Below 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 Bethlehem North Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
Failure to Report Alleged Abuse to State Survey Agency: The facility did not timely report alleged abuse involving six residents to the State Survey Agency as required by policy. One resident with MH diagnoses alleged that an NA touched her inappropriately during incontinence care, another resident with schizoaffective disorder and ID was linked to that allegation, and a third resident with cognitive impairment and multiple MH diagnoses repeatedly reported inappropriate touching by the same NA. Facility documentation also showed awareness of alleged abuse involving three additional residents with significant medical and cognitive conditions, but there was no evidence the allegations were reported as required.
A hospice resident with liver cancer had a PRN order for oral morphine sulfate for pain, and the medication was administered during the night as a change in the resident’s medical status and treatment. Review of the MAR and clinical record showed no documentation that the resident’s responsible party was informed of this change in condition and medication use. In an interview, the Nursing Home Administrator confirmed that the responsible party had not been notified, resulting in a deficiency under nursing services requirements.
Food Storage and Sanitizing Solution Deficiencies: Surveyors found multiple food safety issues in the dietary dept, including food debris in a freezer, undated yogurt, juice past its use-by date, undated mousse mix, croutons, breadcrumbs, and shredded cheese, plus open bags of flour and breadcrumbs exposed to air. They also found enhanced pudding and chopped eggs with use-by/dating concerns, dried red liquid under raw ground beef, an opened package of frozen corned beef dated months earlier, and a pot sink sanitizing solution that was not at the required ppm. The Dietary Mgr confirmed the items were not dated or discarded as required and that the sanitizing solution was not properly sanitizing the pots and pans.
The facility failed to follow physician orders for several residents by not documenting required BP, HR, or blood sugar checks before giving meds and, in one case, giving insulin when it should have been held. Residents with HTN, heart disease, atrial fibrillation, diabetes, and end stage kidney disease received carvedilol, metoprolol tartrate, and insulin aspart without the required documented assessments or provider notification for low blood sugar.
Failure to Assess Residents for Medication Self-Administration: The facility did not assess two residents for the ability to self-administer meds as required by policy. One resident with ESRD on dialysis had calcium acetate left unsecured on a lunch tray, and another resident with HTN, DM, and depression had multiple morning meds unsecured on a tray table. There was no documentation of an assessment for either resident, and the ADON confirmed both were not assessed.
Hiring Screening and License Verification Not Completed Before Employment Facility policy review, personnel file review, and staff interview showed that the facility failed to complete required reference checks and verify a professional license or registration before two newly hired employees started work. One employee worked as the Administrator before the state licensure board inquiry was completed, and one nurse aide began work before a reference check was completed. The HR Operations Partner confirmed there was no documented evidence that these screenings were done prior to employment.
Failure to provide scheduled bathing assistance for two dependent residents. Both residents required extensive ADL help and were totally dependent on staff for bathing; one had a stroke with right-side involvement and diabetic polyneuropathy, and the other had a stroke with bilateral lower-leg contractures and protein-calorie malnutrition. Nurse aide documentation showed missed baths/showers, and both residents stated they were not always offered showers. The ADON confirmed the missed bathing care.
A resident with an open wound of the lower back and pelvis region and a left heel pressure ulcer had a physician order for a heel suspension device to be applied to both heels while in bed. The care plan identified the resident as at risk for skin breakdown, but repeated observations found the resident in bed without the ordered device in place. The resident reported that staff sometimes used a pillow or heel boots depending on who was working, and the ADON confirmed the device was not in place as ordered.
Failure to Implement ROM and Mobility Interventions: The facility failed to carry out ordered interventions for two residents with limited mobility and ROM. One resident had a PT-recommended restorative ambulation program with a rolling walker and staff assistance, but there was no evidence it was provided and the resident said it was never offered. Another resident with a left hand contracture was supposed to wear a splint as part of the care plan, but observations showed the splint was not in place and the resident said he did not refuse it.
A resident with HTN and quadriplegia was frequently incontinent of urine and later had a change in bowel continence, but the record showed no documented incontinence assessment on admission or after the change. The chart also lacked a care plan with specific interventions to address the resident’s urinary and bowel incontinence, and the ADON confirmed the missing assessment and care-planned interventions.
