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Bethlehem Woods Nursing And Rehabilitation

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About Bethlehem Woods Nursing And Rehabilitation

General Information

Legal Business NameThe Health And Hospital Corporation Of Marion County
Ownership TypeGovernment - State
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareOctober 26, 2000 (16 years)
Capacity90
Residents84
Percent Occupied93%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Bethlehem Woods Nursing And Rehabilitation

Bethlehem Woods Nursing And Rehabilitation
was reviewed by Medicare to have a rating of 5 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Indiana Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

August 26, 2015 - 16 months ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
DFewPotential for HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmComplaintProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmComplaintAllow residents the right to participate in the planning or revision of care and treatment.

June 25, 2015 - 18 months ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
DFewPotential for HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmComplaintProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
DFewPotential for HarmComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

July 8, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmFire Safety InspectionOther fire safety features required by fire safety codes.
ESomePotential for HarmFire Safety InspectionHorizontal exits.
ESomePotential for HarmFire Safety InspectionExits that are accessible at all times.
ESomePotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Bethlehem Woods Nursing And Rehabilitation require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 40min
2hr 55min
ReportedExpected
CNA
35min
50min
ReportedExpected
LPN
1hr 10min
1hr 20min
ReportedExpected
RN
4hr 25min
5hr 5min
ReportedExpected
Total Nursing

This facility also provides approximately 25min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

100.0%
100.0%
100.0%
94.7%
Q1 2015Q2 2015Q3 2015IN
Assessed and Appropriately Given the Seasonal Influenza Vaccine
100.0%
100.0%
100.0%
93.7%
Q1 2015Q2 2015Q3 2015IN
Assessed and Appropriately Given the Pneumococcal Vaccine
-
-
-
48.7%
Q1 2015Q2 2015Q3 2015IN
* The data for this facility for some quarters is unavailable.
Low Risk Residents Who Lose Control of Their Bowel or Bladder
12.5%
13.9%
12.0%
17.4%
Q1 2015Q2 2015Q3 2015IN
Received an Antipsychotic Medication
1.4%
4.1%
1.3%
16.6%
Q1 2015Q2 2015Q3 2015IN
Need for Help with ADLs has Increased
0.0%
0.0%
0.0%
7.1%
Q1 2015Q2 2015Q3 2015IN
Self Report Moderate to Severe Pain
16.0%
11.8%
12.8%
8.0%
Q1 2015Q2 2015Q3 2015IN
Lose Too Much Weight
0.0%
2.7%
1.4%
6.5%
Q1 2015Q2 2015Q3 2015IN
High Risk Residents With Pressure Ulcers
3.0%
11.6%
21.3%
6.5%
Q1 2015Q2 2015Q3 2015IN
Have Depressive Symptoms
0.0%
0.0%
0.0%
4.8%
Q1 2015Q2 2015Q3 2015IN
With a Urinary Tract Infection
2.7%
0.0%
1.3%
3.5%
Q1 2015Q2 2015Q3 2015IN
Experiencing One or More Falls with Major Injury
0.0%
0.0%
1.3%
2.9%
Q1 2015Q2 2015Q3 2015IN
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.7%
Q1 2015Q2 2015Q3 2015IN
Were Physically Restrained

Quality Measures for Short Stay Residents

97.7%
100.0%
100.0%
81.7%
Q1 2015Q2 2015Q3 2015IN
Assessed and Appropriately Given the Pneumococcal Vaccine
97.7%
97.7%
97.7%
82.3%
Q1 2015Q2 2015Q3 2015IN
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
0.0%
10.7%
4.0%
16.7%
Q1 2015Q2 2015Q3 2015IN
Self Report Moderate to Severe Pain
4.8%
0.0%
-
2.4%
Q1 2015Q2 2015Q3 2015IN
* The data for this facility for some quarters is unavailable.
Newly Received an Antipsychotic Medication
1.5%
2.2%
2.6%
1.6%
Q1 2015Q2 2015Q3 2015IN
With Pressure Ulcers That Are New or Worsened