Bethel Home
225 N Eagle St, Oshkosh, WI 54902
Bethel Home is a nursing home in Oshkosh, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 4 of 5CMS overall star rating
- 4 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (920) 235-4653
- Last standard health inspection
- September 10, 2025 (1 year ago)
- Certified beds
- 100
- Residents per day, on average
- 69.8
- Ownership type
- Non profit - Corporation
- Legal business name
- Bethel Home, INC.
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Wisconsin average (11 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.1 to 3.7 hours per resident per day.
Ownership
CMS ownership records list new owners for this home.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
CMS update of April 29, 2026
Staffing
Total nurse staffing reported to CMS went from 4.0 to 3.4 hours per resident per day.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of January 14, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 5 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 4 of 5.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 3 of 5 to 5 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
3 citations
Health inspection on September 10, 2025
CMS lists this as a standard inspection.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 6, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on October 6, 2025.
CMS has cited this home for F0755 2 times since 2023.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on October 6, 2025.
10 citations
Fire safety inspection on September 10, 2025
CMS lists this as a standard inspection.
Citation E0020. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures including evacuation.
CMS lists it as corrected on October 15, 2025.
Citation E0024. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures for volunteers.
CMS lists it as corrected on October 3, 2025.
Citation E0036. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish emergency prep training and testing.
CMS lists it as corrected on November 10, 2025.
Citation E0041. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on September 29, 2025.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on September 26, 2025.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on October 30, 2025.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on October 15, 2025.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on September 22, 2025.
CMS has cited this home for K0321 3 times since 2023.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on October 15, 2025.
CMS has cited this home for K0353 3 times since 2023.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on October 15, 2025.
1 citation
Health inspection on August 13, 2025
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
71 of 323 Wisconsin homes (22%) got a citation at the immediate jeopardy level in 2025.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 31, 2025.
CMS has cited this home for F0689 2 times since 2023.
CMS update of July 30, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.4 to 3.9 hours per resident per day.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
2 citations
Health inspection on October 23, 2024
CMS lists this as a complaint inspection.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on November 22, 2024.
Citation F0777. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
CMS lists it as corrected on November 22, 2024.
2 citations
Health inspection on August 7, 2024
CMS lists this as a standard inspection.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on September 5, 2024.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 5, 2024.
17 citations
Fire safety inspection on August 7, 2024
CMS lists this as a standard inspection.
Citation E0018. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish procedures for tracking staff and patients during an emergency.
CMS lists it as corrected on September 24, 2024.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on September 24, 2024.
Citation K0753. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have restrictions on the use of highly flammable decorations.
CMS lists it as corrected on September 24, 2024.
Citation K0912. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have power receptacles that are properly grounded.
CMS lists it as corrected on September 24, 2024.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on November 8, 2024.
Citation K0311. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have an enclosure around a vertical opening shaft.
CMS lists it as corrected on September 24, 2024.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on September 24, 2024.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on September 3, 2024.
Citation K0331. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Construct fire resistant interior walls.
CMS lists it as corrected on November 1, 2024.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on September 24, 2024.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on September 24, 2024.
Citation K0521. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on September 24, 2024.
CMS has cited this home for K0521 2 times since 2023.
Citation K0751. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have restrictions on the use of flammable curtains.
CMS lists it as corrected on September 24, 2024.
Citation K0925. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
CMS lists it as corrected on September 24, 2024.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 24, 2024.
Citation K0223. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on September 24, 2024.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on September 24, 2024.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 1 of 5.
3 citations
Health inspection on June 7, 2023
CMS lists this as a standard inspection.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 7, 2023.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on July 7, 2023.
Citation F0640. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
CMS lists it as corrected on July 7, 2023.
4 citations
Fire safety inspection on June 7, 2023
CMS lists this as a standard inspection.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 19, 2023.
Citation K0521. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on June 13, 2023.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on June 19, 2023.
Citation K0911. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on June 14, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- MIRAVIDA LIVING INC5% or greater direct ownership interest · 100% · since 01/01/1965
- MIRAVIDA LIVING INCOperational/managerial control · not applicable · since 01/01/1965
Questions
When was Bethel Home last inspected?
CMS lists September 10, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Bethel Home have?
CMS lists 11 health citations since June 7, 2023. CMS also calls these deficiencies.
Has Bethel Home been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Bethel Home?
Its CMS overall star rating is 4 of 5.
Is Bethel Home a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.