Failure to monitor significant weight loss. A resident with myasthenia gravis, CVA, and mild protein-calorie malnutrition had a 5.2% weight loss, but the RD was not notified and the resident was not reweighed within 24 hours as required by policy. The RD later stated that reweights are to be completed within 24 hours and that the resident was not reweighed per request and policy.
A resident with PTSD, major depressive disorder, anxiety, and a mood disorder did not have an individualized, person-centered care plan for trauma informed care. The record showed PTSD-related symptoms on the MDS, but there was no documentation of trigger assessment or specific interventions to minimize triggers or re-traumatization, and the SWD confirmed no care plan had been developed.
Failure to review pneumococcal vaccination status for two residents. Facility policy required admission screening for prior pneumococcal immunization and documentation of vaccine education, receipt, or refusal in the EMR, but there was no documented evidence that the residents' vaccine status was reviewed to determine whether an updated vaccine needed to be offered. The Assistant DON confirmed the review had not been completed.
Failure to offer COVID-19 vaccine to two residents: Facility policy required education, offering the vaccine, and documentation of consent or declination, but record review found no documentation that one resident was offered the vaccine after admission and no documentation that another resident was offered the vaccine in subsequent years. The ADON/Infection Preventionist confirmed the residents had not been offered the vaccine per policy.
The facility failed to obtain written authorization to manage a resident’s personal funds. The resident, who had DM and HTN and was able to communicate her needs, stated she did not authorize the facility to become her representative payee and that her money was taken without her permission. Records showed no resident authorization for the facility to manage or open the fund account, and the Administrator confirmed written authorization had not been obtained.
Improper Disposal of Trash and Refuse: Observation of the trash compactor area found plastic and paper debris on the ground, along with a wrapped soiled feminine hygiene product, a soiled piece of gauze, multiple used plastic gloves, and a half-eaten chicken drumstick in front of the compactor.
Food was served at an unappetizing temperature on the 4th floor. Several residents reported that hot food was frequently served cold, and a test tray showed the chicken, mashed potatoes, and vegetables were all below the facility’s expected hot-food temperature and cool to taste. Residents who received trays from the same cart also said the chicken and mashed potatoes were cool, and the Dietary Manager confirmed the temperatures did not meet policy expectations.
A resident with polyneuropathy and dementia, dependent on staff for daily activities, was found with the call bell out of reach on multiple occasions. The care plan required the call bell to be accessible to prevent falls, but it was observed on the floor next to the bed. The ADON confirmed the call bell should have been within reach.
The facility failed to notify the responsible parties of three residents who experienced significant weight loss, as required by their policies. A resident with sarcopenia and dementia lost 10.8% of their weight, another with anemia and anxiety lost 11.8%, and a third with a traumatic brain injury and dysphagia lost 5.0%. The facility's administrator confirmed the lack of evidence for notifying the residents' representatives.
The facility failed to maintain adequate grooming and hygiene for three residents dependent on staff for ADLs. A resident with muscle weakness had long, dirty nails despite preferring them short. Another resident with dementia and dermatitis had long, jagged nails with a dark substance underneath, and a third resident with dementia and anxiety also had long, dirty nails. The ADON confirmed that nail care should have been provided during bathing and as needed.
A resident with a history of stroke and depression did not receive the necessary orthotic device to prevent a decline in range of motion. Despite a physician's order and an occupational therapy discharge assessment recommending a hand grip, staff failed to update the clinical record and assist the resident with the device. Observations confirmed the absence of the device, and the resident reported a lack of staff assistance.
A facility failed to implement smoking safety measures for a resident with depression and anxiety. The facility's policy requires smoking supplies to be stored by staff at the nurses' station, but the resident kept them in a personal bag on his bed. Interviews with the DON and ADON confirmed the supplies should have been stored according to policy.
The facility failed to monitor and address significant weight loss for two residents at risk for nutritional problems. One resident, with traumatic brain injury and dysphagia, lost 12 pounds over a short period, and the RD was not notified until much later. Another resident lost 24.2 pounds, and the weight loss was not addressed promptly. The Administrator confirmed the lack of timely notification and intervention.
