Pennsylvania Department of Health
COUNTRY MEADOWS NURSING CENTER OF BETHLEHEM
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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COUNTRY MEADOWS NURSING CENTER OF BETHLEHEM - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated survey in response to a complaint completed on March 10, 2025, at Country Meadows Nursing Center of Bethlehem, it was determined that there were no federal deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for long Term Care; however, the facility was not in compliance with the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of nursing time schedules the facility failed to provide the required nurse aide (NA) to resident ratio for six of nine days reviewed.

Findings include:

Review of nursing time schedules from March 1, through March 9, 2025, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA to 10 residents on day (7:00 a.m. to 3:00 p.m.) shift on March 3, 4, 6, 8, 9, 2025.

The facility failed to meet the minimum of one NA to 15 residents on the night (11:00 p.m. to 7:00 a.m.) shift on March 7, 8, 2025.

Plan of Correction - To be completed: 04/19/2025

~The staffing coordinator works to ensure staffing is above ratios but in the case of call offs, the facility will not only attempt to fill open CNA positions with CNAs but will also contact licensed staff in case of call offs. In addition we will utilize staffing agencies to cover vacancies and call offs.
~Weekly meetings with DON and staffing coordinator will specifically look at the week ahead in regard to staffing to ensure we meet the ratios/ NHPPD
~We expect to be back in compliance by 4/19/2025

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 3.2 hours of direct care for each resident for one of nine days reviewed.

Findings include:

Review of nursing time schedules for March 1, through March 9, 2025, revealed that the facility failed to provide the minimum of 3.2 hours of direct care for each resident on March 8, 2025.

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