Cycle 1
Health 2024-08-07 · Fire 2024-08-07
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Oshkosh, WI
Bethel Home
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
225 N Eagle St, Oshkosh, WI
(920) 235-4653
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
67
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-12-01
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
0.95
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.02
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.50
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.00
CMS adjusted RN staffing hours
Adjusted total hours
4.25
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,899
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9838
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.31
Performance 20.36% · Measure score 2.31 · Achievement 2.31 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 8.05% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.48
Baseline 52.69% · Performance 49.44% · Measure score 3.48 · Achievement 3.48 · Improvement 0.67
Adjusted total nurse staffing
4.34
Baseline 3.80 hours · Performance 4.31 hours · Measure score 4.34 · Achievement 4.34 · Improvement 2.09
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.73% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 95 · Observed rate 14.74% · Lower 95% interval 8.08% |
| Discharge to community | 39.93% |
50.57%
10.6 pts worse
|
Worse than the National Rate · Eligible stays 82 · Observed rate 34.15% · Lower 95% interval 30.3% |
| Medicare spending per beneficiary | 0.67 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 24 · Denominator 24 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 24 |
| Discharge self-care score | 40% |
53.69%
13.7 pts worse
|
Numerator 8 · Denominator 20 |
| Discharge mobility score | 40% |
50.94%
10.9 pts worse
|
Numerator 8 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 24 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.05% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 12.2% · Lower 95% interval 4.47% |
| Staff COVID-19 vaccination coverage | 10.81% |
8.2%
2.6 pts better
|
Numerator 16 · Denominator 148 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 165 · Denominator 165 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 12 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · 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 | 1.7 |
1.6
0.1 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.2
1 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.0% |
95.7%
2.7 pts worse
|
93.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 89.4% · Q3 95.2% · Q4 95.0% · 4Q avg 93.0% |
| 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 | 1.9% |
3.2%
1.3 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 1.6% · Q4 3.3% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
5.0%
3.7 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 6.9% |
4.9%
2 pts worse
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.1% · Q3 10.2% · Q4 4.7% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.6% |
16.6%
8 pts worse
|
19.6%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 30.0% · Q3 24.5% · Q4 22.7% · 4Q avg 24.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.2% |
16.7%
4.5 pts worse
|
16.7%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 18.9% · Q3 19.5% · Q4 21.4% · 4Q avg 21.2% · 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 | 24.3% |
21.1%
3.2 pts worse
|
16.3%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 31.7% · Q3 35.2% · Q4 15.9% · 4Q avg 24.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.3% |
17.3%
16 pts worse
|
14.9%
18.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.6% · Q2 36.4% · Q3 34.0% · Q4 30.2% · 4Q avg 33.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
2.3%
1.5 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
3.0%
2.2 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.7% |
25.5%
12.2 pts worse
|
19.8%
17.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.5% · Q2 37.3% · Q3 30.0% · Q4 38.5% · 4Q avg 37.7% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.5%
0.5 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.2% · Q3 6.9% · Q4 7.6% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
86.8%
11 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 96.6% · Q3 100.0% · Q4 96.6% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.7% |
15.0%
3.3 pts better
|
12.0%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 12.5% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
1.3%
1.6 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 5.7% · Q4 3.2% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.7% |
82.2%
9.5 pts better
|
79.7%
12 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.0% |
22.7%
6.3 pts worse
|
23.9%
5.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.0% · Observed 25.0% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-07 · Fire 2023-06-07
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-07-20 · Fire 2022-07-20
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-07
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-09-24
F · Potential for more than minimal harm
2024-08-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-24
F · Potential for more than minimal harm
2024-08-07
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-09-24
F · Potential for more than minimal harm
2024-08-07
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-09-24
F · Potential for more than minimal harm
2024-08-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-08-07
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-08-07
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 2024-09-24
E · Potential for more than minimal harm
2024-08-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-03
E · Potential for more than minimal harm
2024-08-07
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-08-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-08-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-08-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-08-07
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-08-07
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-07
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 2024-09-24
D · Potential for more than minimal harm
2024-08-07
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-09-24
E · Potential for more than minimal harm
2023-06-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-19
E · Potential for more than minimal harm
2023-06-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-06-07
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 2023-06-19
D · Potential for more than minimal harm
2023-06-07
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-06-14
E · Potential for more than minimal harm
2022-07-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-05
E · Potential for more than minimal harm
2022-07-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-08-05
Inspection history
Recent health citations
J · Immediate jeopardy
2025-08-13
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 2025-07-31
D · Potential for more than minimal harm
2024-10-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-23
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-08-07
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 2024-09-05
D · Potential for more than minimal harm
2024-08-07
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2024-09-05
D · Potential for more than minimal harm
2023-06-07
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 2023-07-07
D · Potential for more than minimal harm
2023-06-07
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 2023-07-07
B · Minimal harm
2023-06-07
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-04-24
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-04-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-17
D · Potential for more than minimal harm
2022-07-20
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-07-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-07-20
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-07-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-07-20
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-07-20
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-07-21
Penalties and ownership
What sits behind the stars
Ownership
Miravida Living
5% Or Greater Direct Ownership Interest · Organization
Beecher, Mark
Corporate Officer · Individual
Bermingham, Kathy
Corporate Director · Individual
Bertram, Theresa
Corporate Officer · Individual
Bertram, Theresa
W-2 Managing Employee · Individual
Bonell, Jamie
Corporate Director · Individual
Mcniel, Paula
Corporate Director · Individual
Miravida Living
Operational/Managerial Control · Organization
Muller, Laurie
Corporate Director · Individual
Murken, Mary
Corporate Officer · Individual
Olson, Margaret
Corporate Director · Individual
Olson, Nate
Corporate Director · Individual
Rieckman, Stew
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Evergreen Health Center
Oshkosh, WI
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Eden Rehab Suites And Green House Homes
Oshkosh, WI
3-star overall rating with 3-star inspections with $13,886 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Edenbrook Of Oshkosh
Oshkosh, WI
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
Jump out