90/100

BETHLEHEM WOODS NURSING AND REHABILITATION Inspection Report, Violations & Safety Grade (FORT WAYNE, Indiana)

4430 ELSDALE DR, FORT WAYNE, Indiana 46835

Phone: 2604858157

CMS Overall:5/5

Overview & Bed Count

Certified Beds

Avg Residents/Day

81.7

Ownership

For profit - Corporation

Provider Type

Medicare and Medicaid

County

Allen

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

Overall5/5

Health4/5

Staffing3/5

Quality5/5

Metric	This Facility	Indiana Avg	Difference
RN Hours per Resident per Day	0.86	0.68	+0.19
Total Nurse Hours per Resident per Day	3.45	3.73	-0.29
CMS Staffing Rating	3/5	2.6/5	-
Nursing Staff Turnover	43.8%	45.9%	-

4 health citations on record

Date	Category	Description	Severity
2026-03-31	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2026-03-19	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2025-11-17	Resident Rights Deficiencies	Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.	D – Moderate Harm Potential
2025-05-19	Resident Rights Deficiencies	Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.	D – Moderate Harm Potential

10 fire safety citations on record

Date	Category	Description	Severity
2026-03-31	Emergency Preparedness Deficiencies	Implement emergency and standby power systems.	F – Moderate Harm Potential
2026-03-31	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	F – Moderate Harm Potential
2026-03-31	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	F – Moderate Harm Potential
2025-05-19	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	F – Moderate Harm Potential
2025-05-19	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2024-06-17	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential
2024-06-17	Services Deficiencies	Have properly installed electrical wiring and gas equipment.	E – Moderate Harm Potential
2024-06-17	Services Deficiencies	Have an externally vented heating system.	E – Moderate Harm Potential
2024-06-17	Smoke Deficiencies	Properly select, install, inspect, or maintain portable fire extinguishes.	D – Moderate Harm Potential
2024-06-17	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure proper usage of power strips and extension cords.	D – Moderate Harm Potential

Total Fine Amount (CMS)

Number of Fines

Total Penalties

No penalty records found.

Our family advisors can help you find vetted, top-rated facilities in the FORT WAYNE area at no cost.

Advisor service is free for families. We may receive referral compensation.

Our family advisors can help you find vetted, top-rated facilities in the FORT WAYNE area at no cost.

Advisor service is free for families. We may receive referral compensation.