Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethel Pointe Health And Rehab during CMS and state inspections, most recent first.
Delayed wound treatment order and implementation for a diabetic foot ulcer: A resident with DM2 and a right lateral foot pressure injury/diabetic ulcer had wound care documented, including a wound center treatment plan, but the facility did not have an active treatment order in place for an extended period after the resident returned from the hospital. The Wound Nurse stated she forgot to enter the order until later, and the DON confirmed the resident should have had the treatment order upon return and that nursing staff should obtain and implement physician orders promptly.
Failure to follow EBP during resident care. A resident with a PICC line, history of MRSA/VRE, and a knee wound had EBP orders and signage posted, but during a dressing change the wound nurse stated EBP was not needed because the site was a closed surgical wound. She performed the care with gloves only, her jacket brushed against the resident’s bed and body during the procedure, and she used bare hands to replace the knee immobilizer. The DON and IP stated gown and gloves were required for care when a resident had a closed wound and a PICC or other medical device.
A resident with cognitive intactness, mobility limitations, incontinence, and skin integrity issues required staff assistance with ADLs and had a documented preference for showers on specific days. The care plan specified one-staff assistance for bathing and hygiene, but bathing records showed multiple refusals without documentation of re-approach, education, or nurse/family notification, and several scheduled shower days were left completely blank. Staff interviews described the resident as generally cooperative with care and confirmed that refusals should be re-approached and documented, yet the clinical record lacked evidence that showers were consistently offered or provided according to the resident’s preferences and facility policy.
A resident with a feeding tube due to a stroke did not receive adequate site care, as the facility failed to document and implement necessary orders for gastrostomy tube site care. Interviews revealed that the site was not cleaned or the dressing changed regularly, and the care plan lacked interventions for feeding tube site care, leading to a deficiency.
The facility failed to properly label and dispose of insulin vials and pens in two medication carts. An RN and an LPN confirmed that insulin should be used within 28 days of opening, but observations revealed undated and misdated insulin vials and pens. The DON confirmed the expectation for proper dating and disposal according to facility policy.
The facility failed to post complete nurse staffing information daily, affecting all residents. Observations showed that only the first shift's staffing details were visible, with no updates for the second and third shifts. The DON was unaware of the issue, which persisted over several days, violating the facility's policy requiring clear and accessible staffing information.
The facility failed to complete and document wound care treatments for two residents, leading to a deficiency. A resident with multiple sclerosis and diabetes had missing documentation for wound treatments on the right shin and heel, while another resident with Alzheimer's had incomplete records for left ankle wound care. The DON confirmed the lack of documentation for required treatments.
The facility failed to securely store and properly dispose of medications, as observed in the Wound Nurse's office where an unlocked cabinet contained various medications for multiple residents, including those who had been discharged. Staff interviews revealed confusion and non-compliance with the facility's policies on medication storage and disposal, leading to improper handling of medications.
A facility failed to obtain an apical pulse before administering digoxin to a resident with atrial fibrillation. The RN administered the medication without checking the pulse, relying on an undocumented reading from the night shift. Interviews revealed that the standard practice was to check the pulse and hold the medication if it was below 60 bpm. The DON confirmed that physician's orders should be followed, and the facility's policy required pre-administration checks.
A facility failed to monitor and implement interventions for a resident's pressure injury, leading to its progression from stage 2 to unstageable. The resident, with multiple health issues, was not consistently repositioned, and there were gaps in wound assessments and treatments. Staff interviews revealed a lack of awareness and communication about the resident's condition, and the facility's policy on pressure injury prevention was not effectively followed.
A resident with a history of urinary tract infections and chronic kidney disease was observed with an improperly positioned catheter bag and tubing, which were repeatedly found lying on the floor mat. Despite staff presence, the facility failed to adhere to its policy of ensuring catheter bags and tubing were not on the floor, as confirmed by staff interviews and observations.
