Bethany Home
Bethany Home in Waupaca, WI — inspection on October 27, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
525538 10/27/2025
Bethany Home 1226 Berlin Street Waupaca, WI 54981
pieces of education:1.
For All Nursing Staff: Ensuring following a resident's care plan related to
questions and asking a co-worker to assist/work together as a team.2.
For All Nursing Staff: Transfer
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.