Complaint Investigation

Bethlehem Woods Nursing And Rehabilitation

November 17, 2025 · Fort Wayne, IN · 4430 Elsdale Dr

Citations 1

CMS Rating 5/5

Beds 90

Provider ID 155679

Healthcare Facility

Bethlehem Woods Nursing And Rehabilitation

Fort Wayne, IN · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

BETHLEHEM WOODS NURSING AND REHABILITATION in FORT WAYNE, IN — inspection on November 17, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0620

Resident Rights Deficiencies

Potential for More Than Minimal Harm

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. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to perform admission agreements in a timely manner for 3 of 3 residents reviewed. (Resident Q, Resident R, and Resident S).Findings include: 1) Resident Q's record was reviewed on 11/17/25 at 9:26AM.

Resident Q was admitted on [DATE].Resident Q's admission agreement paperwork was signed on 10/29/25, 4 days after admission.

The admission agreement was dated 10/25/25 and included the following: Resident obligations, Consent for Treatment, Services, Payments for Room Rate, Medicare and Medicaid Programs, Personal Finances, Termination Transfers and Discharges, Bed Hold Policy, Personal Property, Resident Records, Privacy, Non-Discrimination, Dispute Resolution, Limitations of Community, Miscellaneous Provisions and signatures.In an interview, on 11/17/25 at 12:57PM, the Executive Director (ED) indicated Resident Q's daughter was not available on 10/27/25 or 10/28/25 to sign the paperwork.

After reviewing Resident Q further, it was determined the resident was able to sign her own admission paperwork on 10/29/25.2) Resident R's record was reviewed on 11/17/25 at 11:31AM.

Resident R was admitted on [DATE].Resident R's admission agreement paperwork was signed on 10/20/25, 3 days after admission, by her daughter and Power of Attorney (POA).

Resident R's admission agreement was signed by Resident R on 11/6/25.

The admission agreement was dated 10/17/25 and included the following: Resident obligations, Consent for Treatment, Services, Payments for Room Rate, Medicare and Medicaid Programs, Personal Finances, Termination Transfers and Discharges, Bed Hold Policy, Personal Property, Resident Records, Privacy, Non-Discrimination, Dispute Resolution, Limitations of Community, Miscellaneous Provisions and signatures.3) Resident S's record was reviewed on 11/17/25 at 10:27AM.

Resident S was admitted on [DATE].Resident S's admission agreement paperwork was signed on 10/27/25, 9 days after admission.

The admission agreement was dated 10/18/25 and included the following: Resident obligations, Consent for Treatment, Services, Payments for Room Rate, Medicare and Medicaid Programs, Personal Finances, Termination Transfers and Discharges, Bed Hold Policy, Personal Property, Resident Records, Privacy, Non-Discrimination, Dispute Resolution, Limitations of Community, Miscellaneous Provisions and signatures.In an interview, on 11/17/25 at 12:57PM, the ED indicated Resident S's wife was sick, not available on 10/24/25 and did not attend the planned meeting (6 days after admission).

Resident S's wife was sick and unavailable until 10/27/25 when she signed the admission paperwork.In an interview, on 11/17/25 at 10:30AM, the ED indicated there was implied consent until an admission agreement can be made, especially when someone comes in on a weekend or late in the evening.No policy or procedure was available at time of exit.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

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Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FORT WAYNE, IN, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BETHLEHEM WOODS NURSING AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.