SeniorHomeViolations
C+
69/100

BETHANY VILLAGE Inspection Report, Violations & Safety Grade (INDIANAPOLIS, Indiana)

3518 S SHELBY ST, INDIANAPOLIS, Indiana 46227

Phone: 3177834042

CMS Overall:3/5

Overview & Bed Count

Certified Beds
100
Avg Residents/Day
85.2
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Marion
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall3/5
Health2/5
Staffing2/5
Quality5/5

Nurse Staffing Check

MetricThis FacilityIndiana AvgDifference
RN Hours per Resident per Day0.750.68+0.08
Total Nurse Hours per Resident per Day3.553.73-0.19
CMS Staffing Rating2/52.6/5-
Nursing Staff Turnover57.4%45.9%-

Health Citation History

20 health citations on record

DateCategoryDescriptionSeverity
2025-09-08Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2025-09-08Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.E – Moderate Harm Potential
2025-09-08Quality of Life and Care DeficienciesProvide safe, appropriate dialysis care/services for a resident who requires such services.D – Moderate Harm Potential
2025-09-08Pharmacy Service DeficienciesEnsure 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.D – Moderate Harm Potential
2025-09-08Infection Control DeficienciesDevelop and implement policies and procedures for flu and pneumonia vaccinations.D – Moderate Harm Potential
2025-09-08Infection Control DeficienciesEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.D – Moderate Harm Potential
2025-07-24Resident Assessment and Care Planning DeficienciesSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D – Moderate Harm Potential
2025-01-28Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from the wrongful use of the resident's belongings or money.E – Moderate Harm Potential
2024-09-10Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.E – Moderate Harm Potential
2024-09-10Resident Rights DeficienciesReasonably accommodate the needs and preferences of each resident.D – Moderate Harm Potential
2024-09-10Resident Rights DeficienciesProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.D – Moderate Harm Potential
2024-09-10Resident Assessment and Care Planning DeficienciesEnsure each resident receives an accurate assessment.D – Moderate Harm Potential
2024-09-10Quality of Life and Care DeficienciesProvide appropriate pressure ulcer care and prevent new ulcers from developing.D – Moderate Harm Potential
2024-09-10Pharmacy Service DeficienciesEnsure 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.D – Moderate Harm Potential
2024-09-10Environmental DeficienciesMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.D – Moderate Harm Potential
2023-12-01Quality of Life and Care DeficienciesProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.D – Moderate Harm Potential
2023-12-01Quality of Life and Care DeficienciesEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.D – Moderate Harm Potential
2023-12-01Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2023-09-29Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.E – Moderate Harm Potential
2023-09-29Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D – Moderate Harm Potential

Fire Safety Citation History

19 fire safety citations on record

DateCategoryDescriptionSeverity
2025-09-08Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2025-09-08Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.F – Moderate Harm Potential
2025-09-08Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.F – Moderate Harm Potential
2025-09-08Smoke DeficienciesInstall an approved automatic sprinkler system.E – Moderate Harm Potential
2025-09-08Services DeficienciesHave properly installed electrical wiring and gas equipment.E – Moderate Harm Potential
2025-09-08Services DeficienciesHave an externally vented heating system.D – Moderate Harm Potential
2024-09-10Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.E – Moderate Harm Potential
2024-09-10Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.E – Moderate Harm Potential
2024-09-10Smoke DeficienciesInstall an approved automatic sprinkler system.D – Moderate Harm Potential
2024-09-10Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.D – Moderate Harm Potential
2024-09-10Services DeficienciesHave properly installed electrical wiring and gas equipment.D – Moderate Harm Potential
2024-09-10Miscellaneous DeficienciesHave posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.D – Moderate Harm Potential
2023-09-29Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.E – Moderate Harm Potential
2023-09-29Smoke DeficienciesInstall an approved automatic sprinkler system.E – Moderate Harm Potential
2023-09-29Smoke DeficienciesProperly select, install, inspect, or maintain portable fire extinguishes.E – Moderate Harm Potential
2023-09-29Smoke DeficienciesInstall corridor and hallway doors that block smoke.E – Moderate Harm Potential
2023-09-29Smoke DeficienciesInstall smoke barrier doors that can resist smoke for at least 20 minutes.E – Moderate Harm Potential
2023-09-29Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.C – Minimal Harm Potential
2023-09-29Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.B – Minimal Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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