A resident with a history of stroke and depression did not receive the required adaptive eating equipment, specifically a curved spoon, as outlined in her care plan. Despite the care plan's directive and the resident's meal tray ticket indicating the need for a curved spoon, observations revealed that she was consistently given a regular spoon during meals.
A dietary employee failed to maintain sanitary conditions during food service by not changing gloves or performing hand hygiene after leaving the tray line, wiping gloves on clothing, and handling cooked chicken with the same gloves.
The facility failed to notify residents and their representatives of appeal rights and Ombudsman information upon hospital transfer. Five residents were transferred due to a change in condition, but there was no documented evidence that they or their representatives received the required notifications.
Failure to Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to report alleged abuse involving six sampled residents to the State Survey Agency. Facility policy required the Administrator or designee to report suspected or alleged abuse immediately upon receiving the information, with allegations involving abuse reported not later than two hours after the allegation was made and to the appropriate state and local authorities within 24 hours if the event did not result in serious bodily injury. The report states that the facility had documentation showing it was aware of alleged abuse involving Residents 1, 2, 3, 4, 5, and 6, but there was a lack of evidence that the allegations were reported to the State Survey Agency within the required timeframes. Resident 1 had diagnoses including major depressive disorder, bipolar disorder, anxiety, and PTSD, and alleged that a nurse aide was inappropriate and touched her vagina during incontinence care. Resident 2 had schizoaffective disorder, bipolar disorder, a developmental disorder of speech and language, and mild intellectual disabilities, and was involved because Resident 1 reported that Resident 2 said the same nurse aide had touched her inappropriately. Resident 3 had encephalopathy, cognitive impairment, anxiety, major depressive disorder, and delusional disorder, and was dependent on staff for ADLs; the resident reported on multiple occasions that the nurse aide had touched her inappropriately. Residents 4, 5, and 6 had diagnoses including muscle disorders, history of cerebral infarction, bone disorder, delirium, anxiety, delusional disorders, dementia with agitation and psychotic disturbance, osteomyelitis, depression, and unspecified affective mood disorder, and the facility documentation showed it was made aware of alleged abuse involving those residents but did not show reporting to the State Survey Agency.
Failure to Notify Responsible Party of Hospice Resident’s Change in Condition and Pain Medication Use
Penalty
Summary
The facility failed to notify a resident’s responsible party of a change in medical condition and new medication administration for a hospice resident. The resident, who had liver cancer and was admitted to hospice services on March 2, 2026, had a physician’s order for oral morphine sulfate every two hours as needed for pain. Review of the April 2026 MAR showed that the narcotic pain medication was administered on April 10, 2026, at 2:40 a.m., representing a change in the resident’s medical status and treatment. However, there was no documentation that the resident’s responsible party was informed of this change in condition and medication use. In an interview on April 10, 2026, at 11:45 a.m., the Nursing Home Administrator confirmed that the responsible party had not been notified of the change in medical condition and the administration of the pain medication. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services, based on clinical record review and staff interview findings that the required notification to the responsible party did not occur.
Food Storage and Sanitizing Solution Deficiencies
Penalty
Summary
The facility failed to store food in a sanitary manner in the dietary department. During review of facility policies, staff were expected to discard prepared foods after 72 hours and frozen foods after 45 days of opening, and the pot and pan sink was to be filled with sanitizing solution at the appropriate concentration. During the kitchen tour, surveyors observed food debris on the bottom of the stockroom reach-in freezer, an undated container of yogurt and a cup of apple juice labeled use-by December 17, 2025 in the reach-in cooler, four packages of mousse mix removed from original packaging without dates, two opened bulk containers of croutons and breadcrumbs without dates, and two large bags of flour and breadcrumbs that were open to air. The breadcrumb container also had breadcrumb debris covering the lid. Additional observations included a bulk container of enhanced pudding with a use-by date of February 7 and a pan of chopped eggs dated February 3 in reach-in cooler #2, an opened bag of shredded cheese without a date in reach-in cooler #3, and dried red liquid on the cooler floor below a tray of raw ground beef. In reach-in freezer #4, there was an opened package of frozen corned beef dated October 22, 2025. The Dietary Manager stated that the foods were not dated when they should have been, expired items should have been discarded and were not, and the pot sink sanitizing solution was not at the required parts per million to sanitize the pots and pans soaking in it.
