Cycle 1
Health 2025-09-08 · Fire 2025-09-08
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Indianapolis, IN
Bethany Village
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
3518 S Shelby St, Indianapolis, IN
(317) 783-4042
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
American Senior Communities
Operator or chain grouping
Approved since
1984-09-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
91 facilities
Chain averages 4 overall / 3 health / 2 staffing / 5 quality stars
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
0.46
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.47
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.97
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.19
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,272
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.18
Baseline 59.52% · Performance 46.58% · Measure score 4.18 · Achievement 4.18 · Improvement 3.23
Adjusted total nurse staffing
0
Baseline 2.81 hours · Performance 2.89 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.6% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 11.9% · Lower 95% interval 7.3% |
| Discharge to community | 39.01% |
50.57%
11.6 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 28.13% · Lower 95% interval 27.42% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 8 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 101 |
| Staff flu vaccination coverage | 22.96% |
42%
19 pts worse
|
Numerator 31 · Denominator 135 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.6
0.9 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.7 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.5
0.5 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.0% |
93.6%
7.6 pts worse
|
93.4%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.9% · Q2 91.8% · Q3 81.8% · Q4 76.3% · 4Q avg 86.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 77.2% |
95.4%
18.2 pts worse
|
95.5%
18.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 77.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.8%
1.4 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.1% · Q3 6.5% · Q4 6.6% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 22.9% |
24.6%
1.7 pts better
|
11.4%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 18.2% · Q3 25.4% · Q4 33.8% · 4Q avg 22.9% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
5.6%
1.6 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 7.7% · Q3 6.0% · Q4 4.3% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
23.5%
8.2 pts better
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 16.7% · Q3 14.5% · Q4 12.9% · 4Q avg 15.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
14.8%
4.7 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 11.1% · Q3 8.3% · Q4 8.0% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 7.8% |
13.3%
5.5 pts better
|
16.3%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 9.6% · Q3 0.0% · Q4 18.1% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.6% |
11.7%
8.1 pts better
|
14.9%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 3.6% · Q3 0.0% · Q4 4.5% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.4%
0.5 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.2%
0.5 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.3% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.7% |
24.2%
1.5 pts better
|
19.8%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 28.4% · Q3 29.6% · Q4 20.2% · 4Q avg 22.7% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
4.1%
1.2 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.3% · Q3 4.2% · Q4 2.1% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 54.5% |
81.6%
27.1 pts worse
|
81.7%
27.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 69.7% · Q2 57.6% · Q3 43.1% · Q4 48.6% · 4Q avg 54.5% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.3%
0.3 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 0.0% · Q4 3.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 47.7% |
79.0%
31.3 pts worse
|
79.7%
32 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 47.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-10 · Fire 2024-09-10
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-09-29 · Fire 2023-09-29
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-20
F · Potential for more than minimal harm
2025-09-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-10-20
F · Potential for more than minimal harm
2025-09-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-20
E · Potential for more than minimal harm
2025-09-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-10-20
E · Potential for more than minimal harm
2025-09-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-10-20
D · Potential for more than minimal harm
2025-09-08
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2025-10-20
E · Potential for more than minimal harm
2024-09-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-10
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 2024-10-10
E · Potential for more than minimal harm
2023-09-29
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 2023-12-23
E · Potential for more than minimal harm
2023-09-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-23
E · Potential for more than minimal harm
2023-09-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-23
E · Potential for more than minimal harm
2023-09-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-23
E · Potential for more than minimal harm
2023-09-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-12-23
C · Minimal harm
2023-09-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-23
B · Minimal harm
2023-09-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-09-08
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 2025-10-01
D · Potential for more than minimal harm
2025-09-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-09-08
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-09-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-09-08
F887 · Infection Control Deficiencies
Health
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.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-07-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-29
E · Potential for more than minimal harm
2025-01-28
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-12-23
E · Potential for more than minimal harm
2024-09-10
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 2024-09-30
D · Potential for more than minimal harm
2024-09-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-09-10
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-09-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-09-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-09-10
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-09-10
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-09-30
D · Potential for more than minimal harm
2023-12-01
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-12-01
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-12-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-20
E · Potential for more than minimal harm
2023-09-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-19
D · Potential for more than minimal harm
2023-09-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-19
Penalties and ownership
What sits behind the stars
Ownership
Henry County Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
American Senior Communities LLC
Operational/Managerial Control · Organization
Dice, Mark
Operational/Managerial Control · Individual
Fingers, Holly
Operational/Managerial Control · Individual
Hafidh, Saad
Operational/Managerial Control · Individual
Ring, Brian
Operational/Managerial Control · Individual
Shane, Andrew
Operational/Managerial Control · Individual
Van Camp, Steven
Operational/Managerial Control · Individual
Voss, Jennifer
Operational/Managerial Control · Individual
Nearby options
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Waters Of Indianapolis, The
Indianapolis, IN
1-star overall rating with 2-star inspections with abuse icon flag with 10 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Fairway Village
Indianapolis, IN
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#3
Forest Creek Village
Indianapolis, IN
2-star overall rating with 1-star inspections with 22 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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