Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 South Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to provide and document ordered wound and pressure ulcer care for three residents who were dependent in ADLs and at risk for or already had skin breakdown. One resident with chronic skin conditions and vascular disease lacked documented daily dressing changes and topical antibiotic applications as ordered. Another resident with hypertension, cellulitis, and an arterial ankle ulcer had missing documentation for ordered daily ankle wound care and every-shift skin protectant to the buttocks. A third resident with hypertension, stroke, memory impairment, and multiple pressure ulcers on the sacrum, heel, and lower leg did not have required every-shift wound assessments documented on numerous day shifts. There was no documentation that any of these residents refused their treatments, and the DON confirmed the absence of evidence that the ordered wound care and assessments were completed.
Surveyors found that two residents with indwelling and suprapubic catheters did not receive catheter care consistent with facility policy. The policy required drainage bags to be kept below bladder level, emptied when half full, and off the floor. One resident with obstructive uropathy, diabetes, and kidney failure was twice observed in bed with the catheter tubing and urine-filled drainage bag lying on the floor. Another resident with neuromuscular bladder dysfunction and diabetes was observed with a suprapubic catheter drainage bag that was more than half full of urine and resting on the floor. An RN, an LPN, and the DON each acknowledged that the bags should have been emptied as required and kept off the floor.
The facility did not verify the professional license or registration status of three newly hired staff members before they began working, as required by policy. Required checks with the state board of nursing and nurse aide registry were not completed prior to employment, and this was confirmed by the Human Resources Manager.
The facility did not follow its own policy for changing and maintaining respiratory equipment, as evidenced by undated or outdated oxygen humidifiers and tubing for several residents with respiratory conditions. Observations and interviews confirmed that equipment was not changed at the required intervals, and one resident reported her humidifier bottle was not changed often enough, with the bottle found nearly empty.
A resident with intact cognitive ability and multiple medical diagnoses was found with an unsecured potassium pill at her bedside after an LPN placed the medication there without documented assessment for self-administration, contrary to facility policy. The DON confirmed that no assessment had been completed.
A resident with significant mobility and cognitive impairments was found on the floor with injuries after being assisted by only one staff member, contrary to the care plan requiring two staff for bed mobility. The incident, which met criteria for potential neglect, was not reported to state or local authorities as required by facility policy. The DON confirmed the failure to report.
A resident dependent on staff for ADLs, with a history of stroke, aphasia, and a feeding tube, was observed with significant oral secretions and mucus on bed sheets, indicating a lack of required oral hygiene assistance. Despite staff presence, oral care was not provided as per facility policy, and the resident expressed a desire to be cleaned. The DON confirmed that oral care should be completed twice daily and as needed.
A resident with a stage four sacral pressure ulcer and multiple comorbidities did not consistently receive wound care as ordered, with several instances lacking documentation of daily dressing changes over a three-month period. The DON confirmed that there was no evidence of care provided or refusals documented on those dates.
A resident with left-sided paralysis and cognitive impairment, who was dependent on staff for care, did not have a physician-ordered palm guard applied to the affected hand during multiple observations. The DON confirmed the device was to be in place as ordered, indicating a failure to follow the care plan for maintaining or improving range of motion.
The facility did not provide required written discharge or transfer notices to the Office of the State LTC Ombudsman for eight residents who were transferred to the hospital after changes in condition. This was confirmed by clinical record review and by the DON, who acknowledged that the notifications were not sent.
A resident with dementia and limited mobility, who required supervision for bathing, was left unsupervised in the shower for over an hour after being told to ring the call bell when finished. The resident was later found to have fallen, and facility leadership confirmed that adequate supervision was not provided.
A resident with multiple diagnoses, including diabetes and dementia, experienced increased fatigue, poor appetite, loose stools, vomiting, and low blood pressure. Nursing staff did not document an assessment after vomiting and failed to notify the physician or responsible party about these changes. The resident was later transferred to the ER due to an acute change in condition.
The facility did not meet the required nurse aide staffing levels across all shifts for seven consecutive days. Specifically, the facility failed to provide the minimum number of NAs per residents on the day, evening, and night shifts, as per the regulation effective July 1, 2024.
The facility did not meet the required LPN staffing levels during the night shift, failing to provide one LPN per 40 residents on two nights. This deficiency was identified through a review of nursing time schedules.
