A

BETHLEHEM WOODS NURSING AND REHABILITATION

4430 ELSDALE DR, FORT WAYNE, IN 46835
Score: 89 / 100

Among nursing homes in Indiana, Bethlehem Woods Nursing And Rehabilitation stands out with an A grade and a score of 89 out of 100. It ranks in the 89th percentile statewide, reflecting consistently high performance across CMS quality metrics.

Staffing at Bethlehem Woods Nursing And Rehabilitation is near the national average, with 3.58 total nursing hours per resident per day (national average: 3.8 hours).

Bethlehem Woods Nursing And Rehabilitation shows a strong inspection record, with just 4 deficiencies noted in recent CMS surveys, none of which were classified as serious.

Score Breakdown

Overall CMS Rating 40 / 40 pts
5 ★ CMS rating
Health Inspections 25 / 25 pts
5 ★ inspection rating
Staffing 12 / 20 pts
3 ★ staffing rating
Quality Measures 12 / 15 pts
4 ★ quality measures

🏥 Staffing Details

Staff Type Hours/Resident/Day National Avg Comparison
Total Nursing 3.58 3.8 Average
Registered Nurses (RN) 0.83 0.7 Above Average
Licensed Practical Nurses (LPN) 0.30 0.7 Below Average
Certified Nursing Assistants (CNA) 2.46 2.4 Average
Weekend Total Nursing 2.96 3.8 Below Average
Weekend RN Hours 0.53 0.7 Below Average

🔍 Inspection & Deficiency History

4
Total Deficiencies
Nov 16, 2025
Most Recent Inspection
🟠 4 Moderate
View recent deficiencies (4 shown)
  • Tag 0620 Severity D
    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 d
    Nov 16, 2025 · Resident Rights Deficiencies
  • Tag 0628 Severity D
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    May 18, 2025 · Resident Rights Deficiencies
  • Tag 0604 Severity D
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    May 2, 2023 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
  • Tag 0656 Severity D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    May 2, 2023 · Resident Assessment and Care Planning Deficiencies

📊 Resident Outcome Measures

Based on CMS quality measure data. Lower percentages are better for most metrics.

Measure This Facility Nat'l Avg
Residents with pressure ulcers 1.5% 4.5% Better
Falls with major injury 5.8% 3.0% Worse
On antipsychotic medication 8.9% 14.5% Better
Urinary tract infections 1.5% 2.5% Better
ADL decline (daily activities) 6.6% 14.0% Better
Excessive weight loss 2.6% 7.5% Better
New/worsened incontinence 18.5% 45.0% Better

How This Grade Was Calculated

This facility's grade of A is based on a score of 89 out of 100, calculated from official CMS Nursing Home Compare data:

  • Overall CMS Rating: 5★ → 40 pts (max 40)
  • Health Inspection Rating: 5★ → 25 pts (max 25)
  • Staffing Rating: 3★ → 12 pts (max 20)
  • Quality Measures Rating: 4★ → 12 pts (max 15)

Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40

Facility Details

Ownership
For profit - Corporation
Certified Beds
90
Provider Type
Medicare and Medicaid
Resident Council
Yes
Family Council
No
Sprinkler System
Yes
Last Inspection
May 18, 2025
Deficiencies (Cycle 1)
2