Failure to Follow Medication Orders and Required Monitoring
Penalty
Summary
The facility failed to ensure physicians’ orders were implemented for five sampled residents by not documenting required assessments before medication administration and, in one case, not following an insulin hold parameter. Resident 8, who had hypertension and heart failure, received carvedilol multiple times without documentation that blood pressure and heart rate were checked before administration as ordered. Resident 12, with atrial fibrillation and high blood pressure, received metoprolol tartrate multiple times without documentation that heart rate was assessed before dosing. Resident 16, who had hypertension, received metoprolol tartrate multiple times without documentation that blood pressure and heart rate were assessed before administration. Resident 159, with heart disease, hypertension, and atrial fibrillation, received metoprolol tartrate without documented evidence that heart rate was taken prior to administration. Resident 18, who had diabetes and end stage kidney disease, had an order for insulin aspart before meals with instructions to hold the medication if blood sugar was below 100 mg/dL and to notify the provider if blood sugar was below 70 mg/dL or above 350 mg/dL. The resident had blood sugar readings of 52 mg/dL on two occasions with no documentation that the provider was notified, and on another occasion had a blood sugar of 86 mg/dL and still received insulin aspart when the medication was not to be given. The Assistant DON confirmed there was no documented evidence that the provider was notified for the low blood sugar readings and that the resident received insulin aspart when it should have been held.
Failure to Assess Residents for Medication Self-Administration
Penalty
Summary
The facility failed to assess whether two residents were capable of self-administering their medications, despite its policy requiring an assessment of the resident’s functionality and health condition, a physician or advanced practice provider order, documentation in the care plan, and a secure locked area for medications if applicable. Review of the clinical record showed that Resident 18 had diagnoses including end-stage kidney disease and dependence on kidney dialysis, and Resident 204 had diagnoses including high blood pressure, diabetes, and depression. During observation on February 11, 2026, Resident 18 had a pill cup containing two pills unsecured on his lunch tray, and he stated the pills were calcium acetate that he was to take with meals. There was no documentation that the facility had assessed him for the ability to self-administer the medication, and the medications were not secured in his room. At another observation the same day, Resident 204 had a pill cup containing multiple pills unsecured on her tray table, and she stated they were her morning medications. RN 1 confirmed the pills were vitamin C, vitamin B 12, sodium bicarbonate, and sodium chloride. There was no documentation that the facility had assessed her for the ability to self-administer the medications, and the medications were not secured in her room. The ADON later confirmed that both residents were not assessed to self-administer the medications as required by facility policy.
Hiring Screening and License Verification Not Completed Before Employment
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after facility policy review, personnel file review, and staff interview showed that the facility failed to complete a reference check and verify a professional license or registration status before the start of employment for two of five newly hired employees. Facility policies titled Abuse Prohibition and Hiring, both dated January 15, 2026, required screening of potential hires, including reference checks and verification of the license required for the position. Employee 1 had been working as the Administrator since January 20, 2026, and the inquiry to the state licensure board was not completed until February 11, 2026. Employee 5 had been working as a nurse aide since November 4, 2025, and a reference check was not completed until November 29, 2025. During an interview on February 20, 2026, the Director of Human Resources Operations Partner confirmed there was no documented evidence that the reference check and license verification were completed prior to the start of employment.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide assistance with bathing for two dependent residents. Resident 127 had diagnoses including a cerebral infarction affecting the right side and diabetes with polyneuropathy. MDS assessments showed the resident required extensive assistance with ADLs and was totally dependent on staff for bathing. The care plan directed staff to provide hygiene assistance and to give a shower or bed bath twice a week, but nurse aide documentation for January and February 2026 showed the resident was scheduled for baths or showers on January 15 and 17, 2026, and did not receive them. Resident 192 had diagnoses including a cerebral infarction affecting the left side, contractures of both lower legs, and protein-calorie malnutrition. MDS assessment showed the resident required extensive assistance with ADLs and was totally dependent on staff for bathing. Nurse aide documentation for January and February 2026 showed the resident was scheduled for baths or showers on January 21 and February 7, 2026, and did not receive them. During interviews, both residents stated they were not always offered showers and wanted to receive them, and the Assistant Director of Nursing confirmed that both residents were not offered a bath or shower on their scheduled shower dates.
