Bethany Home: Fall Safety Training Gaps Put Residents at Risk - WI
Nineteen of the facility's 26 agency nurses never saw the most critical parts of it.
A federal inspection completed October 27, 2025 found that Bethany Home, a nursing facility in Waupaca, Wisconsin, failed to ensure agency staff received and acknowledged safety training that had been created specifically in response to a resident harm event. The deficiency was cited at the "actual harm" level, meaning inspectors determined a real resident had already been hurt before any of this training existed, and the facility's corrective plan was leaving a significant portion of its workforce in the dark.
The inspection report does not name the resident who was harmed. What it documents is the chain of events that followed.
A certified nursing assistant identified in the report as CNA-C was involved in the incident. The facility educated CNA-C verbally, by phone, and did not allow the person to return. A registered nurse identified as RN-D, described as an agency staff member, received one-on-one education on September 26, 2025, covering how to transfer a resident to the hospital, how to reach the after-hours physician group, abuse and neglect recognition, critical thinking, resident rights, and when to complete an incident report.
The facility then built out four broader training modules. Two were for all nursing staff: one on following a resident's care plan for transfers, including the instruction that staff can always use more staff for a transfer but not fewer, and one on transfer technique, specifically what to do if a resident becomes weak mid-transfer. Lower them to a chair, a bed, a toilet, a shower chair. If none of those are reachable, lower the resident to the floor. Two modules were designated for licensed staff only: one on the nurse's obligation to contact a provider or after-hours group when a resident asks to go to the emergency room, and one on how to determine, during a fall investigation, whether the care plan had been followed, and whether a care plan violation might constitute neglect.
That last point is significant. The facility's own training told licensed nurses that if a care plan wasn't followed, the nurse must contact the director of nursing, because not following a care plan may be considered abuse. That framing, embedded in the corrective training, suggests the original incident involved exactly that question.
For direct-hire staff, the system worked. The training was loaded into the facility's electronic platform. By the time the surveyor arrived on October 27, more than 95 percent of direct employees had completed it.
Agency staff were a different matter.
The director of nursing, identified as DON-B, told the surveyor that agency staff do not have access to the facility's electronic training system. The licensed-staff-only modules were never provided to agency nurses in any other format. RN-D, the agency nurse who had been at the center of the original incident, was the only agency licensed staff member who saw those two modules at all.
For the all-staff modules, the facility put paper sign-in sheets on a clipboard. Direct-hire staff, DON-B explained, know to check the clipboard before their shifts. Most agency staff do not know to check it. When the surveyor pulled the sign-in sheets, only a few agency staff signatures appeared. When the surveyor asked for a list of agency workers who had worked at the facility since September 26, the date the retraining began, 26 names came back. Seven had signed.
DON-B, interviewed twice on the day of inspection, at 11:54 in the morning and again at 1:18 in the afternoon, confirmed what the numbers showed. The facility does not have a process to ensure agency staff see and sign education. That was not a disputed finding. It was an admission.
The gap matters because agency nurses are not peripheral to how this facility operates. Twenty-six agency staff worked there in the roughly month-long window between the start of retraining and the day inspectors arrived. That is not a handful of occasional fill-ins. Those are nurses and aides taking assignments, moving residents, making clinical decisions, including decisions about when to call a doctor and how to handle a resident who wants to go to the emergency room, without having been told what the facility now required them to know.
The training they missed was not generic. It was written because someone got hurt. It addressed the specific scenario, a transfer that went wrong, and the specific failure, a care plan that may not have been followed. It told licensed staff that this kind of failure could be classified as neglect. And then the facility distributed that training in a way that guaranteed most of its agency nurses would never read it.
There is a particular quality to this kind of gap. It is not the gap of a facility that ignored a problem. The documentation is real. The electronic system, the clipboard, the sign-in sheets, the one-on-one session with RN-D, those all happened. The facility did the work of creating a response. What it did not do was think through who was actually working its floors and whether those people were reachable through the systems it had built.
DON-B did not dispute any of this when the surveyor laid it out. The clipboard process works for people who know to look for it. Agency staff, by definition, are not steeped in the facility's internal rhythms. They show up for a shift, they take their assignment, and unless someone hands them something directly or tells them explicitly where to look, the clipboard might as well not exist.
The inspection was a complaint survey, meaning someone, a resident, a family member, a staff member, prompted the visit by contacting regulators. The report does not identify who filed the complaint or what specifically they reported. What it shows is that when the surveyor arrived, the question was not whether a resident had been harmed. That had already been established. The question was whether the facility's response was working.
For the direct-hire staff, it largely was. For the agency nurses rotating through the building, taking assignments alongside those trained employees, the answer the director of nursing gave was unambiguous: there was no process to make sure they got the information. The licensed-staff-only training, the part about calling the doctor when a resident wants the ER, the part about care plan violations and neglect, had reached exactly one agency nurse. The one who had already been at the center of the incident that started all of this.
The resident who was harmed in the original incident is not named in the report. Their condition after the event, what the transfer looked like, what happened when it went wrong, none of that is documented in the pages the surveyor filed. What remains is the outline: a fall or near-fall serious enough to prompt a complaint, a CNA barred from returning, a nurse retrained individually, and then a facility-wide education effort that covered most of the people who work there and missed most of the ones it had the least control over.
The clipboard sat at the nurses' station. Most of the agency staff did not know to check it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bethany Home from 2025-10-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 24, 2026 · Our methodology
Bethany Home in Waupaca, WI was cited for violations during a health inspection on October 27, 2025.
Nineteen of the facility's 26 agency nurses never saw the most critical parts of it.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.