Bethlehem North Skilled Nursing and Rehabilitation

Inspectors wroteBased on facility policy review, clinical record review, resident interview, and review of facility documentation, it was determined that the facility failed to report alleged violations involving abuse to the State Survey Agency for six of six sampled residents. (Residents 1, 2, 3, 4, 5, 6)Findings Include: Review of the facility policy entitled, Abuse Prohibition, last reviewed November 14, 2025, revealed that immediately upon receiving information concerning a report of suspected or alleged abuse, the Administrator or designee would report allegations that involved abuse not later than two hours after the allegation was made and report allegations to the appropriate state and local authorities within 24 hours if the event did not result in serious bodily injury. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to notify the responsible party of a change in the resident's medical condition for one of one resident receiving hospice services. (Resident R1)

Inspectors wroteBased on facility policy review, staff interview, and observation, it was determined that the facility failed to store food in a sanitary manner in the dietary department.

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for five of 35 sampled residents. (Residents 8, 12, 16, 18, and 159)

Inspectors wroteBased on facility policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to assess a resident's capability to self-administer medications for two of 35 sampled residents. (Residents 18, 204)

Inspectors wroteBased on clinical record review, resident interview, facility documentation review, and staff interview, it was determined that the facility failed to obtain written authorization to manage personal funds for one of 35 sampled residents. (Resident 160)

Inspectors wroteBased on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to complete a reference check and verify a professional license/registration status prior to the start of employment for two of five newly hired employees. (Employees 1 and 5)

Inspectors wroteBased on clinical record review and staff and resident interviews, it was determined that the facility failed to provide assistance with bathing for two of 36 sampled residents. (Resident 127 and 192)

Inspectors wroteBased on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide interventions to prevent pressure ulcers for one of four sampled residents. (Resident 1)Findings Include: Clinical record review revealed that Resident 1 had diagnoses that included open wound of the lower back and pelvis region (bed sore) and left heel pressure ulcer. A physician's order dated August 20, 2025, directed staff to apply a heel suspension device (a device to prevent and treat pressure sores) to the right and left heels while in bed. Review of the comprehensive care plan revealed that Resident 1 was at risk for skin breakdown. Multiple observations on February 10, 2026, and February 11, 2026, between 10:00 a.m. and 2:00 p.m., revealed Resident 1 in bed, and the heel suspension device was not applied. [...]

Inspectors wroteBased on clinical record review and resident and staff interview, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for two of 35 sampled residents. (Residents 4 and 9)

Inspectors wroteBased on policy review, clinical record review, and staff interview, it was determined that the facility failed to assess bladder incontinence and provide services to restore bladder function as much as possible for one of 35 sampled residents. (Resident 13)

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess nutritional status for one of three sampled residents at risk for weight loss. (Resident 144)

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for one of 35 sampled residents. (Resident 139)

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to evaluate the need to provide pneumococcal disease vaccines in accordance with facility policy for two of five residents whose vaccines were reviewed. (Residents 19, 47)

Inspectors wroteBased on facility policy review, clinical record review, staff interview, and review of the Centers for Disease Control and Prevention guidelines, it was determined that the facility failed to offer coronavirus-19 (COVID-19) vaccines in accordance with facility policy to two of five residents whose vaccines were reviewed. (Residents 1, 19)

Inspectors wroteBased on facility documentation, resident interview, results of a test tray audit, and staff interview, it was determined that the facility failed to provide food that was palatable and at an appetizing temperature on one of four nursing units. (4th floor)

Inspectors wroteBased on observation, it was determined that the facility failed to dispose of trash and refuse properly.

Inspectors wroteBased on clinical record review and observation, it was determined that the facility failed to ensure that a call bell was accessible for one of 39 sampled residents. (Resident 104)

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify a resident's responsible party of a change in condition for three of four sampled residents who experienced significant weight loss. (Residents 44, 46, and 164)

Inspectors wroteBased on observation, clinical record review, and staff and resident interviews, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for three of 39 sampled residents. (Residents 1, 99, 183)

Inspectors wroteBased on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement interventions to prevent a decline in range of motion for one of 39 sampled residents. (Resident 159)

Inspectors wroteBased on facility policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement safety measures related to smoking for one of one sampled residents who smoke. (Resident 171)

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess weight loss for two of four sampled residents at risk for weight loss. (Residents 164 and 46).

Inspectors wroteBased on clinical record review, observation, and resident interview, it was determined that the facility failed to ensure that adaptive equipment was provided to one of 39 sampled residents. (Resident 159)

Inspectors wroteBased on observation, it was determined that the facility failed to serve food under sanitary conditions in the kitchen.

Inspectors wroteBased on clinical record review, it was determined that the facility failed to notify the residents and/or the residents' representative(s) of their appeal rights and Ombudsman information in writing upon transfer from the facility for five of five sampled residents who were transferred to the hospital. (Residents 14, 57, 101, 133, and 164)

Inspectors wroteBased on facility policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess and implement safety measures related to smoking for one of one sampled residents who smoke. (Resident 31)

Inspectors wroteBased on clinical record review and interview, it was determined that the facility failed to ensure that bathing was provided to a resident for one of five sampled residents. (Resident 1)