Bethany St Joseph Care Ctr

Inspection findings

1. Jun 19, 2025 Fire Safety · 12 findings
   • Not serious Scope/severity F

     E0013 Emergency Preparedness Deficiencies

     Develop Emergency Preparedness policies and procedures.

     Corrected Jul 18, 2025 · CMS fire safety

   • Serious Scope/severity G

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Jul 17, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0688 Quality of Life and Care Deficiencies

     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

     Corrected Jul 17, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     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 Jul 17, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0698 Quality of Life and Care Deficiencies

     Provide safe, appropriate dialysis care/services for a resident who requires such services.

     Corrected Jul 17, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jul 17, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 17, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0331 Smoke Deficiencies

     Construct fire resistant interior walls.

     Corrected Jul 18, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Jul 18, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jul 18, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0919 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the use of electrical equipment.

     Corrected Jul 18, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Jul 18, 2025 · CMS fire safety

2. Apr 25, 2024 Health · 9 findings
   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected May 25, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected May 25, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 25, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Jun 7, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0222 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.

     Corrected Jun 7, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 7, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0362 Smoke Deficiencies

     Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

     Corrected Jun 7, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0919 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the use of electrical equipment.

     Corrected Jun 7, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Jun 7, 2024 · CMS fire safety

3. Mar 15, 2023 Health · 5 findings
   • Not serious Scope/severity F

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Apr 15, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Apr 15, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Apr 15, 2023 · CMS health inspection

   • Not serious Scope/severity C

     F0888 Infection Control Deficiencies

     Ensure staff are vaccinated for COVID-19

     Corrected Apr 15, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0232 Egress Deficiencies

     Have corridors or aisles that are unobstructed and are at least 8 feet in width.

