Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holy Family Manor during CMS and state inspections, most recent first.
Failure to obtain informed consent for psychotropic meds: A resident with metabolic encephalopathy, dementia, and anxiety received lorazepam PRN and sertraline without documentation that the resident or responsible party was informed in advance about the benefits and potential side effects or that consent was obtained. The DON confirmed the resident and responsible party were not educated on the risks and benefits before the meds were given.
A resident with heart failure, diabetes, depression, and HTN was observed receiving a medication cup with five pills left on the bedside table for later self-administration. The record had no physician order or interdisciplinary assessment supporting self-administration, and the NHA and DON confirmed the resident had not been assessed for this practice.
A resident with metabolic encephalopathy, dementia, and muscle weakness had a change in condition with incontinence, behavior changes, and pain when urinating. The MD was notified and ordered a stat urine sample and an increased sertraline dose, but there was no documentation that the responsible party was informed of the change in condition or the prescribed treatments, and the DON confirmed the notification did not occur.
A resident with metabolic encephalopathy, dementia, and muscle weakness had a change in condition with incontinence, behavior changes, and pain when urinating. The physician ordered a stat urine sample and increased sertraline from 25 mg to 50 mg, but there was no documentation that the responsible party was notified of the change in condition or the prescribed treatments, and the DON confirmed the notification did not occur.
Failure to Verify Licenses and References Before Hire: Facility review found that three of five newly hired employees, including two LPNs and the Administrator, started work before required reference checks and license verification were documented. The facility policy required screening potential hires through the appropriate licensing boards and registries, but there was no evidence that those checks were completed before the employees began working among residents. The Administrator confirmed the missing documentation during interview.
Failure to document pre-dialysis weight and vital signs for a resident receiving dialysis. A resident with ESRD and dependence on renal dialysis had a physician order for dialysis 3 times per week, but the facility did not complete the pre-dialysis portion of the dialysis communication form as required. The resident’s pre-dialysis weight was not documented on 24 of 36 occasions, and vital signs were not documented on one identified occasion. The Administrator confirmed the missing documentation.
Improper food storage was observed in a second-floor resident dining room cooler. Surveyors found a reach-in refrigerator with dark red discoloration on the bottom shelf, standing water with a soaked dish cloth, an undated carafe of water, expired chocolate milk, a container with dried white residue on the outside, and a bread knife left touching a shelf in the cooler. The Food Operations Manager confirmed the water should have been dated, the milk removed, and the knife sent for washing and sanitizing.
Two residents experienced delays in receiving assistance, compromising their dignity. A resident with mild cognitive impairment was left in bed for nearly an hour despite requesting help, while another resident, incontinent of urine, waited over 30 minutes for assistance to use the toilet.
A facility failed to follow physician's orders for a resident with muscle weakness, dementia, and Parkinson's disease. The resident's care plan required Dermasaver gloves and a Tubigrip for skin protection, but observations revealed these were not applied as ordered. There was no documentation of the resident refusing these applications.
A resident with COPD, anxiety, and hypotension was given another resident's medications due to an LPN's failure to properly identify the resident. The DON confirmed the failure to follow accepted standards.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform a resident and/or the resident’s responsible party in advance of a treatment and treatment options before administering psychotropic medications. Resident 67 was admitted with diagnoses including metabolic encephalopathy, dementia, and anxiety. The resident’s MDS assessment indicated cognitive impairment and symptoms of feeling depressed and hopeless. Physician’s orders directed staff to administer lorazepam every six hours as needed beginning April 22, 2026 and again on May 5, 2026, and sertraline once daily on May 7, 2026. Facility documentation stated that informed consent was required before any psychotropic medication was given, including education about benefits and potential side effects, but there was no documentation that this information was provided or that consent was obtained before the medications were administered. The DON confirmed on June 2, 2026 that informed consent had not been obtained and that the resident and responsible party were not educated on the risks and benefits of the psychotropic medications.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to assess whether Resident 60 was capable of self-administering medications. The resident was admitted with diagnoses including heart failure, diabetes, depression, and high blood pressure, and the April 21, 2026 MDS assessment described the resident as alert and oriented. Facility policy stated that if a resident wanted to self-administer medications, the interdisciplinary team was to complete a Self-Administration of Medications UDA to determine the resident’s ability to safely do so, and the care plan was to document supporting interventions. During observation of scheduled medication administration on May 31, 2026, an LPN placed a medication cup containing five pills on the resident’s bedside table and left the room, later confirming that the medications were left there for the resident to take later. The record contained no documentation of a physician’s order allowing self-administration and no evidence that the interdisciplinary team had assessed the resident for self-administration. The NHA and DON confirmed that the resident did not have a physician’s order to self-administer medications and had not been assessed for that purpose.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to ensure that the resident's responsible party was notified of a change in condition for Resident 67. The resident had diagnoses including metabolic encephalopathy, dementia, and muscle weakness. A nurse's note documented that the physician was notified the resident was incontinent, had a change in behavior, and complained of pain when urinating, and the physician ordered a stat urine sample for urinalysis to rule out infection. A physician's order also increased sertraline from 25 mg to 50 mg. The record did not contain documentation showing that the responsible party was notified of the urinalysis order or the increased medication dose, and the DON confirmed in interview that the responsible party was not notified of the resident's changes in condition, including prescribed treatments.
