Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethel Home during CMS and state inspections, most recent first.
Failure to Use TBP for Residents With Pneumonia: The facility did not place two residents with respiratory symptoms and pneumonia on TBP at the onset of illness. One resident later required hospitalization for sepsis due to pneumonia, and another resident diagnosed by chest X-ray had no TBP sign or PPE cart at the door. Staff interviews confirmed the facility was using standard precautions rather than droplet or other TBP for these residents.
Two residents were not accurately assessed for self-administration of medication. One resident with dementia had pain relief spray at the bedside even though the latest assessment said the resident could not self-administer medications, and staff said the assessment was not actually completed. Another resident with intact cognition but an activated POAHC had an incomplete assessment, signed consent while previously deemed incapacitated, and had pills and eye drops at the bedside; staff gave inconsistent answers about bedside meds and whether the POAHC knew the resident self-administered.
Two residents were not provided pneumococcal vaccination in a timely manner. One resident’s consent or declination was not obtained promptly, and another resident had signed consent but the vaccine was delayed until later. The IP stated both residents should have received the vaccine within one or two days of admission or return from the hospital, and the MDS RN said the vaccine status was marked up to date in error after reviewing the state immunization registry.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
A resident with orthostatic hypotension and unresponsive episodes did not have their care plan updated to include an APNP's recommendations for slow transfers and hydration. Despite the resident's intact cognition and multiple diagnoses, the facility failed to incorporate these critical interventions, as confirmed by the DON and NHA during a surveyor's review.
A resident experienced an unresponsive episode and shoulder pain, leading to X-rays that revealed a clavicle fracture. The facility failed to ensure the physician received and reviewed the clavicle X-ray results, resulting in a delay in appropriate management. The physician only became aware of the fracture during an orthopedic appointment, highlighting a communication lapse in the facility's process.
The facility failed to provide adequate transfer notices to three residents who were hospitalized, lacking essential information such as the date, reason, and location of transfer, appeal rights, and ombudsman contact details. This deficiency was partly due to inconsistent practices for Medicaid residents, as acknowledged by the DON and NHA.
The facility failed to provide bed hold notifications to three residents during hospital transfers. One resident with intact cognition did not receive notifications for two transfers, and attempts were made to backdate forms. Two other residents, one with moderately impaired cognition and another with severe cognitive impairment, also did not receive notifications. The DON and NHA confirmed that Medicaid residents were not always given notices due to an automatic 15-day bed hold policy.
Failure to Use Transmission-Based Precautions for Residents With Respiratory Illness
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for two residents, R26 and R64, as well as staff, volunteers, visitors, and other individuals providing resident services. The deficiency involved the facility not implementing transmission-based precautions at the onset of respiratory symptoms for residents with pneumonia-related illness. The report states this practice had the potential to affect more than 4 of the 70 residents residing in the facility. R26 was admitted with diagnoses including infection and inflammatory reaction due to an internal left knee prosthesis, COPD, and obstructive sleep apnea, and had a BIMS score of 15 with intact cognition. R26 had been on enhanced barrier precautions since admission. On 8/11/25, a progress note documented that R26 felt cold, was hypotensive, had chattering teeth, and had a temperature of 100.4 degrees. R26 was later admitted to the hospital and diagnosed with sepsis due to pneumonia of the right lower lobe due to an infectious organism. The record and staff interviews indicated R26 was not placed on droplet precautions or other transmission-based precautions at the onset of respiratory symptoms. R64 was admitted with diagnoses including diabetes and chronic kidney disease and had a BIMS score of 15, indicating intact cognition. R64 was diagnosed with pneumonia by chest X-ray and was prescribed Augmentin for pneumonia for 7 days starting 9/3/25. Survey observation found no transmission-based precautions sign or PPE cart near R64's door, and R64 stated staff did not wear PPE during cares except gloves. Interviews with the DON, IP, CNA, and MD showed the facility was using standard precautions for pneumonia and did not place R64 on transmission-based precautions, despite the diagnosis and respiratory illness.
Inaccurate Self-Administration Medication Assessments
Penalty
Summary
The facility did not ensure that 2 residents were accurately assessed for self-administration of medication. One resident had diagnoses including neurocognitive disorder with Lewy Body dementia, depression, and insomnia, and had a BIMS score of 7 out of 15 with an activated POAHC. A bottle of Theraworks pain relief spray was observed at the resident’s bedside, even though the resident’s most recent self-administration assessment indicated the resident was unable to self-administer medication. Staff later stated the resident had been assessed as capable of self-administering topical medications earlier, but the 9/3/25 assessment was not completed per policy and was not an actual assessment. The second resident had diagnoses including diabetes, atrial fibrillation, hypertension, anxiety, and depression, with a BIMS score of 14 out of 15 and an activated POAHC assisting with medical decisions. The resident had been deemed incapacitated in the past, yet signed a self-administration consent form without a corresponding signature from the POAHC. The resident’s assessment was incomplete, as it did not fully evaluate the ability to correctly dispense medication or administer by route, and it documented abilities that were not supported by the findings. Medications, including acetaminophen and eye drops, were observed at the bedside, and the resident stated the pills had been left after falling asleep and that staff usually administered the eye drops in the evening. Staff interviews showed inconsistent understanding of whether medications could be kept at the bedside and whether residents who self-administered were actually taking the medications before documentation on the MAR. The DON stated the resident could keep medication at the bedside after a nurse prepared it and that staff should verify the resident takes bedside medications before documenting administration. The DON also stated consent for self-administration was not redone when a resident was later identified as incapacitated, and the POAHC did not recall being informed that the resident self-administered medication.