Failure to Apply Ordered Heel Suspension Device
Penalty
Summary
Resident 1 had diagnoses that included an open wound of the lower back and pelvis region and a left heel pressure ulcer. A physician’s order dated August 20, 2025 directed staff to apply a heel suspension device to both heels while the resident was in bed, and the comprehensive care plan identified the resident as at risk for skin breakdown. However, multiple observations on February 10 and February 11, 2026 between 10:00 a.m. and 2:00 p.m. found Resident 1 in bed without the heel suspension device in place. During an interview on February 11, 2026, Resident 1 stated that staff sometimes applied a pillow under the heels or heel boots and that it depended on who was working. On February 12, 2026, the Assistant Director of Nursing confirmed that the heel suspension device was not in place as ordered.
Failure to Implement ROM and Mobility Interventions
Penalty
Summary
The facility failed to implement interventions to maintain and/or improve range of motion and mobility for two residents with documented limited mobility. One resident had diagnoses including muscle weakness, bladder cancer, and chronic obstructive pulmonary disorder, and was cognitively intact on the MDS. On January 16, 2026, the physical therapist recommended a restorative nursing program for ambulation using a rolling walker and contact guard assistance to walk 100 to 200 feet for 15 minutes daily, but there was no documented evidence that the program was provided. The resident stated he had not been offered the program and would not have refused it, and the Assistant DON confirmed the recommended restorative nursing program was not implemented. The Director of Rehabilitation stated the program would have been for functional maintenance of mobility. Another resident had diagnoses including other specified disorders of muscle, rheumatoid arthritis, and spondylosis, and the MDS indicated no cognitive impairment, dependence on staff for personal hygiene, and loss of ROM. The care plan identified dependence for ADLs related to functional deterioration due to limited mobility and included interventions to apply a splint in the morning and remove it in the evening for a left hand contracture. However, observations on two consecutive days showed the resident in bed without the splint on the left hand, and the resident stated he did not refuse to wear it. The Assistant DON confirmed the splint was supposed to have been in place.
Failure to Assess and Care Plan Incontinence
Penalty
Summary
The facility failed to assess bladder incontinence and provide services to restore bladder function as much as possible for one sampled resident. The facility policy for Continence Management required a urinary and/or bowel incontinence assessment upon admission, quarterly, and whenever there was a change in continence, with individualized interventions and a plan of care based on the assessment and voiding records. Resident 13 was admitted with diagnoses of hypertension and quadriplegia. The MDS dated September 25, 2025, showed the resident could communicate needs, required no assistance with toileting, was frequently incontinent of urine, continent of bowel, and was not on a toileting program; it also indicated urinary incontinence was to be addressed in the care plan. A later MDS showed the resident required some assistance with toileting and was frequently incontinent of urine and occasionally incontinent of bowel, still with no toileting program. The record contained no documented incontinence assessment on admission, no documented assessment after the change in bowel incontinence, and no care plan with specific interventions to address the resident’s urinary and bowel incontinence. The Assistant DON confirmed there was no documented evidence that staff completed an incontinence assessment or developed and implemented specific care planned interventions.
Failure to Monitor Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and assess the nutritional status of one resident at risk for weight loss. Resident 144 had diagnoses including myasthenia gravis, cerebral infarction, and mild protein-calorie malnutrition, and the care plan identified the resident as at risk for malnutrition with an intervention for staff to monitor for changes in nutritional status. The resident weighed 188 lbs. on February 2, 2026 and then 178.2 lbs. on February 5, 2026, a significant loss of 9.8 lbs. (5.2%). There was no evidence that the RD was notified of the significant weight loss, and although the RD noted on February 6, 2026 that the resident needed to be reweighed, the resident was not weighed again until February 11, 2026. The facility policy required that if a resident's body weight was not as expected, the resident be reweighed within 24 hours, and the RD stated in interview that reweights are to be done within 24 hours and that Resident 144 was not reweighed per request and policy.