Delayed wound treatment order and implementation for a diabetic foot ulcer
Penalty
Summary
The facility failed to obtain a physician's order for wound treatment in a timely manner and failed to implement physician's orders promptly for a resident with a diabetic ulcer on the right lateral foot. Resident 5 had diagnoses including type 2 diabetes mellitus, generalized muscle weakness, and primary hypertension, and was documented as severely cognitively impaired. The resident's record showed a stage 3 pressure injury/diabetic foot ulcer on the right lateral foot, with assessments noting slough, drainage, and later eschar. A wound center note documented the ulcer and listed a treatment order for cleansing with Vashe, applying Prisma, and covering with a dry dressing and gauze wrap on a scheduled basis. The clinical record lacked an active wound treatment order from 1/31/26 through 2/11/26. During observation, the wound dressing on the resident's right lateral foot was dated 2/11/26, and the Wound Nurse stated she had forgotten to enter the treatment order until the evening of 2/11/26 after the resident had returned from the hospital and been seen at the wound center. The DON stated that when a resident returns to the facility, the nurse should complete a skin assessment, document wounds, contact the physician for treatment orders, and enter and implement those orders, and that Resident 5 should have had a treatment order upon return to the facility.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to follow enhanced barrier precautions (EBP) during high-contact care activities for a resident with an indwelling medical device. Resident 47 had diagnoses including a left artificial knee joint, infection and inflammatory reaction due to an internal left knee prosthesis, and disruption of an external surgical wound. The physician’s orders included EBP due to a PICC line and a history of MRSA/VRE, along with daptomycin for a knee joint infection and non-weight bearing status to the left lower extremity. The care plan also identified the need for EBP related to the PICC line and history of MRSA/VRE. During observation, EBP signage was posted at the resident’s doorway and a PPE cart was present at bedside. During a dressing change, the wound nurse performed hand hygiene and stated EBP was not required because the site was a closed surgical wound. She donned gloves, removed the knee immobilizer, and her jacket brushed against the resident’s bed and bare thigh. After hand hygiene and new gloves, she cleaned the area and applied a new dressing, with her jacket again brushing against the bed, thigh, and shirt. She then removed her gloves and used bare hands to replace the knee immobilizer. The DON and Infection Preventionist both stated that a gown and gloves were required for resident care when a resident had a closed wound and a PICC or other medical device, and the facility policy stated EBP should be used for device care or use, including PICC lines, and for wound care requiring a dressing.
Failure to Provide/Offer Showers per Resident Preference and Inadequate Bathing Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide or offer showers according to a resident’s stated preferences and to maintain proper hygiene. Resident B, who was cognitively intact and required substantial staff assistance for lower body dressing, footwear, bathing, shower transfers, and toileting hygiene, had care plans indicating a need for one staff to assist with a.m./p.m. care, dressing, and bathing. A specific choices care plan documented the resident’s preference for showers on Tuesday and Friday day shifts, and there was no indication in the care plan that the resident was noncompliant with bathing. The resident also had unhealed pressure ulcers, a surgical wound, and MASD, with interventions that included education and reminders regarding good hygiene and daily changing of clothing and undergarments. Review of bathing documentation showed multiple dates on which the resident either refused or had no recorded bathing activity despite the established shower schedule. On some scheduled shower days, refusals were documented (e.g., certain Tuesdays and Fridays), but the clinical record did not contain any documentation of additional attempts, resident education, or notification of a nurse or family regarding these refusals. On several other scheduled shower days, the bathing record was left blank, with no indication that bathing was offered or provided. This lack of documentation made it impossible to determine whether the resident was actually offered showers in accordance with his preferences on those dates. Interviews with staff further highlighted inconsistencies between the resident’s documented refusals and staff recollections. CNA 3, who was assigned to the resident on the day he went to a community appointment, described the resident as pleasant, cooperative with care, and compliant with toileting and daily cleaning and dressing, and was unsure if the resident refused showers. Other staff, including QMA 4 and QMA 5, stated that residents were to be offered bathing according to their preferences, that refusals required multiple re-approaches and nurse notification, and that it was not acceptable to leave bathing or refusals uncharted. The DON acknowledged that there was no additional information available to show the resident’s bathing on the dates with blank documentation and that the record lacked any nurse or family notification regarding shower refusals, resulting in an inability to verify that showers were offered as required by the resident’s care plan and facility policy.
Deficiency in Feeding Tube Site Care for Resident
Penalty
Summary
The facility failed to provide adequate care for a resident with a feeding tube, leading to a deficiency in the care provided. Resident 47, who had a feeding tube due to a stroke, was found to have insufficient documentation and orders for the care of her gastrostomy tube site. The clinical record lacked specific orders for site care, and the care plan did not include interventions for feeding tube site care. Despite having a physician order to change the enteral tube as needed, there were no documented orders for regular site care, which is typically included in the Treatment Administration Record (TAR) for residents with feeding tubes. Interviews with staff and the resident revealed that the feeding tube site was not cleaned and the dressing was not changed every shift or daily, as would be expected. The Corporate Nurse Consultant confirmed that the facility lacked documentation to show that the feeding tube site care had been performed. The facility's policy on the care and treatment of feeding tubes emphasized the need for interventions to prevent complications, yet the resident's care plan did not adequately address these needs. This oversight in care and documentation led to the deficiency noted in the report.
