Cycle 1
Health 2025-05-21 · Fire 2025-05-21
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Waupaca, WI
Bethany Home
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1226 Berlin Street, Waupaca, WI
(715) 258-5521
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.04
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.67
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.54
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.86
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.85
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.08
CMS adjusted RN staffing hours
Adjusted total hours
4.72
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,643
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.57
Composite VBP score used to determine payment impact.
Payment multiplier
1.0023
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.52
Baseline 16.83% · Performance 18.41% · Measure score 6.52 · Achievement 6.52 · Improvement 0
Healthcare-associated infections
1.04
Baseline 5.75% · Performance 7.52% · Measure score 1.04 · Achievement 1.04 · Improvement 0
Total nurse turnover
8.37
Baseline 100.00% · Performance 33.33% · Measure score 8.37 · Achievement 7.42 · Improvement 8.37
Adjusted total nurse staffing
3.49
Baseline 3.34 hours · Performance 4.07 hours · Measure score 3.49 · Achievement 3.49 · Improvement 2.50
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.41% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 5.06% · Lower 95% interval 6.34% |
| Discharge to community | 46.43% |
50.57%
4.1 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 40.54% · Lower 95% interval 34.82% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.22% |
95.27%
2 pts better
|
Numerator 70 · Denominator 72 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 72 |
| Discharge self-care score | 58.33% |
53.69%
4.6 pts better
|
Numerator 35 · Denominator 60 |
| Discharge mobility score | 63.33% |
50.94%
12.4 pts better
|
Numerator 38 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 72 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.52% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 8.33% · Lower 95% interval 4.53% |
| Staff COVID-19 vaccination coverage | 8.59% |
8.2%
0.4 pts better
|
Numerator 14 · Denominator 163 |
| Staff flu vaccination coverage | 95.21% |
42%
53.2 pts better
|
Numerator 179 · Denominator 188 |
| Discharge function score | 75% |
56.45%
18.5 pts better
|
Numerator 45 · Denominator 60 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 41 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 31.71% |
25.2%
6.5 pts better
|
Numerator 13 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.6
1.1 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.2
0.7 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
95.7%
3.5 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.5% · Q3 98.4% · Q4 100.0% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.2%
1.2 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.1% · Q3 1.6% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
5.0%
1.2 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.3% · Q3 7.0% · Q4 1.7% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
4.9%
1.5 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.0% · Q3 5.6% · Q4 1.9% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
16.6%
1.6 pts worse
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 24.0% · Q3 14.5% · Q4 14.5% · 4Q avg 18.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.9% |
16.7%
1.8 pts better
|
16.7%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 17.9% · Q3 15.2% · Q4 13.0% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.9% |
21.1%
1.8 pts worse
|
16.3%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 15.5% · 4Q avg 22.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.8% |
17.3%
0.5 pts better
|
14.9%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 14.9% · Q3 15.4% · Q4 13.7% · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
2.3%
1.8 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
3.0%
2.6 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.0% |
25.5%
4.5 pts worse
|
19.8%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.1% · Q2 36.7% · Q3 20.4% · Q4 33.3% · 4Q avg 30.0% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
5.5%
4.3 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.3% · Q4 2.5% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
86.8%
9.9 pts better
|
81.7%
15 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.9% · Q2 97.9% · Q3 97.4% · Q4 97.9% · 4Q avg 96.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
15.0%
7.6 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 7.5% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.7% |
82.2%
4.5 pts better
|
79.7%
7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.0% |
22.7%
8.7 pts better
|
23.9%
9.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.0% · Observed 13.4% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-17 · Fire 2024-04-17
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-03-15 · Fire 2023-03-15
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-16
E · Potential for more than minimal harm
2025-05-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-01
E · Potential for more than minimal harm
2025-05-21
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-06-11
E · Potential for more than minimal harm
2025-05-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-05-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-10
F · Potential for more than minimal harm
2024-04-17
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-04-17
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-04-17
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-04-17
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-04-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-04-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-04-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-04-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-04-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-17
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-05-07
D · Potential for more than minimal harm
2024-04-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-17
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-17
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-05-17
D · Potential for more than minimal harm
2023-03-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-03-15
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-03-27
Inspection history
Recent health citations
G · Actual harm
2025-10-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-10-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-11-21
E · Potential for more than minimal harm
2025-05-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-16
D · Potential for more than minimal harm
2025-05-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-06-16
D · Potential for more than minimal harm
2025-05-21
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-06-16
D · Potential for more than minimal harm
2024-09-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-04-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-17
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-05-17
Penalties and ownership
What sits behind the stars
Ownership
Abrahamson, Sue
Corporate Director · Individual
Conradt, Barbara
Corporate Director · Individual
Gutho, Hannah
Corporate Director · Individual
Jacquart, Mike
Corporate Director · Individual
Mazemke, Michele
Operational/Managerial Control · Individual
Mazemke, Michele
Corporate Director · Individual
Reichenbach, Gregory
Operational/Managerial Control · Individual
Reichenbach, Gregory
Corporate Officer · Individual
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#3
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