Delayed Pneumococcal Vaccination Documentation and Administration
Penalty
Summary
The facility did not ensure pneumococcal vaccination was offered and documented in a timely manner for 2 residents sampled for review. One resident was eligible for a pneumococcal vaccine, had intact cognition with a BIMS score of 15, and had an activated POAHC. The resident’s record showed a history that included COPD, obstructive sleep apnea, infection and inflammatory reaction due to an internal left knee prosthesis, and a hospitalization for sepsis due to pneumonia of the right lower lobe. Although the resident’s record later contained a consent form and documentation that the pneumococcal vaccine was given, the Infection Preventionist stated the vaccine should have been offered and administered within one or two days of admission, and the resident was not obtained consent or declination in a timely manner. A second resident was also eligible for pneumococcal vaccination, had a BIMS score of 15, and was responsible for personal medical decisions. The resident’s record included signed consent for the pneumococcal vaccine, but the vaccine was not administered until later, after the resident had returned from the hospital. The Infection Preventionist stated this resident should have received the pneumococcal vaccine within one or two days after returning from the hospital. The MDS RN stated the vaccine status for both residents had been documented as up to date in error after reviewing the Wisconsin Immunization Registry.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Care Plan Revision Deficiency for Resident with Orthostatic Hypotension
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced unresponsive episodes and orthostatic hypotension. The resident, who had intact cognition and was their own decision maker, was admitted with multiple diagnoses including surgical aftercare, cervical spine issues, and hypertension. An Advanced Practice Nurse Prescriber (APNP) recommended monitoring the resident for orthostatic hypotension, assisting with slow position changes, and ensuring adequate hydration. However, these recommendations were not incorporated into the resident's care plan. The deficiency was identified when the surveyor reviewed the resident's medical record and noted that the care plan did not include the APNP's recommendations. The Director of Nursing and Nursing Home Administrator confirmed that the care plan lacked these interventions. The care plan only addressed potential unresponsive episodes with interventions such as acknowledging the resident's feelings and assessing unmet needs, but did not include specific instructions for slow transfers or hydration as advised by the APNP.
Failure to Communicate X-ray Results to Physician
Penalty
Summary
The facility failed to ensure that a physician saw and responded to the radiological records for a resident who had X-rays of the shoulder and clavicle after experiencing an unresponsive episode and complaining of pain. The X-rays were completed, and the results for the shoulder showed no acute fracture, which was signed by the physician. However, the clavicle X-ray indicated a fracture, but the results were not signed or acknowledged by the physician, indicating that the physician did not receive or review these results. The resident, who had intact cognition and was their own decision-maker, was admitted for rehabilitation following surgery on the nervous system and had multiple diagnoses, including a right clavicle fracture. Despite the facility receiving the clavicle X-ray results, the registered nurse who documented the shoulder X-ray results did not recall receiving the clavicle X-ray results. Consequently, the physician was not informed of the fracture, and the resident continued to experience pain and instability in the shoulder area. Interviews with the occupational therapist and the director of nursing revealed that the clavicle fracture was only discovered when preparing for an orthopedic appointment. The physician confirmed that they had not seen the clavicle X-ray results and indicated that the treatment would not have changed significantly. However, the lack of communication and oversight resulted in a delay in the appropriate acknowledgment and management of the resident's clavicle fracture.
Failure to Provide Adequate Transfer Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide timely and adequate transfer notices to three residents (R50, R65, and R27) who were hospitalized. These notices should have included the date of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. R50, who had intact cognition and was their own decision maker, was transferred to the hospital on three occasions without receiving a written transfer notice. Similarly, R65, who had moderately impaired cognition and an activated Power of Attorney for Healthcare (POAHC), was transferred without a written notice. R27, with severe cognitive impairment and an activated POAHC, was also transferred without receiving the necessary documentation. The surveyor's review revealed that the facility's practice was inconsistent, particularly for Medicaid residents, due to an automatic 15-day bed hold policy. The Director of Nursing acknowledged that staff did not always issue the required forms for Medicaid residents, and the Nursing Home Administrator confirmed the lack of a comprehensive written transfer notice. The forms provided at the time of transfer did not contain all necessary information, contributing to the deficiency in communication and documentation for these residents.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide proper bed hold notifications to three residents during their transfers to the hospital. Resident 50, who had intact cognition and was their own decision-maker, was transferred to the hospital on two occasions without receiving a bed hold notification. The Director of Nursing and Nurse Manager confirmed that a bed hold form was not completed at the time of the transfer, and an attempt was made to backdate a form, which was acknowledged as inappropriate by the Nursing Home Administrator. Resident 65, who had moderately impaired cognition and an activated Power of Attorney for Healthcare (POAHC), was also transferred without a bed hold notification being provided to either the resident or their POAHC. Similarly, Resident 27, with severe cognitive impairment and an activated POAHC, was transferred without a bed hold notice. The Director of Nursing stated that Medicaid residents were not always given a bed hold notice due to an automatic 15-day bed hold policy, which was confirmed by the Nursing Home Administrator.
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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 Oshkosh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evergreen Health Center | 0.8 mi | ★★★★★ | 7 | 0 |
| Eden Rehab Suites And Green House Homes | 2.2 mi | ★★★★★ | 5 | 0 |
| Edenbrook Of Oshkosh | 2.6 mi | ★★★★★ | 12 | 0 |
| Park View Health Center | 4.5 mi | ★★★★★ | 0 | 0 |
| Edenbrook Omro | 9 mi | ★★★★★ | 2 | 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 August 2026) and official state health department websites.