Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
BETHANY VILLAGE
INDIANAPOLIS, IN · 100 certified beds · Last Life Safety survey September 8, 2025
CMS Certification Number 155237 · first certified September 1984
Ownership
Operated by AMERICAN SENIOR COMMUNITIES · For profit - Corporation
- Ownership changed January 1, 2023 (change of ownership)from THE HEALTH AND HOSPITAL CORPORATION OF MARION COUNTY
Position within IN
19 citations — more than 63% of the 507 certified nursing homes in IN. Compared within IN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 6.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: August 2026 to October 2026. This facility’s last Life Safety survey was September 2025. Facilities in IN are typically surveyed 11–14 months after the last one (median 13), measured over 883 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 19 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in IN, and nationally. Surveyors differ markedly between states, so the IN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 19 |
| Median facility in IN | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 29, 2023 | 7 |
| September 10, 2024 | 6 |
| September 8, 2025 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0351 | Install an approved automatic sprinkler system. | 3 | 2025-09-08 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-09-08 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2025-09-08 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2024-09-10 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-09-08 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2023-09-29 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2023-09-29 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2025-09-08 |
What the citations cover
- Smoke Deficiencies 10
- Services Deficiencies 3
- Miscellaneous Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Services Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 8, 2025 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (October 20, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 20, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 20, 2025) |
| K-0522 | Have an externally vented heating system. | Deficient, Provider has date of correction (October 20, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 20, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 20, 2025) |
September 10, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 10, 2024) |
September 29, 2023 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 23, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (December 23, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (December 23, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 23, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (December 23, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 23, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 23, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.