Improper Labeling and Disposal of Insulin in Medication Carts
Penalty
Summary
The facility failed to ensure proper labeling and disposal of insulin vials and pens, which are critical for managing diabetes mellitus in residents. During an observation of the East hall medication cart, an open vial of Glargine insulin was found undated, and a vial of Lispro insulin was misdated with three different dates. The Registered Nurse (RN) accompanying the surveyor confirmed that the cart served eight diabetic residents and acknowledged that insulin should be used within 28 days of opening. The Director of Nursing (DON) also confirmed that misdated insulin should be disposed of if the open date is uncertain. Similarly, during an observation of the Center hall medication cart, an open Lantus Solostar insulin pen was found undated, and a vial of Lispro insulin had illegible markings. The Licensed Practical Nurse (LPN) confirmed that the cart served five diabetic residents and reiterated the 28-day usage policy. The DON emphasized that insulin should be dated upon opening and reviewed with each dose to ensure it is not used beyond the expiration period. The facility's policies on medication labeling and expiration were provided, indicating that all medications must be labeled legibly and multi-use vials should be discarded within 28 days unless otherwise specified by the manufacturer.
Incomplete Nurse Staffing Information Posting
Penalty
Summary
The facility failed to post complete nurse staffing information daily, which had the potential to affect all 103 residents. Observations on multiple days revealed that the nurse staffing information for the second and third shifts was not visible to residents and visitors. The postings were only showing the first shift's staffing details, and the information was not updated at the beginning of each shift as required. This issue persisted from March 18 to March 21, 2025, with the Director of Nursing (DON) unaware that the postings had not been changed daily. The facility's policy, last revised in August 2024, mandates that nurse staffing information be readily available and visible in a clear format to residents and visitors. The policy requires the posting of the facility name, current date, resident census, and the total number and actual hours worked by RNs, LPNs, and CNAs per shift. However, the facility did not comply with this policy, as the postings were not updated for the second and third shifts, and the information was not presented in a prominent place accessible to residents and visitors.
Failure to Document and Complete Wound Care Treatments
Penalty
Summary
The facility failed to complete ordered wound treatments and assessments for two residents, leading to a deficiency in care. Resident B, diagnosed with multiple sclerosis, dementia, malnutrition, and type II diabetes, had several physician's orders for wound care on the right shin and heel. However, the electronic treatment administration record (eTAR) lacked documentation of these treatments being completed on multiple occasions, including specific dates in July 2024. Additionally, there was a failure to document the drainage amount for the right heel wound on several dates as required by the physician's order. Similarly, Resident C, diagnosed with Alzheimer's disease, malnutrition, and iron-deficient anemia, had physician's orders for wound care on the left ankle. The eTAR lacked documentation of the treatments being completed on several dates in August 2024, including both daily and bedtime applications. Furthermore, the drainage amount for the left ankle wound was not documented for a series of dates. During an interview, the Director of Nursing (DON) confirmed that all treatments should be completed and documented per physician's order, acknowledging the lack of documentation for wound descriptions and dressing changes.
Improper Medication Storage and Disposal
Penalty
Summary
The facility failed to ensure medications were stored securely and disposed of according to policy and compliance regulations. During an observation of the Wound Nurse's office, a small, unlocked two-drawer file cabinet was found containing various medications for multiple residents, some of whom had been discharged from the facility. These medications included ondansetron, hydroxyzine pamoate, finasteride, lisinopril, atorvastatin calcium, and many others, which were not stored in accordance with the facility's policy that requires all drugs and biologicals to be stored in locked compartments. Interviews with the facility staff, including the Administrator, Wound Nurse, RN 1, RN 2, ADON, and the Rehab Unit Manager, revealed a lack of adherence to the facility's medication storage and disposal policies. The Administrator acknowledged that the medications should not have been in the Wound Nurse's office. The Wound Nurse and other staff members indicated that medications should have been sent with residents upon discharge or destroyed if not picked up by families. However, there was confusion among staff regarding the procedures for handling medications of discharged residents, with some staff unaware of the time frame for holding medications before destruction. The facility's current policies, titled 'Medication Storage' and 'Drug Disposition,' outline the requirements for storing and disposing of medications, including the destruction of unused drugs within seven days if not returned to the pharmacy or released to the resident. Despite these policies, the facility failed to comply, resulting in medications being improperly stored in an unsecured location, which was acknowledged by the staff during interviews.