The facility failed to provide the mandated 3.2 hours of direct resident care per day on six out of seven days reviewed. Nursing time schedules showed that care hours fell short on multiple days, with residents receiving between 2.54 and 3.17 hours of care, indicating a consistent shortfall in meeting regulatory requirements.
The facility failed to maintain adequate grooming and hygiene for two residents, both of whom were observed with long and dirty fingernails despite care plans requiring regular maintenance. One resident had hemiplegia and chronic pain, while the other had dementia and a hand contracture. The administrator confirmed the oversight in nursing services.
The facility failed to apply prescribed devices for two residents to prevent decline in range of motion. One resident with hemiplegia was observed without a required elbow splint, and another with dementia and hand contracture was without a prescribed carrot device. There was no documentation of refusal by the residents, and the administrator confirmed the devices should have been applied.
The facility failed to provide written notification to residents and their representatives before hospital transfers, as required by policy and federal regulations. Three residents, with conditions such as schizoaffective disorder, heart disease, and acute kidney failure, were transferred without documented written notifications. The Administrator confirmed this deficiency, which had been previously cited.
A facility failed to provide timely vision services to a resident with vision problems, despite a referral and a request from the resident's Power of Attorney. The resident was observed without glasses, which were necessary for watching television as per her care plan. The Social Services Director confirmed the lack of eye care services.
Failure to Provide and Document Ordered Wound and Pressure Ulcer Care
Penalty
Summary
The deficiency involves the facility’s failure to provide and document ordered wound care and pressure ulcer assessments for multiple residents at risk for or with existing skin breakdown. One resident with hidradenitis suppurativa, peripheral vascular disease, and heart failure was identified as dependent in ADLs and at risk for pressure ulcers, with care plans noting skin breakdown in the left axilla and right gluteal fold. Physician orders directed daily cleansing of the left axilla with wound cleanser, application of clindamycin 1% lotion, and dressing changes on day shift, as well as daily application of clindamycin phosphate 1% cream to inflamed skin. The April treatment administration record (TAR) lacked documentation that the daily dressing was completed on four day shifts and that the topical medication was applied on three day shifts, with no documentation of treatment refusal. Another resident with hypertension and cellulitis of the left lower limb, dependent in ADLs and at risk for pressure ulcers, had a care plan noting fragile skin, poor safety awareness, and an arterial ulcer on the left ankle, with instructions for staff to provide wound treatment as ordered. A physician ordered daily removal, sterile cleansing, redressing, and bandage wrapping of the left ankle wound on day shift, and application of a skin protectant to the buttocks every shift for redness. The April TAR lacked documentation that the ankle wound treatment was completed on three day shifts and that the skin protectant was applied on seven occasions, with no evidence of refusal. A third resident with hypertension, stroke, memory problems, dependence in ADLs, and existing pressure ulcers on the sacrum, left heel, and left lower leg had physician orders for every-shift assessment and documentation of the appearance and outcome of each wound. The April TAR showed missing documentation of left heel wound assessments on eight day shifts, sacral wound assessments on seven day shifts, and left lower leg wound assessments on seven day shifts, again without any documented refusals. The DON confirmed there was no documented evidence that staff assessed the wounds, provided ordered wound care, or that residents refused treatments on the identified dates.
Failure to Follow Catheter Care Policy for Two Catheterized Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide catheter care in accordance with its own policy for residents with indwelling and suprapubic catheters. The facility’s catheter care policy, last reviewed January 15, 2026, required that catheter drainage bags be positioned lower than the bladder, emptied when half full, and kept off the floor. For one resident with diagnoses including obstructive uropathy, diabetes, and kidney failure, who had an indwelling urinary catheter ordered on January 27, 2026, surveyors twice observed the catheter tubing and urine-filled drainage bag lying directly on the floor while the resident was in bed. During one of these observations, an RN acknowledged that the catheter bag should have been kept off the floor. Another resident, with diagnoses including neuromuscular dysfunction of the bladder and diabetes, had a physician’s order dated December 28, 2024, directing staff to monitor the suprapubic catheter every shift. During observation, this resident was found lying in bed with a catheter drainage bag that was more than half full of urine and resting on the floor. At the time of this observation, an LPN stated that the catheter drainage bag should have been emptied and kept off the floor. In a subsequent interview, the DON confirmed that catheter bags should be emptied and not be in contact with the floor, underscoring that the observed practices did not comply with the facility’s catheter care policy.