     Corrected Apr 15, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BARTON, SCOTT — adp of the snf, NOT APPLICABLE, since 08/09/1999
• BARTON, SCOTT — operational/managerial control, NOT APPLICABLE, since 08/09/1999
• BENNETT, TISHA — adp of the snf, NOT APPLICABLE, since 11/18/2015
• BENNETT, TISHA — operational/managerial control, NOT APPLICABLE, since 11/18/2015
• BERRA, KAY — adp of the snf, NOT APPLICABLE, since 01/07/2025
• BERRA, KAY — trustee of the snf, NOT APPLICABLE, since 03/28/2023
• BERRA, KAY — operational/managerial control, NOT APPLICABLE, since 01/07/2025
• BERRA, KAY — corporate director, NOT APPLICABLE, since 03/28/2023
• BRALEY, MATTHEW — adp of the snf, NOT APPLICABLE, since 01/06/2025
• BRALEY, MATTHEW — operational/managerial control, NOT APPLICABLE, since 12/26/2024
• BRALEY, MATTHEW — corporate director, NOT APPLICABLE, since 03/01/2022
• FEIRTAG, MEGAN — adp of the snf, NOT APPLICABLE, since 01/31/2017
• FEIRTAG, MEGAN — operational/managerial control, NOT APPLICABLE, since 01/31/2017
• GOCHANOUR, KIMBERLY — corporate officer, NOT APPLICABLE, since 03/25/2024
• GOCHANOUR, KIMBERLY — operational/managerial control, NOT APPLICABLE, since 03/25/2024
• GOCHANOUR, KIMBERLY — adp of the snf, NOT APPLICABLE, since 03/25/2024
• HANSON, CHARLES — corporate director, NOT APPLICABLE, since 03/01/2022
• HANSON, CHARLES — trustee of the snf, NOT APPLICABLE, since 03/01/2022
• HANSON, CHARLES — operational/managerial control, NOT APPLICABLE, since 01/06/2025
• HANSON, CHARLES — adp of the snf, NOT APPLICABLE, since 01/06/2025
• KITE, CINDI — trustee of the snf, NOT APPLICABLE, since 03/01/2018
• KITE, CINDI — operational/managerial control, NOT APPLICABLE, since 01/06/2025
• KITE, CINDI — corporate director, NOT APPLICABLE, since 03/01/2018
• KITE, CINDI — adp of the snf, NOT APPLICABLE, since 01/06/2025
• KUTT, DAWN — trustee of the snf, NOT APPLICABLE, since 03/26/2024
• KUTT, DAWN — adp of the snf, NOT APPLICABLE, since 01/07/2025
• KUTT, DAWN — operational/managerial control, NOT APPLICABLE, since 01/07/2025
• KUTT, DAWN — corporate director, NOT APPLICABLE, since 03/26/2024
• MAKI, ERICK — trustee of the snf, NOT APPLICABLE, since 03/26/2024
• MAKI, ERICK — adp of the snf, NOT APPLICABLE, since 01/07/2025
• MAKI, ERICK — operational/managerial control, NOT APPLICABLE, since 01/07/2025
• MAKI, ERICK — corporate director, NOT APPLICABLE, since 03/26/2024
• MALONE, EDWARD — operational/managerial control, NOT APPLICABLE, since 12/31/2024
• MALONE, EDWARD — adp of the snf, NOT APPLICABLE, since 12/31/2024
• MARTIN, SEAN — trustee of the snf, NOT APPLICABLE, since 03/28/2023
• MARTIN, SEAN — adp of the snf, NOT APPLICABLE, since 01/07/2025
• MARTIN, SEAN — operational/managerial control, NOT APPLICABLE, since 01/07/2025
• MARTIN, SEAN — corporate director, NOT APPLICABLE, since 03/28/2023
• PASSE, NICHOLAS — adp of the snf, NOT APPLICABLE, since 01/06/2025
• PASSE, NICHOLAS — trustee of the snf, NOT APPLICABLE, since 03/01/2019
• PASSE, NICHOLAS — operational/managerial control, NOT APPLICABLE, since 01/06/2025
• PASSE, NICHOLAS — corporate director, NOT APPLICABLE, since 03/01/2019
• PEDACE, TERRI — corporate director, NOT APPLICABLE, since 03/01/2021
• PEDACE, TERRI — trustee of the snf, NOT APPLICABLE, since 03/01/2021
• PEDACE, TERRI — operational/managerial control, NOT APPLICABLE, since 01/06/2025
• PEDACE, TERRI — adp of the snf, NOT APPLICABLE, since 01/06/2025
• SACIE, BONITA — corporate director, NOT APPLICABLE, since 03/01/2022
• SACIE, BONITA — adp of the snf, NOT APPLICABLE, since 01/06/2025
• SACIE, BONITA — trustee of the snf, NOT APPLICABLE, since 03/01/2022
• SACIE, BONITA — operational/managerial control, NOT APPLICABLE, since 01/06/2025
• SCHATZKE, PAIGE — adp of the snf, NOT APPLICABLE, since 11/03/2015
• SCHATZKE, PAIGE — operational/managerial control, NOT APPLICABLE, since 11/03/2015
• SPILDE, STEVE — trustee of the snf, NOT APPLICABLE, since 03/01/2017
• SPILDE, STEVE — adp of the snf, NOT APPLICABLE, since 01/06/2025
• SPILDE, STEVE — corporate director, NOT APPLICABLE, since 03/01/2017
• SPILDE, STEVE — operational/managerial control, NOT APPLICABLE, since 01/06/2025
• WHITE, KARLIE — operational/managerial control, NOT APPLICABLE, since 01/01/2016
• WHITE, KARLIE — adp of the snf, NOT APPLICABLE, since 01/01/2016
• WHITE, MICHELLE — operational/managerial control, NOT APPLICABLE, since 12/02/2024
• WHITE, MICHELLE — adp of the snf, NOT APPLICABLE, since 12/02/2024
• WIPFLI LLP — operational/managerial control, NOT APPLICABLE, since 01/23/2025
• WIPFLI LLP — adp of the snf, NOT APPLICABLE, since 01/23/2025