BETHLEHEM WOODS NURSING AND REHABILITATION CENTER
Address
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
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 Services | Resident Conditions | Percent of Service Days |
Ultra-High Rehabilitation
- At least one rehabilitation discipline five days/week
- A second rehabilitation discipline three days/week
| ADL Index Range: 11-16 | 5.3% |
| ADL Index Range: 6-10 | 13.6% |
| Total Percent: | 18.9% |
Very High Rehabilitation
- At least one rehabilitation discipline five days/week
| ADL Index Range: 11-16 | 14.4% |
| Total Percent: | 14.4% |
High Rehabilitation
- At least one rehabilitation discipline five days/week
| ADL Index Range: 11-16 | 17.9% |
| ADL Index Range: 6-10 | 14.8% |
| ADL Index Range: 0-5 | 6.9% |
| Total Percent: | 39.7% |
Medium Rehabilitation
- Five days any combination of three rehabilitation disciplines
| ADL Index Range: 11-16 | 18.9% |
| ADL Index Range: 6-10 | 3.8% |
| ADL Index Range: 0-5 | 4.3% |
| 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 Day | Reported | Expected |
| Registered Nurse (RN) Hours | 30 Minutes | 1 Hour and 19 Minutes |
| Licensed Practical/Vocational Nurse (LPN/LVN) Hours | 45 Minutes | 44 Minutes |
| Certified Nursing Assistant (CNA) Hours | 1 Hour and 46 Minutes | 2 Hours and 42 Minutes |
| Total Licensed Nurse Hours | 1 Hour and 15 Minutes | 2 Hours and 3 Minutes |
| Total Nurse Hours | 3 Hours and 2 Minutes | 4 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 Facility | Indiana Average |
Long-Term Stay Preventive Actions
| Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season | 90-100% | 92% |
| Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 90-100% | 89% |
Long-Term Stay Deficiencies
| Percent of Long-Stay Residents Who Are More Depressed or Anxious | 19% | 16% |
| Percent of Long-Stay Residents Who Lose Too Much Weight | 5% | 8% |
| Percent of High-Risk Long-Stay Residents Who Have Pressure Sores | 4% | 10% |
| Percent of Long-Stay Residents Who Had a Urinary Tract Infection | 7% | 9% |
| Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased | 9% | 20% |
| Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair | 2% | 4% |
| Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder | 60% | 50% |
| Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse | 7% | 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 Bladder | 4% | 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 Season | 87% | 84% |
| Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 90-100% | 81% |
Short-Term Stay Deficiencies
| Percent of Short-Stay Residents Who Had Moderate to Severe Pain | 1% | 18% |
| Percent of Short-Stay Residents Who Have Pressure Sores | 4% | 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 Inspectors | Degree of Harm | Residents Affected |
Administration
Keep Accurate and Appropriate Medical Records.
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Nutrition and Dietary
Store, Cook, and Give out Food in a Safe and Clean Way.
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Resident Assessment
Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
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Make Sure That Doctors See a Resident's Plan of Care at Every Visit and Make Notes About Progress and Orders in Writing.
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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 Complaints | Degree of Harm | Residents Affected |
Administration
Keep Accurate and Appropriate Medical Records.
| | |
Environmental
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Resident Assessment
Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
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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.
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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 Inspectors | Degree of Harm | Residents Affected |
Automatic Sprinkler Systems
Portable Fire Extinguishers.
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An Approved Automatic Sprinkler System Connected to the Fire Alarm System.
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Properly Working Alarms on Sprinkler Valves.
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Automatic Sprinkler Systems That Have Been Maintained in Working Order.
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Portable Fire Extinguishers.
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Building Service Equipment
Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions.
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An Externally Vented Heating System.
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Electrical
Weekly Inspections and Monthly Testing of Generators.
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Emergency Plans and Fire Drills
Record of Quarterly Fire Drills for Each Shift Under Varying Conditions.
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Exits and Egress
Proper Exit Design.
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Fire Alarm Systems
Properly Maintained Smoke Detectors.
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A Fire Alarm System That Can Be Heard Throughout the Facility.
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An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems.
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Illumination and Emergency Power
Emergency Lighting That Can Last at Least 1 1/2 Hours.
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Emergency Lighting That Can Last at Least 1 1/2 Hours.
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Medical Gases and Anesthetizing Areas
Proper Fire Barriers, Ventilation and Signs for the Transport of Oxygen.
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Miscellaneous
Fire Safety Features Required by Current Fire Safety Codes.
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Fire Safety Features Required by Current Fire Safety Codes.
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Smoke Compartmentation and Control
Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour.
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Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes.
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