BETHLEHEM WOODS NURSING AND REHABILITATION CENTER

The information listed below provides an in-depth look into the type and quality of care offered at Bethlehem Woods Nursing and Rehabilitation Center. It is important to note that when evaluating if a nursing home is right for you or a loved one, ratings should not be taken as the sole deciding factor, but as one of many aspects to be considered.

Address

BETHLEHEM WOODS NURSING AND REHABILITATION CENTER
4430 ELSDALE DR
FORT WAYNE, IN 46835
(260) 485-8157

Nursing Home Ratings

Health Inspections
Quality Measures
Nursing Staff
R.N. Staff Only
Overall Rating

Percent of Beds Occupied

96%

Number of Residents and Certified Beds

  • Residents: 86
  • Certified Beds: 90

This Facility Accepts

  • Medicare
  • Medicaid

Operational Details

  • Operated By Government - County
  • Offers Only Resident Counseling
  • This Facility is Part of a Chain or Franchise

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Nearby Cities:

New Haven | Leo | Garrett

Resident Services

The information below lists services this facility has provided for residents from October through December 2010. During this period, the most common type of service provided was "High Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by Bethlehem Woods Nursing and Rehabilitation Center. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.

Resident ServicesResident ConditionsPercent of Service Days

Ultra-High Rehabilitation

Rehabilitation 720 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
  • A second rehabilitation discipline three days/week
ADL Index Range: 11-165.3%
ADL Index Range: 6-1013.6%
Total Percent:18.9%
 

Very High Rehabilitation

Rehabilitation 500 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 11-1614.4%
Total Percent:14.4%
 

High Rehabilitation

Rehabilitation 325 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 11-1617.9%
ADL Index Range: 6-1014.8%
ADL Index Range: 0-56.9%
Total Percent:39.7%
 

Medium Rehabilitation

Rehabilitation 150 Minutes Per Week Minimum
  • Five days any combination of three rehabilitation disciplines
ADL Index Range: 11-1618.9%
ADL Index Range: 6-103.8%
ADL Index Range: 0-54.3%
Total Percent:27.0%
 

Rating Details For Bethlehem Woods Nursing and Rehabilitation Center

Nursing Staff -

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Nursing Hours Per Resident Per DayReportedExpected
Registered Nurse (RN) Hours30 Minutes1 Hour and 19 Minutes
Licensed Practical/Vocational Nurse (LPN/LVN) Hours45 Minutes44 Minutes
Certified Nursing Assistant (CNA) Hours1 Hour and 46 Minutes2 Hours and 42 Minutes
Total Licensed Nurse Hours1 Hour and 15 Minutes2 Hours and 3 Minutes
Total Nurse Hours3 Hours and 2 Minutes4 Hours and 45 Minutes

Quality of Care -

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Indiana are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

This FacilityIndiana Average

Long-Term Stay Preventive Actions

Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season90-100%92%
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination90-100%89%

Long-Term Stay Deficiencies

Percent of Long-Stay Residents Who Are More Depressed or Anxious19%16%
Percent of Long-Stay Residents Who Lose Too Much Weight5%8%
Percent of High-Risk Long-Stay Residents Who Have Pressure Sores4%10%
Percent of Long-Stay Residents Who Had a Urinary Tract Infection7%9%
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased9%20%
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair2%4%
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder60%50%
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse7%12%
Percent of Long-Stay Residents Who Have Moderate to Severe Pain-3%
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder4%6%
Percent of Long-Stay Residents Who Were Physically Restrained-4%
Percent of Low-Risk Long-Stay Residents Who Have Pressure Sores-3%

Short-Term Stay Preventive Actions

Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season87%84%
Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination90-100%81%

Short-Term Stay Deficiencies

Percent of Short-Stay Residents Who Had Moderate to Severe Pain1%18%
Percent of Short-Stay Residents Who Have Pressure Sores4%10%
Percent of Short-Stay Residents Who Have Delirium-2%

Health Inspection Details -

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 03/24/2011.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

Administration

Keep Accurate and Appropriate Medical Records.
  • Inspection Date: 03/24/2011
  • Correction Date: 04/15/2011

Nutrition and Dietary

Store, Cook, and Give out Food in a Safe and Clean Way.
  • Inspection Date: 04/09/2009
  • Correction Date: 05/09/2009

