A-
85/100Bethel Home Inspection Report, Violations & Safety Grade (Oshkosh, Wisconsin)
225 N Eagle St, Oshkosh, Wisconsin 54902
Phone: 9202354653
CMS Overall:4/5
Overview & Bed Count
Certified Beds
100
Avg Residents/Day
69.8
Ownership
Non profit - Corporation
Provider Type
Medicare and Medicaid
County
Winnebago
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall4/5
Health4/5
Staffing4/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | Wisconsin Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.96 | 0.98 | -0.03 |
| Total Nurse Hours per Resident per Day | 3.68 | 4.25 | -0.56 |
| CMS Staffing Rating | 4/5 | 3.7/5 | - |
| Nursing Staff Turnover | 53.7% | 46.7% | - |
Health Citation History
11 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-09-10 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2025-09-10 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2025-09-10 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D – Moderate Harm Potential |
| 2025-08-13 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2024-10-23 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2024-10-23 | Administration Deficiencies | Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | D – Moderate Harm Potential |
| 2024-08-07 | Resident Rights Deficiencies | Provide 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 |
| 2024-08-07 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2023-06-07 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2023-06-07 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2023-06-07 | Resident Assessment and Care Planning Deficiencies | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | B – Minimal Harm Potential |
Fire Safety Citation History
31 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-09-10 | Emergency Preparedness Deficiencies | Establish policies and procedures including evacuation. | F – Moderate Harm Potential |
| 2025-09-10 | Emergency Preparedness Deficiencies | Establish policies and procedures for volunteers. | F – Moderate Harm Potential |
| 2025-09-10 | Emergency Preparedness Deficiencies | Establish emergency prep training and testing. | F – Moderate Harm Potential |
| 2025-09-10 | Emergency Preparedness Deficiencies | Implement emergency and standby power systems. | F – Moderate Harm Potential |
| 2025-09-10 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-09-10 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2025-09-10 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2025-09-10 | Smoke Deficiencies | Ensure 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 |
| 2025-09-10 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2025-09-10 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | E – Moderate Harm Potential |
| 2024-08-07 | Emergency Preparedness Deficiencies | Establish procedures for tracking staff and patients during an emergency. | F – Moderate Harm Potential |
| 2024-08-07 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2024-08-07 | Miscellaneous Deficiencies | Have restrictions on the use of highly flammable decorations. | F – Moderate Harm Potential |
| 2024-08-07 | Gas, Vacuum, and Electrical Systems Deficiencies | Have power receptacles that are properly grounded. | F – Moderate Harm Potential |
| 2024-08-07 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2024-08-07 | Smoke Deficiencies | Have an enclosure around a vertical opening shaft. | E – Moderate Harm Potential |
| 2024-08-07 | Smoke Deficiencies | Ensure 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 |
| 2024-08-07 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2024-08-07 | Smoke Deficiencies | Construct fire resistant interior walls. | E – Moderate Harm Potential |
| 2024-08-07 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2024-08-07 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2024-08-07 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | E – Moderate Harm Potential |
| 2024-08-07 | Miscellaneous Deficiencies | Have restrictions on the use of flammable curtains. | E – Moderate Harm Potential |
| 2024-08-07 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure that sources of ignition are removed from patients receiving respiratory therapy. | E – Moderate Harm Potential |
| 2024-08-07 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | D – Moderate Harm Potential |
| 2024-08-07 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | D – Moderate Harm Potential |
| 2024-08-07 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | D – Moderate Harm Potential |
| 2023-06-07 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2023-06-07 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | E – Moderate Harm Potential |
| 2023-06-07 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2023-06-07 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the installation and maintenance of electrical systems. | D – Moderate 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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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Oshkosh area at no cost.
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.