Muncie, IN

Bethel Pointe Health And Rehab

5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

3400 W Community Dr, Muncie, IN

(765) 289-2273

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

114

Certified beds

Average residents

111

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Tlc Management

Operator or chain grouping

Approved since

1994-06-30

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

20 facilities

Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.53

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.93

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

1.99

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.44

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.45

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

2.76

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.32

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.48

CMS adjusted RN staffing hours

Adjusted total hours

3.16

CMS adjusted total nurse staffing hours

Case-mix index

1.49

Higher values indicate more complex resident acuity

RN turnover

36%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

43%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,165

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

17.81

Composite VBP score used to determine payment impact.

Payment multiplier

0.9819

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.24

Baseline 19.30% · Performance 19.93% · Measure score 3.24 · Achievement 3.24 · Improvement 0

Healthcare-associated infections

0

Baseline 7.83% · Performance 8.01% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

3.89

Baseline 49.11% · Performance 47.79% · Measure score 3.89 · Achievement 3.89 · Improvement 0.04

Adjusted total nurse staffing

0

Baseline 3.21 hours · Performance 2.99 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.09%	10.72% 0.6 pts better	No Different than the National Rate · Eligible stays 281 · Observed rate 9.96% · Lower 95% interval 7.6%
Discharge to community	68.66%	50.57% 18.1 pts better	Better than the National Rate · Eligible stays 275 · Observed rate 62.55% · Lower 95% interval 63.13%
Medicare spending per beneficiary	0.98	1.02 About the same
Drug regimen review with follow-up	99.45%	95.27% 4.2 pts better	Numerator 181 · Denominator 182
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 182
Discharge self-care score	61.29%	53.69% 7.6 pts better	Numerator 76 · Denominator 124
Discharge mobility score	55.65%	50.94% 4.7 pts better	Numerator 69 · Denominator 124
Pressure ulcers or injuries, new or worsened	3.31%	2.29% 1 pts worse	Numerator 6 · Denominator 181 · Adjusted rate 3.29%
Healthcare-associated infections requiring hospitalization	8.01%	7.12% 0.9 pts worse	No Different than the National Rate · Eligible stays 174 · Observed rate 8.05% · Lower 95% interval 5.27%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 177
Staff flu vaccination coverage	11.43%	42% 30.6 pts worse	Numerator 24 · Denominator 210
Discharge function score	58.06%	56.45% 1.6 pts better	Numerator 72 · Denominator 124
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 71 · Denominator 71
Transfer of health information to patient	97.62%	96.28% 1.3 pts better	Numerator 82 · Denominator 84
Resident COVID-19 vaccinations up to date	8.25%	25.2% 16.9 pts worse	Numerator 8 · Denominator 97

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.2	1.6 0.6 pts worse	1.9 0.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.9 · Expected 2.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.4	1.5 0.1 pts better	1.8 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	96.3%	93.6% 2.7 pts better	93.4% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 94.7% · Q2 98.6% · Q3 96.0% · Q4 96.1% · 4Q avg 96.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	92.5%	95.4% 2.9 pts worse	95.5% 3 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 92.5%
Percentage of long-stay residents experiencing one or more falls with major injury	2.0%	3.8% 1.8 pts better	3.3% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.4% · Q3 1.3% · Q4 2.6% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	11.3%	24.6% 13.3 pts better	11.4% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 6.1% · Q3 7.0% · Q4 26.4% · 4Q avg 11.3%
Percentage of long-stay residents who lose too much weight	9.7%	5.6% 4.1 pts worse	5.4% 4.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 9.4% · Q3 8.7% · Q4 6.8% · 4Q avg 9.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	20.9%	23.5% 2.6 pts better	19.6% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 20.3% · Q3 15.3% · Q4 18.9% · 4Q avg 20.9%
Percentage of long-stay residents who received an antipsychotic medication	14.6%	14.8% 0.2 pts better	16.7% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 15.7% · Q3 12.7% · Q4 12.7% · 4Q avg 14.6% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	14.6%	13.3% 1.3 pts worse	16.3% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 11.3% · Q3 5.8% · Q4 10.5% · 4Q avg 14.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	10.2%	11.7% 1.5 pts better	14.9% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 3.2% · Q3 15.7% · Q4 9.7% · 4Q avg 10.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.2%	0.4% 0.8 pts worse	1.0% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.7% · Q3 1.8% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.3%	1.2% 0.9 pts better	1.7% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	27.9%	24.2% 3.7 pts worse	19.8% 8.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 24.1% · Q3 38.2% · Q4 22.9% · 4Q avg 27.9%
Percentage of long-stay residents with pressure ulcers	3.4%	4.1% 0.7 pts better	5.1% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 2.7% · Q3 4.4% · Q4 1.4% · 4Q avg 3.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	76.3%	81.6% 5.3 pts worse	81.7% 5.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 70.9% · Q2 68.0% · Q3 78.5% · Q4 89.2% · 4Q avg 76.3%
Percentage of short-stay residents who had an outpatient emergency department visit	9.0%	10.5% 1.5 pts better	12.0% 3 pts better	Short Stay · 20240701-20250630 · Adjusted 9.0% · Observed 8.8% · Expected 11.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.2%	1.3% 1.1 pts better	1.6% 1.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	74.2%	79.0% 4.8 pts worse	79.7% 5.5 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 74.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	32.8%	22.4% 10.4 pts worse	23.9% 8.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 32.8% · Observed 32.4% · Expected 23.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-21 · Fire 2025-03-21

4 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-06-07 · Fire 2024-06-07

5 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-05-09 · Fire 2023-05-09

6 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

3 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-03-21

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-04-21

E · Potential for more than minimal harm 2025-03-21

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-04-21

D · Potential for more than minimal harm 2025-03-21

K200 · Egress Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2025-04-21

F · Potential for more than minimal harm 2024-06-07

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2024-07-26

E · Potential for more than minimal harm 2024-06-07

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-07-26

E · Potential for more than minimal harm 2024-06-07

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-07-26

E · Potential for more than minimal harm 2024-06-07

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-07-26

E · Potential for more than minimal harm 2023-05-09

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2023-06-20

E · Potential for more than minimal harm 2023-05-09

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-06-20

C · Minimal harm 2023-05-09

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-06-20

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-22

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2026-01-30

D · Potential for more than minimal harm 2025-03-21

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-03-21

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-04-11

C · Minimal harm 2025-03-21

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-04-11

D · Potential for more than minimal harm 2024-09-06

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-09-20

D · Potential for more than minimal harm 2024-07-12

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-08-02

D · Potential for more than minimal harm 2024-06-07

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-06-07

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-06-07

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-06-28