Resident Assessment

Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
  • Inspection Date: 04/09/2009
  • Correction Date: 05/09/2009
Make Sure That Doctors See a Resident's Plan of Care at Every Visit and Make Notes About Progress and Orders in Writing.
  • Inspection Date: 04/09/2009
  • Correction Date: 05/09/2009

Deficiencies from Complaints and Incidents

The table below lists incident reports by the nursing staff or administration for Bethlehem Woods Nursing and Rehabilitation Center, as well as complaints by residents or their family in the previous three years.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Formal ComplaintsDegree of HarmResidents Affected

Administration

Keep Accurate and Appropriate Medical Records.
  • Complaint Filed: 09/08/2008
  • Correction Date: 10/01/2008

Environmental

Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Complaint Filed: 04/09/2009
  • Correction Date: 05/09/2009

Resident Assessment

Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
  • Complaint Filed: 09/08/2008
  • Correction Date: 10/01/2008

Resident Rights

Immediately Tell the Resident, Doctor, and a Family Member If: the Resident is Injured, There is a Major Change in Resident's Physical/Mental Health, There is a Need to Alter Treatment Significantly, or the Resident Must Be Transferred or Discharged.
  • Complaint Filed: 09/08/2008
  • Correction Date: 10/01/2008

Fire Safety

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Bethlehem Woods Nursing and Rehabilitation Center had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 04/11/2011.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

Automatic Sprinkler Systems

Portable Fire Extinguishers.
  • Inspection Date: 04/16/2009
  • Correction Date: 05/16/2009
An Approved Automatic Sprinkler System Connected to the Fire Alarm System.
  • Inspection Date: 04/11/2011
  • Correction Date: 05/11/2011
Properly Working Alarms on Sprinkler Valves.
  • Inspection Date: 04/11/2011
  • Correction Date: 05/10/2011
Automatic Sprinkler Systems That Have Been Maintained in Working Order.
  • Inspection Date: 04/11/2011
  • Correction Date: 05/10/2011
Portable Fire Extinguishers.
  • Inspection Date: 04/11/2011
  • Correction Date: 05/10/2011

Building Service Equipment

Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions.
  • Inspection Date: 04/16/2009
  • Correction Date: 05/16/2009
An Externally Vented Heating System.
  • Inspection Date: 04/16/2009
  • Correction Date: 05/16/2009

Electrical

Weekly Inspections and Monthly Testing of Generators.
  • Inspection Date: 04/16/2009
  • Correction Date: 05/16/2009

Emergency Plans and Fire Drills

Record of Quarterly Fire Drills for Each Shift Under Varying Conditions.
  • Inspection Date: 04/16/2009
  • Correction Date: 05/16/2009

Exits and Egress

Proper Exit Design.
  • Inspection Date: 03/12/2010
  • Correction Date: 04/11/2010

Fire Alarm Systems

Properly Maintained Smoke Detectors.
  • Inspection Date: 03/12/2010
  • Correction Date: 04/11/2010
A Fire Alarm System That Can Be Heard Throughout the Facility.
  • Inspection Date: 04/11/2011
  • Correction Date: 05/10/2011
An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems.
  • Inspection Date: 04/11/2011
  • Correction Date: 05/10/2011

Illumination and Emergency Power

Emergency Lighting That Can Last at Least 1 1/2 Hours.
  • Inspection Date: 04/16/2009
  • Correction Date: 05/16/2009
Emergency Lighting That Can Last at Least 1 1/2 Hours.
  • Inspection Date: 04/11/2011
  • Correction Date: 05/10/2011

Medical Gases and Anesthetizing Areas

Proper Fire Barriers, Ventilation and Signs for the Transport of Oxygen.
  • Inspection Date: 03/12/2010
  • Correction Date: 04/11/2010

Miscellaneous

Fire Safety Features Required by Current Fire Safety Codes.
  • Inspection Date: 04/16/2009
  • Correction Date: 05/16/2009
Fire Safety Features Required by Current Fire Safety Codes.
  • Inspection Date: 03/12/2010
  • Correction Date: 04/11/2010

Smoke Compartmentation and Control

Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour.
  • Inspection Date: 04/16/2009
  • Correction Date: 05/16/2009
Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes.
  • Inspection Date: 03/12/2010
  • Correction Date: 04/11/2010
Source: Medicare Nursing Home Compare; Department of Health of Indiana - Long Term Care Division - Retrieved 2011