Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Kirkland Village during CMS and state inspections, most recent first.
A resident with memory impairment, gait abnormalities, and muscle weakness, who required assistance with ambulation, was last seen walking in a hallway and was not adequately supervised thereafter. The resident exited through unmonitored, unlocked doors leading to an independent living area and accessed an elevator to a parking garage, where the resident was later found on the concrete floor with multiple skin tears and a scalp laceration. The facility’s elopement policy required monitoring to prevent such events, yet exit doors were not alarmed, locked, or monitored, and residents at risk for elopement had access to this area, leading surveyors to cite Immediate Jeopardy under F689-J.
A facility failed to notify a resident's responsible party of a significant weight loss, violating their policy on timely notification of changes in medical condition. A resident with dementia, adult failure to thrive, and dysphagia experienced a 14% weight loss over a month, but there was no documented evidence of notification to the responsible party. The Administrator confirmed this deficiency.
A facility failed to implement a physician's order for daily weight monitoring for a resident with chronic kidney disease and heart failure. Despite the order, there was no documentation of weights being taken over several days, and the Administrator confirmed the lack of records or resident refusal.
A resident with dementia, adult failure to thrive, and dysphagia experienced a significant weight loss over a 30-day period, dropping from 146 lbs to 124.6 lbs. Despite facility policy requiring a dietitian's evaluation for such weight changes, there was no documented evidence of the dietitian addressing this issue, as confirmed by the facility's administrator.
The facility failed to implement proper droplet precautions and PPE use for two residents with COVID-19. Staff entered rooms wearing only surgical masks, contrary to policy requiring full PPE. The administrator confirmed non-compliance with policies.
Failure to Supervise High-Risk Resident Resulting in Elopement and Injury
Penalty
Summary
The facility failed to provide necessary supervision and environmental controls to monitor a resident’s location and prevent an elopement. Facility policy on elopement required staff to monitor residents to prevent unauthorized departures. The resident involved had diagnoses including infection and inflammatory reaction due to an indwelling catheter, abnormalities of gait and mobility, and muscle weakness. An MDS assessment documented memory impairment and a need for partial assistance to walk, and the care plan identified that the resident ambulated with a front-wheeled walker and assistance from one staff member. Despite these identified needs, the resident was last seen by staff at 10:00 a.m. walking in the skilled nursing hallway and was not adequately supervised thereafter. At 11:44 a.m., the resident’s family notified staff that they could not locate the resident when they arrived for a visit. The facility was unaware of the resident’s location or that he had left the skilled nursing area for one hour and 45 minutes. The resident was later found at 12:30 p.m. lying on the concrete floor of a parking garage associated with an independent living apartment area located at the opposite end of a connected building, not part of the skilled nursing units. The resident stated he was cold and was observed with skin tears on the left foot/toes, left leg, and both elbows, dried blood on the back of the head, and a scalp laceration requiring staples. The Administrator reported that they believed the resident exited through unmonitored, unlocked doors leading to the independent living section and then accessed an elevator to the parking garage. There was no evidence that the skilled nursing exit doors were alarmed, locked, or monitored, and residents at risk for elopement had access to this area, resulting in an Immediate Jeopardy situation at F689-J.
Removal Plan
- Resident 1 was assessed by a licensed nurse and sent to the hospital for evaluation.
- All facility residents had a new elopement assessment completed.
- All residents at risk for elopement were communicated to staff and had their care plans/interventions updated.
- All safety devices were checked to ensure they were in place, including electronic devices applied to at risk residents to prevent doors from opening (Wander Guard system).
- An audit was conducted of all skilled nursing community exits.
- A staff member was placed to observe any exits that are not locked at all times until the facility's vendor completes the installation of new locking mechanisms.
- All staff were re-educated on the elopement policy and that staff must monitor the exit doors at all times until the locking mechanisms are installed.
- The Director of Nursing or designee was to initiate weekly audits and report results to the QAPI (Quality Assurance, Performance Improvement) committee.
Failure to Notify Responsible Party of Significant Weight Loss
Penalty
Summary
The facility failed to notify a resident's responsible party of a significant weight loss, which is a deficiency in adhering to their policy on notifying changes in medical condition. The policy, dated August 29, 2024, requires timely notification to the resident's representative of significant changes in the resident's physical status. Resident 11, who had diagnoses including dementia, adult failure to thrive, and dysphagia, experienced a 14 percent weight loss from 146 pounds on July 4, 2024, to 124.6 pounds on August 13, 2024, confirmed with a reweigh. Despite this significant change, there was no documented evidence that the resident's responsible party was informed. The Administrator confirmed the lack of notification documentation during an interview on September 12, 2024.
Failure to Implement Physician's Orders for Daily Weight Monitoring
Penalty
Summary
The facility failed to implement physician's orders for a resident diagnosed with chronic kidney disease and heart failure. The physician had ordered daily weight monitoring for the resident starting on June 14, 2024. However, a review of the resident's clinical records showed no documented evidence of weight measurements being taken on September 5, 6, 7, and 8, 2024. During an interview on September 12, 2024, the Administrator confirmed the absence of documentation indicating that weights were either obtained by staff or refused by the resident on those dates.
Failure to Monitor Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and assess a significant weight change for one of the residents. According to the facility's policy on Nutrition Risk Identification, residents experiencing a weight loss of five percent total body weight in a 30-day period should be evaluated by a dietitian, who would then recommend necessary changes to aid in the resident's return to optimal nutritional status. Resident 11, who had diagnoses including dementia, adult failure to thrive, and dysphagia, experienced a significant weight loss from 146 pounds on July 4, 2024, to 124.6 pounds on August 13, 2024, confirmed with a reweigh. Despite this significant weight loss, there was no documented evidence that the dietitian addressed the issue. The facility's administrator confirmed the lack of documentation regarding the dietitian's intervention.
Failure to Implement Droplet Precautions and PPE Use
Penalty
Summary
The facility failed to implement proper transmission-based droplet precautions and use of personal protective equipment (PPE) for two residents who tested positive for COVID-19. According to the facility's policies, staff were required to wear cleanable or disposable eye wear, non-sterile disposable isolation gowns, respirator-type face masks, and gloves when entering and exiting patients' rooms. However, observations revealed that a food server and a registered nurse entered the room of a resident with a confirmed COVID-19 case wearing only surgical face masks, without the required PPE. They also failed to remove their face masks upon exiting the room. Similarly, another resident who tested positive for COVID-19 was on droplet precautions, yet the same registered nurse entered the room wearing only a surgical face mask and did not remove it upon exiting. The facility's administrator confirmed that the droplet and COVID-19 PPE precautions were not being followed by the staff, which was a violation of the facility's policies and state regulations.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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) |
|---|---|---|---|---|
| Advanced Health Care Of Hanover | 0 mi | ★★★★★ | 6 | 0 |
| Country Meadows Nursing Center Of Bethlehem | 1.7 mi | ★★★★★ | 0 | 0 |
| Moravian Village Of Bethlehem | 2.6 mi | ★★★★★ | 3 | 0 |
| Northampton Post Acute | 3.2 mi | ★★★★★ | 4 | 0 |
| Bethlehem North Skilled Nursing And Rehabilitation | 3.8 mi | ★★★★★ | 20 | 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 July 2026) and official state health department websites.