Bethany Home

F 0607

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or potential for actual harm

Based on staff interview and record review, the facility did not implement policies and procedures to prevent abuse for 1 (Certified Nursing Assistant (CNA)-C)) of 8 staff reviewed for caregiver background checks.The facility did not ensure an out-of-state background check was completed for CNA-C.Findings include: The facility's Abuse Prohibition policy, revised 4/19/21, indicates: Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff .On 10/27/25, Surveyor reviewed background check information for agency CNA-C whose first day of work at the facility was 8/26/25.

CNA-C's Background Information Disclosure (BID) form was signed and dated 6/11/25. The form was completed when CNA-C began working for Agency (AG)-F and indicated CNA-C lived outside the state of Wisconsin in the previous 3 years. CNA-C's background check information did not indicate an out-of-state or national search was completed.On 10/27/25 at 11:45 AM, Surveyor interviewed Director of Nursing (DON)-B who provided Surveyor with a national search completed on 10/27/25. DON-B indicated the facility relies on the agency to ensure background checks are done correctly prior to staff working at the facility.

DON-B indicated Director of Human Resources (DHR)-E handles all of the background check information.On 10/27/25 at 12:00 PM, Surveyor interviewed DHR-E who indicated DHR-E tries to keep agency staff background checks on site and tries to catch anything that looks incorrect. DHR-E verified an out-of-state background check was not provided or completed for CNA-C. DHR-E confirmed the facility should have complete background check information prior to agency staff starting at the facility.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bethany Home

1226 Berlin Street Waupaca, WI 54981

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

initiated education. CNA-C was educated verbally via phone and was not allowed to return to the facility.On 9/26/25, RN-D was provided with 1:1 education regarding where to find forms to transfer a resident to the hospital, how to use the after-hours physician group, abuse/neglect, critical thinking skills, resident rights, and when to fill out an incident report. The facility initiated the following 4 pieces of education:1. For All Nursing Staff: Ensuring following a resident's care plan related to transfer status. Staff can always use more staff but not less. Where to find care plans if there are questions and asking a co-worker to assist/work together as a team.2. For All Nursing Staff: Transfer training and if a resident gets weak during a transfer, try lowering them to a chair, bed, toilet, shower chair. If unable to lower them to another surface, then lower

the resident to the floor.3. For Licensed Staff Only: If a resident requests to go to the ER, the nurse must contact the provider or after-hours group.4. For Licensed Staff Only: Ruling out abuse or neglect as part of

a fall investigation. The unit nurse completes the fall investigation and then must determine whether the care plan was followed. If there was a care plan violation, the nurse should then contact the DON as not following a care plan may be considered abuse.On 10/27/25, Surveyor reviewed the education to ensure facility and agency staff acknowledged receipt of the education. Surveyor reviewed the facility's direct hire staff and noted the education was added to the facility's electronic training system. Over 95% of direct staff had completed the education.On 10/27/25, Surveyor requested proof of education for agency staff. DON-B provided 2 sign-in sheets for the All Staff trainings. Surveyor did not receive any signed acknowledgements for the Licensed Staff Only trainings.On 10/27/25, Surveyor requested a list of agency staff who had worked since 9/26/25 and noted only approximately 7 of 26 agency staff had signed the education regarding following a resident's care plan for transfer status.On 10/27/25 at 11:54 AM and 1:18 PM, Surveyor interviewed DON-B who indicated Licensed Staff Only training was added to the facility's electronic training system but was not provided for agency licensed staff to review and sign. DON-B indicated agency staff do not have access to the facility's electronic training system and verified RN-D was the only agency staff who saw the Licensed Staff Only training. When informed that the All Nursing Staff training signature sheets contained signatures of only a few agency staff, DON-B indicated the facility does not have a process to ensure agency staff see and sign education. DON-B indicated the education is put on a clipboard that direct staff know to check prior to their shift, however, most agency staff do not know to check the clipboard.

Event ID:

Facility ID:

If continuation sheet