01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-09-10 | 4 | 2025-09-10 | 10 |
| Cycle 2 | 2024-08-07 | 4 | 2024-08-07 | 17 |
| Cycle 3 | 2023-06-07 | 3 | 2023-06-07 | 4 |
CMS CCN 5255542026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Bethel Home
225 N Eagle St · Oshkosh, WI 54902 · Winnebago County
Certified beds100CMS provider file
Recent citation rows42current 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
42 rows in the current release
1 rows carry G–L scope/severity codes; 1 carry J–L. 5 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-09-10 · FIREE0020Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish policies and procedures including evacuation.
Correction field: Deficient, Provider has date of correction · 2025-10-152025-09-10 · FIREE0024Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish policies and procedures for volunteers.
Correction field: Deficient, Provider has date of correction · 2025-10-032025-09-10 · FIREE0036Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Correction field: Deficient, Provider has date of correction · 2025-11-102025-09-10 · FIREE0041Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has date of correction · 2025-09-292025-09-10 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-10-062025-09-10 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-10-062025-09-10 · 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 · 2025-10-062025-09-10 · FIREK0211Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2025-10-152025-09-10 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-09-222025-09-10 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-09-262025-09-10 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-10-152025-09-10 · 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 · 2025-10-302025-09-10 · FIREK0923Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2025-10-152025-08-13 · HEALTHF0689Severity J · isolated immediate jeopardy
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: Past Non-Compliance · 2025-07-31 · complaint2024-10-23 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2024-11-22 · complaint2024-10-23 · HEALTHF0777Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Correction field: Deficient, Provider has date of correction · 2024-11-22 · complaint2024-08-07 · FIREE0018Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish procedures for tracking staff and patients during an emergency.
Correction field: Deficient, Provider has date of correction · 2024-09-242024-08-07 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2024-09-242024-08-07 · 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 · 2024-09-052024-08-07 · HEALTHF0625Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Correction field: Deficient, Provider has date of correction · 2024-09-052024-08-07 · FIREK0222Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-09-242024-08-07 · FIREK0223Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Correction field: Deficient, Provider has date of correction · 2024-09-242024-08-07 · FIREK0311Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Have an enclosure around a vertical opening shaft.
Correction field: Deficient, Provider has date of correction · 2024-09-242024-08-07 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2024-09-2403 / 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
- MIRAVIDA LIVINGOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 01/01/1965
- BERTRAM, THERESAIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 10/31/2015
- BERMINGHAM, KATHYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2020
- BONELL, JAMIEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2021
- MCNIEL, PAULAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2021
- MULLER, LAURIEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2021
- OLSON, MARGARETIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/14/2016
- OLSON, NATEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2021
- RIECKMAN, STEWIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2021
- BEECHER, MARKIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2021
- BERTRAM, THERESAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/07/2013
- MURKEN, MARYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2021
- MIRAVIDA LIVINGOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/1965
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 hours4.12per resident day
RN hours1.21per resident day
Weekend nurse hours3.69per resident day
Staff turnover43.6%CMS reported field
06 / LOCAL RECORDS
Open the Oshkosh ledger →