01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-09-08 | 6 | 2025-09-08 | 6 |
| Cycle 2 | 2024-09-10 | 9 | 2024-09-10 | 6 |
| Cycle 3 | 2023-09-29 | 5 | 2023-09-29 | 7 |
CMS CCN 1552372026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Bethany Village
3518 S Shelby St · Indianapolis, IN 46227 · Marion County
Certified beds100CMS provider file
Recent citation rows39current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
39 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 7 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-09-08 · HEALTHF0689Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-09-08 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-09-08 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-09-08 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-09-08 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-09-08 · HEALTHF0887Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-09-08 · FIREK0351Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2025-10-202025-09-08 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-10-202025-09-08 · FIREK0511Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2025-10-202025-09-08 · FIREK0522Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have an externally vented heating system.
Correction field: Deficient, Provider has date of correction · 2025-10-202025-09-08 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-10-202025-09-08 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-10-202025-07-24 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-07-29 · complaint2025-01-28 · HEALTHF0602Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Correction field: Past Non-Compliance · 2024-12-23 · complaint2024-09-10 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2024-09-302024-09-10 · HEALTHF0623Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Correction field: Deficient, Provider has date of correction · 2024-09-302024-09-10 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2024-09-302024-09-10 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-09-302024-09-10 · HEALTHF0689Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-09-302024-09-10 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2024-09-30 · complaint2024-09-10 · HEALTHF0921Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2024-09-302024-09-10 · FIREK0351Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2024-10-102024-09-10 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-10-102024-09-10 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2024-10-1003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- HENRY COUNTY MEMORIAL HOSPITALOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 01/01/2023
- CHIES, STEVENIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2023
- DYNES, SHELDONIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2013
- JACKSON, BLAKEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2023
- JACKSON, ETHANIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2023
- JACKSON, MARKIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2023
- JACKSON, MICHAELIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/14/2024
- JACKSON, WESSLEYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2023
- JUSTICE, DAVIDIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2023
- KELSEY, DONNAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 07/18/2024
- PIDGEON, JOHNIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2013
- SHORE, MARIONIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2013
- STITLE, STEPHENIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2023
- WARE, DEBORAHIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 08/27/2021
- WRIGHT, THERESSAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2023
- AMERICAN SENIOR COMMUNITIES LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/2023
- DICE, MARKIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2023
- FINGERS, HOLLYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/24/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.41per resident day
RN hours0.50per resident day
Weekend nurse hours2.94per resident day
Staff turnover59.6%CMS reported field
06 / LOCAL RECORDS
Open the Indianapolis ledger →Other published facilities nearby
Allison Pointe Healthcare Center144 beds · CMS overall 2/583 citation rowsAlpha Home - A Waters Community86 beds · CMS overall 1/557 citation rowsAltenheim Health & Living Community87 beds · CMS overall 4/538 citation rowsAmerican Village150 beds · CMS overall 3/573 citation rowsArlington Place Health Campus84 beds · CMS overall 4/536 citation rowsBrickyard Healthcare - Brookview Care Center136 beds · CMS overall 3/543 citation rowsBrickyard Healthcare - Churchman Care Center115 beds · CMS overall 4/547 citation rowsBrickyard Healthcare - Willow Springs Care Center134 beds · CMS overall 2/565 citation rows