Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Bethlehem Woods Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that medications on three medication carts were not properly labeled or stored, with multiple open liquid medications and an open lidocaine vial lacking open dates and some remaining on carts after physician orders were discontinued or after a resident was discharged. A DON interview confirmed that the lidocaine should have been removed when no longer needed and that nurses should have dated opened medications, contrary to the facility’s own medication storage policy.
A resident with HTN and type 2 DM did not receive ordered clonidine 0.5 mg BID over an extended period because the drug was documented as awaiting pharmacy delivery, with no doses administered. Nursing notes showed no evidence that the pharmacy or NP were notified about the missing medication, and the pharmacy reported no additional communication from the facility. An RN stated nurses should contact the pharmacy and update the resident and NP when medications are not delivered, while the DON acknowledged a communication lapse and noted that the facility’s medication administration policy addressed timing of doses but lacked a protocol for handling undelivered medications.
The facility did not complete admission agreements in a timely manner for three residents, with delays ranging from three to nine days after admission due to unavailability of responsible parties. In each case, the required paperwork, which included consent for treatment and payment information, was not signed at the time of admission, and the facility relied on implied consent until signatures could be obtained. No policy or procedure was available to guide staff in these situations.
A resident with complex medical needs was transferred to the hospital multiple times without consistent documentation of family notification or inclusion of the required bed hold policy with the transfer paperwork. Facility staff confirmed that these notifications and documents were not always completed as required.
Improper Medication Labeling and Storage on Multiple Medication Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication labeling and storage practices on three of three medication carts reviewed, affecting seven residents. During observations on multiple medication carts, several open medication containers lacked required open dates, including liquid potassium chloride 10% for a resident with dementia with psychotic disturbance, guaifenesin liquid for multiple residents with conditions such as aphasia following cerebral infarction and unspecified dementia, Biotene Dry Mouth oral rinse for a resident with paroxysmal atrial fibrillation, chlorhexidine 0.12% mouthwash for a resident with chronic obstructive pulmonary disease, and lactulose for a resident who had already been discharged. Additionally, an open vial of lidocaine 1% was found on a cart without an open date and without a current physician order for the resident with malignant neoplasm of the right kidney. Record review showed that several of these medications had been discontinued by the physician on or before the survey dates, yet the open containers remained on the carts without proper labeling or removal. The DON stated that the lidocaine should have been removed from the cart when it was no longer needed for a resident’s antibiotic treatment and acknowledged that the nurse who opened the medications should have dated them. The facility’s own Medication Storage policy required medications to be stored and monitored for expiration dates consistent with applicable laws and regulations, including 410 IAC 16.2-3.1-25(j), but the observed practices did not comply with these requirements.
Failure to Administer Ordered Antihypertensive Due to Lack of Follow-Up on Missing Medication
Penalty
Summary
The deficiency involves the facility’s failure to administer a prescribed antihypertensive medication as ordered for one resident. The resident, who had diagnoses including hypertension and type 2 diabetes mellitus, reported in an interview that he did not receive his medications as ordered. Review of the Medication Administration Record for a specified period showed an active order for clonidine HCl 0.5 mg to be given orally twice daily, yet the record indicated the resident did not receive any doses during that entire period, with the reason documented as awaiting delivery from the pharmacy. Nursing notes for the same timeframe contained no documentation that the pharmacy or the nurse practitioner (NP) was notified that the resident had not received the ordered clonidine due to pharmacy delay. In interviews, an RN stated that when a medication has not been delivered, the nurse should call the pharmacy for updates and keep the resident and NP informed, and the DON stated that the pharmacy reported receiving no additional communication from the facility regarding this medication. The DON also described a lack of communication on the day the NP was to see the resident, resulting in the missed clonidine not being addressed. The facility’s medication administration policy specified timing parameters for giving medications but did not include a protocol for handling missing medications from the pharmacy.
Failure to Timely Complete Admission Agreements
Penalty
Summary
The facility failed to complete admission agreements in a timely manner for three residents. For one resident, the admission agreement paperwork was signed four days after admission, despite the resident being able to sign the paperwork herself. In another case, the admission agreement was signed three days after admission by the resident's daughter and Power of Attorney, and the resident herself signed the agreement several weeks later. For the third resident, the admission agreement was signed nine days after admission due to the unavailability of the resident's wife, who was ill and unable to attend the planned meeting until later. Interviews with the Executive Director revealed that in cases where responsible parties were unavailable, the facility relied on implied consent until the admission agreement could be completed. The facility did not have a policy or procedure available regarding the handling of admission agreements when responsible parties were not immediately available. The admission agreements included important information such as resident obligations, consent for treatment, payment details, and other required disclosures.
Failure to Provide Required Transfer Documentation and Bed Hold Policy
Penalty
Summary
The facility failed to provide the required documentation and notifications related to hospital transfers for a resident with multiple complex medical conditions, including end stage kidney disease, heart failure, and emphysema. On several occasions, the resident was transferred to the hospital, but the documentation did not consistently indicate that the resident's family or representative had been notified. In some instances, event reports noted that a representative was notified, but did not include the representative's name or contact information. Progress notes often lacked documentation of family notification at the time of transfer. Additionally, the facility did not attach a copy of the bed hold policy to the Notice of Transfer or Discharge forms as required. Although the bed hold policy was included in the admission agreement, it was not provided with the transfer documentation for any of the hospital transfers reviewed. Facility policy required that the bed hold policy be reviewed with the responsible party and documented in the medical record, but this was not done. Interviews with staff confirmed that the required notifications and documentation were not consistently completed.
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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 Fort Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Canterbury Nursing And Rehabilitation Center | 1.4 mi | ★★★★★ | 7 | 0 |
| Towne House Retirement Community | 1.5 mi | ★★★★★ | 1 | 0 |
| Heritage Pointe Of Fort Wayne | 1.6 mi | ★★★★★ | 4 | 0 |
| University Park Rehabilitation And Healthcare | 2.3 mi | ★★★★★ | 4 | 0 |
| Chateau Rehabilitation And Healthcare Center | 2.9 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.