Failure to Verify Professional Licensure Prior to Employment
Penalty
Summary
The facility failed to verify the professional license or registration status of three out of five newly hired employees prior to the start of their employment. According to the facility's Abuse Prohibition policy, screening of potential hires should include checking with the appropriate licensing boards and registries to ensure there is no history of abuse, neglect, or mistreatment of patients. Personnel file reviews showed that for three employees, there was no evidence that inquiries were submitted to the state board of nursing or the state nurse aide registry before or after they began working. The Human Resources Manager confirmed that these required checks were not performed prior to employment.
Failure to Maintain and Change Respiratory Equipment per Policy
Penalty
Summary
The facility failed to provide adequate respiratory care and maintain respiratory equipment in a sanitary manner for four of six sampled residents who utilized respiratory equipment. Facility policy required oxygen humidifiers to be changed every seven days and as needed, and nebulizer equipment to be changed daily. However, observations revealed that humidification bottles on oxygen concentrators for multiple residents were not dated, and nebulizer tubing and oxygen tubing were not changed according to policy. For example, one resident's nebulizer tubing was dated nine days prior to observation, and another resident's oxygen tubing was dated eleven days prior. In one case, a resident's oxygen tubing was not dated at all. Additionally, a resident reported that her oxygen humidifier bottle was very low and had not been changed since a specific date, which was confirmed by observation of an almost empty humidifier bottle and a dated bag indicating it had not been changed in over two weeks. Interviews with the Director of Nursing confirmed that the facility's policy was not followed, as equipment was not changed at the required intervals. These deficiencies were identified through review of clinical records, resident and staff interviews, and direct observation.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident's capability to self-administer medications as required by its own policy. The policy states that residents must be evaluated for self-administration, require a physician's order, and, when applicable, be provided with a secure, locked area for medications. A resident with diagnoses including pneumonia, heart failure, and hypokalemia, and with intact cognitive ability per the Minimum Data Set assessment, was observed sleeping with a potassium pill in a medication cup on her bedside table. An LPN confirmed that the medication had been placed in front of the resident 45 minutes to an hour prior to observation. There was no documentation of an assessment for self-administration, and the medication was not secured in the resident's room. The Director of Nursing confirmed that the required assessment had not been completed.
Failure to Report Alleged Neglect Following Resident Fall
Penalty
Summary
The facility failed to report an alleged violation of potential neglect involving a resident with chronic obstructive pulmonary disease, intellectual disabilities, and lumbago sciatica. The resident, who had some memory impairment and required assistance of two staff for transfers and was totally dependent for bed mobility, was found lying on the floor beside the bed with a bruise on the right shin and bleeding from the right second toenail. Facility documentation indicated that only one nurse aide was present during the incident, despite the care plan requiring two staff for bed mobility. The aide reported that the resident slid from the bed to the floor while being turned. There was no documented evidence that the facility reported this incident of alleged neglect to the appropriate state and local agencies as required by facility policy. The Director of Nursing confirmed in an interview that the incident was not reported to the authorities, which is a violation of both facility policy and state regulations.
Failure to Provide Required Oral Hygiene Assistance
Penalty
Summary
A deficiency was identified when a resident with aphasia, right-sided weakness due to stroke, difficulty swallowing, and a feeding tube, who was dependent on staff for activities of daily living, did not receive appropriate oral hygiene assistance as required by facility policy. The policy specified that oral care should be performed at least twice daily. Clinical record review and care plan documentation indicated the resident required staff assistance for oral care. During observations, the resident was found with thick yellow secretions on the lips and inside the mouth, as well as pools of green mucus on the bed sheets, and staff present at the bedside did not provide oral care. The resident expressed a desire to be cleaned, and the DON confirmed that oral care was to be provided twice daily and as needed.
Failure to Provide Ordered Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing for a resident with a stage four sacral pressure ulcer. Clinical record review showed that the resident, who had multiple sclerosis, venous insufficiency, and was dependent on staff for ADLs, had a physician's order for daily wound care, including dressing changes and cleaning. However, treatment administration records revealed multiple instances over three months where there was no documentation that the wound care was completed as ordered. The resident reported that wound care was not always provided as prescribed, and the Director of Nursing confirmed the lack of documentation for both the provision of care and any resident refusals on those dates.