Lack of Person-Centered PTSD Care Planning
Penalty
Summary
Failure to provide trauma informed and culturally competent care occurred when the facility did not develop and implement an individualized, person-centered care plan for Resident 139, who was admitted with diagnoses including PTSD, major depressive disorder, anxiety, and mood disorder. The Minimum Data Set assessment documented PTSD and symptoms of feeling tired, feeling hopeless, having trouble falling asleep, and feeling bad, but the clinical record did not contain documentation showing that PTSD-related symptoms or triggers were assessed. The record also lacked specific interventions to address minimizing triggers and/or re-traumatization. During an interview, the Social Work Director confirmed that no care plan had been developed to address the resident’s PTSD symptoms or triggers.
Failure to Review Pneumococcal Vaccination Status
Penalty
Summary
The facility failed to evaluate the need to provide pneumococcal disease vaccines in accordance with its policy for two of five residents whose vaccines were reviewed. The facility policy required staff, upon admission, to assess whether each resident had previously been vaccinated for pneumococcal disease and to offer the vaccine if the resident had not received it or was not up to date according to CDC adult pneumococcal vaccine timing guidelines, with documentation of education and whether the vaccine was received or declined in the EMR. Resident 19 was admitted to the facility and had received Prevnar 13 on December 6, 2016, but there was no documented evidence that the facility reviewed the resident's vaccination status to determine whether an updated vaccine needed to be offered. Resident 47 was admitted to the facility and had received PPSV23 on September 3, 2014, and Prevnar 13 on March 18, 2016, but there was no documented evidence that the facility reviewed the resident's vaccination status to determine whether an updated vaccine needed to be offered. During an interview on February 12, 2026, at 1:45 p.m., the Assistant DON confirmed that the residents' pneumococcal vaccination status had not been reviewed to determine if an updated vaccine needed to be offered.
Failure to Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to offer the COVID-19 vaccine in accordance with its policy to two residents whose records were reviewed. Facility policy stated that the COVID-19 vaccine was to be offered to residents and healthcare workers when available, that education on the risks versus benefits of the vaccine was to be provided, and that consent or declination was to be documented. CDC guidance reviewed in the report stated that staying up to date with the 2025-2026 COVID-19 vaccine is especially important for those living in a long-term care facility. Clinical record review showed that one resident had received a COVID-19 vaccine in October 2021, but there was no documentation that the resident had been offered the vaccine since admission to the facility. Another resident had received a COVID-19 vaccine in November 2023, but there was no documentation that the resident was offered the vaccine in 2024, 2025, or 2026. In an interview, the Assistant DON/Infection Preventionist confirmed that the residents had not been offered the COVID-19 vaccine per facility policy.
Failure to Obtain Written Authorization for Resident Funds
Penalty
Summary
The facility failed to obtain written authorization to manage personal funds for Resident 160. The resident was admitted with diagnoses including diabetes and hypertension, and the MDS assessment dated January 21, 2026 indicated she was able to communicate her needs and could be understood. During an interview on February 10, 2026, the resident stated she had received a letter from Social Security saying she would no longer receive her money and that the facility would manage her funds, but she did not authorize the facility to become her representative payee and said the facility took her money without her permission. Review of representative payee authorization forms sent to Social Security on October 23, 2025 showed no authorization from the resident for the facility to manage her funds. Review of the Resident Fund Account showed funds in the account on February 1, 2026, and there was no documented evidence that the facility obtained authorization from the resident to open the account. The Administrator confirmed on February 12, 2026 that written authorization to manage funds for Resident 160 had not been obtained.
Improper Disposal of Trash and Refuse
Penalty
Summary
The facility failed to dispose of trash and refuse properly. Observation of the trash compactor area revealed multiple pieces of plastic and paper debris on the ground adjacent to the compactor, along with a wrapped soiled feminine hygiene product, a soiled piece of gauze, multiple used plastic gloves, and a half-eaten chicken drumstick in front of the compactor.
