff should not crush medications labeled as extended-release and should clarify any discrepancies with the pharmacy. Both incidents highlight a failure in the facility's pharmaceutical services to ensure that medications were accurately acquired, received, dispensed, and administered. The errors were identified through staff interviews, record reviews, and direct observation by the surveyor. The facility's policies on oral and crushed medications were not followed, leading to these deficiencies in medication administration for the two residents involved.
Failure to Monitor High-Risk Medication
Penalty
Summary
The facility did not ensure adequate monitoring of a high-risk medication for one resident (R4). R4 was prescribed digoxin for atrial fibrillation and congestive heart failure. The staff failed to take R4's apical pulse for one minute prior to administering the medication, as required. Additionally, R4's digoxin level was not checked as indicated in the care plan. The care plan specifically instructed staff to check the apical pulse and hold the medication if the pulse rate was below 60 bpm, and to regularly check digoxin levels and report any abnormalities to the physician. Interviews with staff revealed that the Licensed Practical Nurse (LPN) did not monitor R4's pulse prior to administering digoxin, and there was no order to check R4's digoxin level after discharge from the hospital. The Director of Nursing (DON) confirmed that the facility lacked a policy for high-risk medication monitoring but expected staff to obtain a pulse before administering digoxin. The Medical Doctor (MD) also expected to be alerted if R4's pulse was low. These lapses in following the care plan and monitoring protocols led to the deficiency.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Waupaca
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wi Veterans Home Moses Hall | 2.1 mi | ★★★★★ | 3 | 1 |
| Wi Veterans Hm Ainsworth Hall | 2.1 mi | ★★★★★ | 0 | 0 |
| Avina Of Weyauwega | 8.1 mi | ★★★★★ | 6 | 0 |
| Manawa Com Nur Ctr | 11.5 mi | ★★★★★ | 0 | 0 |
| St Joseph Residence | 17.1 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.