Failure to Implement Ordered Palm Guard for Resident with Limited ROM
Penalty
Summary
A resident with a history of left-sided weakness and paralysis due to a stroke, as well as cognitive impairment and dependence on staff for daily activities, was identified as having a loss of range of motion in the left upper extremity. The care plan included a physician's order for staff to apply a palm guard to the resident's left hand in the morning and remove it in the evening. However, during multiple observations over two days, the resident was found without the palm guard on the affected hand. The DON confirmed that the palm guard was to be in place as ordered by the physician. This failure to implement the ordered intervention resulted in the facility not providing appropriate care to maintain or improve the resident's range of motion.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide copies of written discharge or transfer notices to a representative of the Office of the State Long Term Care Ombudsman for eight out of nine residents who were transferred out of the facility. Clinical record reviews showed that multiple residents were transferred to the hospital following changes in their conditions, but there was no documented evidence that the required notifications were sent to the Ombudsman. This deficiency was identified for residents who experienced transfers on various dates, with some residents being transferred more than once without the appropriate notifications being documented. During an interview, the Director of Nursing confirmed that the written discharge or transfer notices were not sent to the Office of the State Long Term Care Ombudsman as required. The lack of documentation and notification was consistent across all identified cases, indicating a systemic failure to comply with the notification requirements outlined in 28 Pa. Code 201.14(a).
Failure to Provide Adequate Supervision During Showering
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with diagnoses including dementia, chronic obstructive pulmonary disease, and emphysema. Clinical records and the Minimum Data Set (MDS) assessment indicated that the resident required supervision or touch-assistance for showering or bathing, and the care plan specified a need for setup assistance due to limited mobility. On the morning of July 5, 2025, a nurse aide set the resident up in the shower and instructed the resident to ring the call bell when finished. The aide checked on the resident after ten minutes, but then left the resident unsupervised for over an hour. When the aide returned, the resident was found to have fallen in the shower room. Facility leadership confirmed that adequate supervision was not provided during this time.
Failure to Notify Physician and Responsible Party of Change in Condition
Penalty
Summary
The facility failed to ensure timely notification of a physician and responsible party following a significant change in a resident's condition. Clinical records show that a resident with diabetes mellitus, dementia, and mood disorder experienced increased tiredness, poor meal intake, and multiple episodes of loose stools. Later, the resident vomited during supper and was found to have low blood pressure. Despite these changes, there was no documented nursing assessment after the vomiting episode, nor was there any documentation that the physician or responsible party was notified of the resident's condition changes. The resident was subsequently transferred to the emergency room the following morning due to an acute change in condition.
Failure to Meet Nurse Aide Staffing Requirements
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) as per the regulation effective July 1, 2024. During the review of nursing time schedules from March 2 to March 8, 2025, it was found that the facility did not provide the minimum number of NAs per residents across all shifts. Specifically, on the day shift, the facility did not meet the requirement of one NA per ten residents on March 2, 4, 7, and 8. On the evening shift, the facility failed to provide one NA per eleven residents on all days from March 2 to March 8. Additionally, on the night shift, the facility did not meet the requirement of one NA per fifteen residents on March 2, 4, 5, 6, 7, and 8. This deficiency was observed for all seven days reviewed, indicating a consistent failure to comply with the staffing regulation.
Plan Of Correction
1,2) Nurse aide staffing ratios will be reviewed for the last 7 days to evaluate if nurse aide ratio is met. 3) Nursing admin and scheduler will be re-educated on new July 1 nurse aide staffing ratio and PPD requirements. 4) Weekly audit of nurse aid ratios will be conducted for 60 days by NHA/designee to assure nurse aid ratio is met. Tracking and trends to be submitted to QAPI committee for any further action needed.
Inadequate LPN Staffing During Night Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of one Licensed Practical Nurse (LPN) for every 40 residents during the night shift. This deficiency was identified during a review of nursing time schedules for the period from March 2 to March 8, 2025. Specifically, on the nights of March 3 and March 4, 2025, the facility did not have the required number of LPNs on duty, resulting in inadequate staffing levels for the residents during the overnight hours.
Plan Of Correction
1,2) LPN staffing ratios will be reviewed for the last 7 days to evaluate if LPN ratio is met. 3) Nursing admin and scheduler will be re-educated on new July 1 LPN nurse staffing ratio and PPD requirements. 4) Weekly audit of LPN ratios will be conducted for 60 days by NHA/designee to ensure LPN ratio is met. Tracking and trends to be submitted to QAPI committee for any further action needed.