Cold Meal Trays Served on the 4th Floor
Penalty
Summary
Food and drink were not kept palatable and at a safe, appetizing temperature on one nursing unit, the 4th floor. During a group interview, Residents 12, 15, 49, and 166 reported that hot food was frequently served cold. Facility documentation for Food and Nutrition Services Test Tray Evaluation stated that the hot main entree, starch, and vegetable should be greater than 140 degrees Fahrenheit at the point of service. A test tray audit found that a smothered chicken thigh was 115.2 degrees Fahrenheit, mashed potatoes were 115.7 degrees Fahrenheit, and mixed vegetables were 108.5 degrees Fahrenheit, and all items were cool to taste. Residents 92 and 115, who received trays from the same cart, stated that the chicken and mashed potatoes were cool to taste, and Resident 127 also stated that the chicken and mashed potatoes were cool to taste. The Dietary Manager confirmed that the hot food temperatures did not meet policy expectations.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call bell was accessible for a resident, identified as Resident 104, who was part of a sample of 39 residents. Resident 104 had medical diagnoses including polyneuropathy and dementia, and was dependent on staff for activities of daily living such as toileting, dressing, and personal hygiene. The care plan for Resident 104 indicated a risk for falls and included an intervention for staff to keep commonly used articles within easy reach and to reinforce the need for the resident to call for assistance. However, on March 5, 2025, the resident was observed in bed with the call bell on the floor and out of reach at three different times: 11:16 a.m., 12:19 p.m., and 2:40 p.m. The Assistant Director of Nursing confirmed that the call bell should have been placed within the resident's reach.
Failure to Notify Representatives of Significant Weight Loss
Penalty
Summary
The facility failed to notify the responsible parties of three residents who experienced significant weight loss, as required by their policies. The facility's policy on 'Weights and Heights' and 'Change in Condition: Notification of' mandates immediate notification to a resident's representative in the event of a significant change in condition, such as weight loss. However, clinical record reviews revealed that the facility did not adhere to these policies for three residents. Resident 44, diagnosed with sarcopenia and dementia, experienced a 10.8% weight loss over a month, with no evidence of notification to their representative. Resident 46, with anemia and anxiety, lost 11.8% of their weight in a month, again without notification. Resident 164, who had a traumatic brain injury and dysphagia, lost 5.0% of their weight in a short period, and there was no evidence of notification. The facility administrator confirmed the lack of evidence for notifying the residents' representatives about these significant weight losses.
Failure to Provide Adequate Grooming and Hygiene
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for three residents who were dependent on staff for activities of daily living (ADLs). Resident 1, diagnosed with muscle weakness, required assistance with ADLs and preferred her nails to be kept short. However, observations on consecutive days revealed her nails were long and dirty, and she confirmed that staff had not offered assistance with nail care. There was no evidence of her refusing such care. Resident 99, who had dementia and dermatitis, was also dependent on staff for ADLs. Observations showed her fingernails were long, jagged, and dirty, with a dark substance underneath. She indicated a preference for her nails to be cut, yet no assistance was provided. Similarly, Resident 183, with unspecified dementia and anxiety, was observed with long, jagged, and dirty nails. Despite her dependence on staff for ADLs and her expressed dislike for long nails, no assistance was offered. The Assistant Director of Nursing confirmed that nail care should have been provided during bathing and as needed.
Failure to Implement Orthotic Device for Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent a decline in range of motion for Resident 159, who had a history of stroke and depression. The resident's care plan indicated self-care deficits and required staff assistance for activities of daily living. A physician's order dated December 27, 2024, instructed staff to apply a soft hand splint to the resident's right hand during the day shift. However, the clinical record was not updated to reflect the correct orthotic device as per the occupational therapy discharge assessment, which recommended a right palm grip to be placed during morning care. Observations on March 4 and 5, 2025, revealed that Resident 159's right hand was contracted, and no orthotic device was in place. The resident reported that staff often did not assist with the placement of the orthotic device, and she had not refused assistance. The Assistant Director of Nursing confirmed that the order for the new hand grip was not implemented according to the therapy discharge summary. There were no documented refusals from the resident regarding the use of the orthotic device.