Failure to Obtain Apical Pulse Before Digoxin Administration
Penalty
Summary
The facility failed to ensure that an apical pulse was obtained prior to the administration of digoxin for one resident during medication administration. During an observation, a registered nurse (RN) administered multiple medications, including digoxin, to a resident without checking the resident's pulse beforehand. The resident had a diagnosis of atrial fibrillation, and the physician's orders for digoxin did not include specific parameters for when to hold the medication or notify the physician. The resident's pulse records showed inconsistent documentation, with the last recorded pulse being several days prior to the observation. Interviews with nursing staff revealed that the standard practice was to check the pulse and blood pressure before administering digoxin, and to hold the medication if the pulse was below 60 beats per minute. However, the RN relied on a pulse reading taken by the night shift nurse earlier that day, which was not documented in the resident's record. The Director of Nursing (DON) confirmed that physician's orders should be followed, and a pulse should be obtained before administering digoxin. The facility's policy on medication administration also required pre-administration checks, such as pulse and blood pressure, to be performed before preparing medications.
Failure to Monitor and Treat Pressure Injury
Penalty
Summary
The facility failed to adequately monitor and implement interventions for a pressure injury in one of the residents, identified as Resident C. Observations revealed that Resident C was frequently positioned on her right side on a low air loss mattress, and there was a lack of consistent repositioning. The resident's clinical record indicated multiple diagnoses, including dementia, chronic heart failure, and severe malnutrition, which increased her risk for pressure injuries. Despite these risks, the care plan lacked updated interventions after December 2023, and there were significant gaps in wound assessments and treatments. Resident C's pressure injury was initially noted in a Physiatry Progress Note in January 2024, but there was no documented wound assessment or treatment until the end of that month. Subsequent assessments showed the progression of the wound from a stage 2 to an unstageable pressure injury, with varying degrees of granulation, slough, and eschar. The facility's documentation was inconsistent, with missing assessments and unclear wound descriptions, leading to inadequate treatment and monitoring of the pressure injury. Interviews with staff, including the Wound Nurse and the DON, highlighted a lack of awareness and communication regarding the resident's condition. The Wound Nurse was unaware of earlier documentation indicating the presence of a pressure sore, and the DON could not locate assessments corresponding to the initial findings. The facility's policy on pressure injury prevention and management was not effectively implemented, as evidenced by the lack of timely and appropriate interventions to promote healing and prevent further deterioration of the resident's condition.
Improper Catheter Care and Positioning
Penalty
Summary
The facility failed to ensure proper positioning of an indwelling catheter and tubing for a resident, identified as Resident C, which led to potential contamination. Observations revealed that the resident's catheter bag and tubing were repeatedly found lying on the floor mat, which is against the facility's policy. On multiple occasions, the catheter bag was observed hanging off the bed frame and touching the floor mat, with the tubing extending towards the door. Despite staff presence and room checks, the improper positioning of the catheter bag and tubing was not corrected. Resident C's clinical record indicated a history of urinary tract infections, chronic kidney disease, and dementia, with a significant cognitive impairment. The resident was dependent on staff for various activities, including toileting and personal hygiene. The facility's policy, as provided by the Director of Nursing, clearly stated that catheter bags and tubing should not rest on the floor, yet this was not adhered to, as evidenced by the observations and staff interviews. Staff members, including a CNA and an LPN, acknowledged the expectation to ensure catheter bags were not on the floor, but this was not consistently practiced.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Muncie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brickyard Healthcare - Muncie Care Center | 0.3 mi | ★★★★★ | 1 | 0 |
| Morrison Woods Health Campus | 1 mi | ★★★★★ | 0 | 0 |
| Westminster Village Muncie Inc | 1.5 mi | ★★★★★ | 10 | 0 |
| Woodlands The | 1.7 mi | ★★★★★ | 0 | 0 |
| Waters Of Muncie, The | 2.1 mi | ★★★★★ | 0 | 0 |
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