Deficiency in Meeting Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per day. A review of nursing time schedules from March 2 to March 8, 2025, revealed that on six out of the seven days reviewed, the facility did not provide the required hours of care. Specifically, on March 2, 2025, residents received 2.54 hours of care; on March 3, 2025, 3.06 hours; on March 4, 2025, 3.15 hours; on March 6, 2025, 2.87 hours; on March 7, 2025, 3.17 hours; and on March 8, 2025, 2.94 hours. This deficiency indicates a consistent shortfall in meeting the mandated care hours for residents during the specified period.
Plan Of Correction
5640 1,2) HPPD will be reviewed for the last 7 days to evaluate if the state minimum PPD of 3.2 hours of direct care is met. Master PCA has been updated and the facility is hiring to schedule needs to ensure ratios and HPPD at being met. 3) Nursing admin and scheduler will be re-educated on July 1 nurse staffing and PPD requirements. 4) Weekly audit of HPPD will be conducted for 60 days by NHA/designee to ensure minimal HPPD is met. Tracking and trends to be submitted to QAPI committee for any further action needed.
Failure to Maintain Resident Grooming and Hygiene
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for two residents, as observed during a survey. Resident 39, who has diagnoses including hemiplegia, hemiparesis following cerebral infarction, adult failure to thrive, and chronic pain in the left hand, was found with long and dirty fingernails on two consecutive days. The care plan for Resident 39 indicated that staff were responsible for checking and maintaining the resident's fingernail hygiene on bath days and as needed, but this was not adhered to. Similarly, Resident 67, diagnosed with unspecified dementia and contracture of the left hand, was also observed with long and dirty fingernails on two separate occasions. The care plan for Resident 67 required staff to ensure fingernail hygiene, but this was not executed. The facility administrator confirmed that the residents' fingernails should have been trimmed and cleaned regularly, indicating a lapse in the provision of necessary nursing services as per the care plans.
Failure to Implement Range of Motion Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent further decline and/or improve range of motion for two residents. Resident 39, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed without a prescribed left elbow extension splint on two separate occasions. The care plan required the splint to be applied during morning care and removed at night, but there was no documentation indicating that the resident refused to wear the splint. Similarly, Resident 67, diagnosed with unspecified dementia and a contracture of the left hand, was observed without a prescribed carrot device on two occasions. The care plan specified that the carrot should be applied at all times except during range of motion exercises and morning and evening care. Again, there was no documentation to suggest that the resident refused the device. The facility's administrator confirmed that the devices should have been applied according to the care plans.
Failure to Notify Residents of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers to the hospital, as required by their policy and federal regulations. This deficiency was identified for three out of four sampled residents who were transferred to the hospital due to changes in their medical conditions. The facility's policy, last reviewed on March 14, 2024, mandates that residents and their representatives be notified in writing prior to any transfer or discharge. However, there was no documented evidence that such notifications were provided for the transfers of these residents. Resident 1, diagnosed with schizoaffective disorder and epilepsy, was transferred to the hospital on June 29, 2024, following a change in condition. Resident 2, with a diagnosis of heart disease, was transferred on May 31, 2024, and Resident 3, suffering from acute kidney failure, was transferred on July 7, 2024. In an interview conducted on July 26, 2024, the Administrator confirmed the absence of documented written notifications for these transfers, which is a violation of CFR 483.15 (C)(3)-(6)(8) Notice Requirements Before Transfer/Discharge. This issue had been previously cited on November 2, 2023.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to ensure timely treatment and services to maintain visual abilities for a resident with vision problems. The resident, who had diagnoses including anxiety and hypertension, was observed without her glasses while watching television, despite her care plan indicating she should use corrective lenses daily for this activity. A referral for eye care services was made in March, and the resident's Power of Attorney also requested these services in April. However, there was no documented evidence that the resident received the necessary eye care services. The Social Services Director confirmed that the resident had not been seen for eye care services as required.
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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 Bethlehem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethlehem North Skilled Nursing And Rehabilitation | 0 mi | ★★★★★ | 20 | 0 |
| Good Shepherd Home-bethlehem | 0.6 mi | ★★★★★ | 1 | 0 |
| Riverton Rehabilitation And Healthcare Center | 1.3 mi | ★★★★★ | 9 | 0 |
| Holy Family Manor | 1.6 mi | ★★★★★ | 0 | 0 |
| Moravian Village Of Bethlehem | 2.6 mi | ★★★★★ | 3 | 0 |
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