Failure to Implement Smoking Safety Measures
Penalty
Summary
The facility failed to implement safety measures related to smoking for a resident who smokes. The facility's smoking policy, last reviewed in November 2024, requires that smoking supplies, including cigarettes and lighters, be labeled with the resident's name, room number, and bed number, and be maintained by staff in a suitable cabinet at the nurses' station. However, a clinical record review revealed that the resident, who has diagnoses of depression and anxiety, was independent for smoking, and staff were to educate and monitor compliance with the smoking policy. On March 4, 2025, the resident was observed with his smoking supplies in his personal bag on his bed, contrary to the policy. Interviews with the Director of Nursing and the Assistant Director of Nursing confirmed that the supplies should have been kept behind the nurses' station, and the resident's possession of the supplies was acknowledged as a deviation from the policy.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and assess weight loss for two residents at risk for nutritional problems. Resident 164, diagnosed with traumatic brain injury and dysphagia, experienced a significant weight loss of 12 pounds (5.2%) between December 19 and December 24, 2024. Despite the facility's policy requiring notification of the registered dietitian (RD) for significant weight changes, there was no evidence that the RD was informed of this weight loss. The RD did not address the issue until January 30, 2025, by which time the resident's weight had fluctuated significantly, indicating continued weight loss. The resident's nutritional supplements were discontinued without confirmation of weight gain, and the RD was not notified of the ongoing weight loss. Similarly, Resident 46, who had a history of significant weight loss and was at risk for nutritional problems, lost 24.2 pounds (11.8%) between December 3, 2024, and January 3, 2025. The facility's care plan required staff to monitor changes in nutritional status, but there was no evidence that the RD was notified of this significant weight loss. The weight loss was not addressed until February 10, 2025. In an interview, the Administrator confirmed the lack of evidence that the RD was notified or that the weight loss was addressed in a timely manner.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive equipment to a resident, identified as Resident 159, who required it due to medical conditions including stroke and depression. The resident's care plan specified the need for a curved right spoon to mitigate nutrition risks. However, during observations on March 4 and March 5, 2025, the resident was repeatedly provided with a regular spoon instead of the required curved spoon during meal times. The resident confirmed that she often did not receive the curved spoon as indicated on her meal tray ticket.
Failure to Maintain Sanitary Conditions During Food Service
Penalty
Summary
The facility failed to maintain sanitary conditions during food service in the kitchen. During an observation of the tray line service, a dietary employee was seen wearing gloves while assembling resident meals. The employee left the tray line to obtain plates, pushing a rolling cart, and did not change gloves or perform hand hygiene upon returning. The employee continued to assemble meals with the same gloves and was observed wiping the gloves on her clothing twice without changing them or performing hand hygiene. Additionally, the employee picked up cooked chicken from a steam table pan with the same gloves and placed it onto resident meal trays six times without changing gloves or performing hand hygiene throughout the observation period.
Failure to Notify Residents of Appeal Rights and Ombudsman Information
Penalty
Summary
The facility failed to provide timely notification to residents and their representatives regarding their appeal rights and Ombudsman information upon transfer to the hospital. This deficiency was identified for five residents who were transferred due to a change in condition. The clinical record reviews for Residents 14, 57, 101, 133, and 164 revealed that there was no documented evidence that these residents, their responsible parties, or legal representatives were informed in writing about their appeal rights and the Ombudsman when they were transferred to the hospital. Each of the five residents experienced a change in condition that necessitated their transfer to the hospital. However, the facility did not fulfill its obligation to provide the required notifications, which are crucial for ensuring that residents and their representatives are aware of their rights and the resources available to them during such transitions. The absence of documentation in the clinical records indicates a systemic issue in the facility's process for handling transfers and ensuring compliance with regulatory requirements.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 266 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bethlehem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethlehem South Skilled Nursing And Rehabilitation | 0 mi | ★★★★★ | 10 | 0 |
| Good Shepherd Home-bethlehem | 0.6 mi | ★★★★★ | 1 | 0 |
| Riverton Rehabilitation And Healthcare Center | 1.4 mi | ★★★★★ | 9 | 0 |
| Holy Family Manor | 1.6 mi | ★★★★★ | 0 | 0 |
| Moravian Village Of Bethlehem | 2.6 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.