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
Staffing
Hours and turnover
RN hours / resident day
0.46
Registered nurse staffing
LPN hours / resident day
0.84
Licensed practical nurse staffing
Aide hours / resident day
2.16
Nurse aide staffing
Weekend hours
2.97
Weekend nurse staffing
RN turnover
65%
Annual RN turnover
Total nurse turnover
61%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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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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