Failure to Notify Responsible Party of Change in Condition and Treatment
Penalty
Summary
The facility failed to offer non-pharmacological interventions before administering as needed anti-anxiety medication for one of 19 sampled residents, Resident 67. Resident 67 had diagnoses including metabolic encephalopathy, dementia, and muscle weakness. The clinical record showed that the resident had a change in condition with incontinence, behavior changes, and pain when urinating, and the physician was notified and directed staff to obtain a stat urine sample for urinalysis to rule out infection. The record also showed a physician order to increase sertraline from 25 mg to 50 mg. There was no documentation that the resident's responsible party was notified of the urinalysis order or the increased medication dose, and the DON confirmed in interview that the responsible party was not notified of the resident's changes in condition, including prescribed treatments.
Failure to Verify Licenses and References Before Hire
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after facility review of policies, personnel files, and staff interview showed the facility failed to complete a reference check and verify professional license or registration status before three of five newly hired employees began working. The facility policy, Resident Abuse Prevention and Reporting Reasonable Suspicion of a Crime, dated April 28, 2026, required screening potential hires for a history of abuse, neglect, or mistreatment of residents, including checking the appropriate licensing boards and registries to verify that licenses or certifications were in good standing. Employee 3, an LPN working since April 15, 2026, had no evidence of a state licensure board inquiry before starting work among residents. Employee 4, an LPN working since April 6, 2026, also had no evidence of a state licensure board inquiry before starting work among residents. Employee 5, the Administrator working since April 27, 2026, likewise had no evidence of a state licensure board inquiry before starting work among residents. During an interview on June 3, 2026, at 9:28 a.m., the Administrator confirmed there was no documented evidence that the license verifications were completed prior to the start of employment for Employees 3, 4, and 5.
Failure to Document Pre-Dialysis Weight and Vital Signs
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was deficient because the facility did not consistently complete required ongoing assessment and monitoring for a resident receiving dialysis. The resident had diagnoses including end-stage renal disease and dependence on renal dialysis, with a physician order for dialysis three days per week. Facility policy required staff to complete the pre-dialysis portion of the dialysis communication form, including the resident’s pre-dialysis weight and vital signs, before the resident left for dialysis. However, there was no evidence that the resident’s pre-dialysis weight was obtained and documented on the dialysis communication forms on 24 of 36 occasions between March 2, 2026, and June 1, 2026, and there was no documented evidence that vital signs were obtained on May 20, 2026. During interview, the Administrator confirmed that the pre-dialysis weight and vital signs were to be obtained and documented before leaving for dialysis and that there was no evidence this occurred on the identified days.
Improper Food Storage in Resident Dining Room Cooler
Penalty
Summary
Food was not stored in a sanitary manner in one of three resident dining rooms on the second floor. During observation of the reach-in refrigerator, surveyors found dark red discoloration along the bottom shelf, a puddle of water with a soaked dish cloth, an undated carafe of water, a carton of chocolate milk with a use-by date of May 30, 2026, a plastic container holding tartar sauce packets with a thick layer of dried white substance on the outside, and a bread knife touching a shelf inside the cooler. In interview, the Food Operations Manager confirmed that the water should have been dated, the expired milk should have been removed, and the knife had been used to cut sandwiches and left in the reach-in cooler instead of being sent for washing and sanitizing.
Failure to Provide Timely Assistance with Care
Penalty
Summary
The facility failed to provide timely assistance with care in a manner that maintained dignity for two residents. Resident 30, who had mild cognitive impairment and a depressed mood, required assistance to get out of bed. Despite her call light being on and her verbal requests for help, staff members walked by without assisting her, and a staff member turned off the call light without providing help. She was left calling out for help until assistance was finally provided nearly an hour later. Resident 86, who was incontinent of urine and required assistance to use the toilet, turned on her call light and requested help to use the bathroom. A nurse entered the room, turned off the call light, and left without assisting the resident. The resident was not assisted to the bathroom until over 30 minutes later.
Failure to Implement Physician's Orders for Skin Protection
Penalty
Summary
The facility failed to implement physician's orders for a resident with diagnoses including muscle weakness, dementia, and Parkinson's disease. The resident's care plan indicated a potential for impaired skin integrity, requiring the application of Dermasaver gloves to both arms while in a wheelchair. Additionally, a physician ordered the application of a Tubigrip to the right hand under the Dermasaver glove. However, on multiple occasions, the resident was observed in a wheelchair without the Dermasaver gloves or Tubigrip in place. There was no documented evidence of the resident refusing the application of these items.
Failure to Properly Identify Resident Before Medication Administration
Penalty
Summary
The facility failed to ensure that professional standards of quality regarding the administration of physician-prescribed medications were followed for one of four residents who received medication. Resident 1, who had diagnoses including COPD, anxiety, and hypotension, was administered another resident's medications due to LPN 1's failure to properly identify the resident by name band, photo identification, or verbal confirmation. This error occurred on January 31, 2024, at 9:40 p.m., resulting in Resident 1 receiving medications for hypertension, schizophrenia, tremors, and depression that were not prescribed for them. The Director of Nursing confirmed this failure to follow the accepted standard during an interview on February 6, 2024.
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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) |
|---|---|---|---|---|
| Riverton Rehabilitation And Healthcare Center | 1.3 mi | ★★★★★ | 9 | 0 |
| Bethlehem South Skilled Nursing And Rehabilitation | 1.6 mi | ★★★★★ | 7 | 1 |
| Bethlehem North Skilled Nursing And Rehabilitation | 1.6 mi | ★★★★★ | 20 | 0 |
| Moravian Village Of Bethlehem | 1.9 mi | ★★★★★ | 3 | 0 |
| Good Shepherd Home-bethlehem | 2.2 mi | ★★★★★ | 1 | 0 |
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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 August 2026) and official state health department websites.