Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Bethel Home
Oshkosh, WI · 100 certified beds · Last Life Safety survey September 10, 2025
CMS Certification Number 525554 · first certified December 1994
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WI
31 citations — more than 87% of the 323 certified nursing homes in WI. Compared within WI 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 10 citations; the earlier surveys in the window averaged 10.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens October 2026 — about 1 month from now. This facility’s last Life Safety survey was September 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 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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2 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.
Emergency preparedness
6 of the 31 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 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 31 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 31 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 7, 2023 | 4 |
| August 7, 2024 | 17 |
| September 10, 2025 | 10 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 3 | 2025-09-10 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-09-10 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2024-08-07 |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | 1 | 2024-08-07 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-09-10 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2025-09-10 |
| E-0024 | Establish policies and procedures for volunteers. | 1 | 2025-09-10 |
| K-0222 | 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. | 1 | 2024-08-07 |
What the citations cover
- Smoke Deficiencies 12
- Emergency Preparedness Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Egress Deficiencies 3
- Other 5
| Category | Citations |
|---|---|
| Smoke Deficiencies | 12 |
| Emergency Preparedness Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Egress Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
| Services Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 10, 2025 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (October 15, 2025) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (October 3, 2025) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (November 10, 2025) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (September 29, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (October 15, 2025) |
| 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 (September 22, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (September 26, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 15, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 30, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (October 15, 2025) |
August 7, 2024 — 17 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (September 24, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (September 24, 2024) |
| K-0222 | 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. | Deficient, Provider has date of correction (September 24, 2024) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (September 24, 2024) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (September 24, 2024) |
| 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 (September 24, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 3, 2024) |
| K-0331 | Construct fire resistant interior walls. | Waiver has been granted (November 1, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 24, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (September 24, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 24, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (September 24, 2024) |
| K-0751 | Have restrictions on the use of flammable curtains. | Deficient, Provider has date of correction (September 24, 2024) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (September 24, 2024) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (September 24, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Waiver has been granted (November 8, 2024) |
| K-0925 | Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Deficient, Provider has date of correction (September 24, 2024) |
June 7, 2023 — 4 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 (June 19, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 19, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (June 13, 2023) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (June 14, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.