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Health Inspection Summary

Bethel Home

225 N Eagle St

Oshkosh, WI 54902

(920) 235-4653

Deficiency Category	Inspection Date: 8/7/24 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 6/7/23 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 7/20/22 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	0	1	2
Quality of Life and Care Deficiencies	0	1	3
Infection Control Deficiencies	0	0	0
Resident Assessment and Care Planning Deficiencies	1	2	1
Nursing and Physician Services Deficiencies	0	0	0
Resident Rights Deficiencies	2	0	2
Nutrition and Dietary Deficiencies	0	0	0
Pharmacy Service Deficiencies	0	1	0
Environmental Deficiencies	0	0	0
Administration Deficiencies	1	0	0

Detailed result for inspection on 8/7/24

Date of last standard health inspection:	8/7/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	10/23/24Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	4
Average number of Health Deficiencies in Wisconsin:	9.3
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
No Quality of Life and Care Deficiencies were found during this inspection period.

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	10/23/24	11/22/24	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.	8/7/24	9/5/24	2 - Minimal harm or potential for actual harm	Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	8/7/24	9/5/24	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.	10/23/24	11/22/24	2 - Minimal harm or potential for actual harm	Few

Detailed result for inspection on 6/7/23

Date of last standard health inspection:	6/7/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	4/24/23Read the full report (PDF) 4/17/23Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	5
Average number of Health Deficiencies in Wisconsin:	8
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Respond appropriately to all alleged violations.	4/17/23	5/17/23	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	6/7/23	7/7/23	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	4/24/23	5/24/23	2 - Minimal harm or potential for actual harm	Few
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.	6/7/23	7/7/23	1 - Potential for minimal harm	Some

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	6/7/23	7/7/23	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 7/20/22

Date of last standard health inspection:	7/20/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	5/3/22Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	No infection control inspections
Total number of Health Deficiencies for this nursing home:	8
Average number of Health Deficiencies in Wisconsin:	8.5
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	5/3/22	6/3/22	2 - Minimal harm or potential for actual harm	Few
Respond appropriately to all alleged violations.	7/20/22	7/21/22	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide safe, appropriate dialysis care/services for a resident who requires such services.	7/20/22	7/21/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	5/3/22	6/3/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	7/20/22	7/21/22	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
PASARR screening for Mental disorders or Intellectual Disabilities	7/20/22	7/21/22	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	5/3/22	6/3/22	2 - Minimal harm or potential for actual harm	Few
Allow resident to participate in the development and implementation of his or her person-centered plan of care.	7/20/22	7/21/22	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	10/23/24	11/22/24	2 - Minimal harm or potential for actual harm	Few
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.	10/23/24	11/22/24	2 - Minimal harm or potential for actual harm	Few
Respond appropriately to all alleged violations.	4/17/23	5/17/23	2 - Minimal harm or potential for actual harm	Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	4/24/23	5/24/23	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	5/3/22	6/3/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	5/3/22	6/3/22	2 - Minimal harm or potential for actual harm	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	5/3/22	6/3/22	2 - Minimal harm or potential for actual harm	Few

Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.

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