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

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 64 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


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

Initial comments:
The Risk-Based Survey (RBS) process was used to conduct a federal Medicare Recertification survey, State Licensure survey, and a Civil Rights Compliance survey completed August 5, 2026, at Country Meadows Nursing Center of Bethlehem; it was determined that there were deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:
Based on facility policy review, staff and resident interviews, clinical record review, and review of electronic call bell logs, it was determined that the facility failed to answer call bells in a timely manner to provide care and services respectful of each resident's dignity and preferences to promote the quality of life for two of eight sampled residents. (Residents 54 and 58)

Findings include:

Review of the facility policy entitled "Call Lights: Accessibility and Timely Response," dated April 15, 2026, revealed that staff were responsible for responding to a call light in a reasonable amount of time.

Clinical record review revealed that Resident 54 had diagnoses that included acute post-hemorrhagic anemia (inability of healthy red blood cells to carry oxygen to the tissues and organs due to losing a large amount of blood very quickly). A physician's progress note, dated July 30, 2026, indicated that the resident was alert and oriented and required assistance from staff for activities of daily living such as, transfers, personal hygiene, and toileting. Review of the care plan revealed that Resident 54 was at risk for injury due to falls related to a decline in function from lack of movement). The interventions included that staff encourage the resident to use the call bell for assistance. In an interview on August 5, 2026, at 10:30 a.m., Resident 54 stated that staff took a long time to answer call bells which had affected his ability to receive care and services in a timely manner.

Clinical record review revealed that Resident 58 had diagnoses that included fracture of the right femur, presence of right artificial joint, and muscle weakness. The MDS assessment dated July 28, 2026, indicated that the resident was able to communicate her needs to staff and required assistance from staff for activities of daily living, such as toileting and dressing. Review of the care plan revealed that Resident 58 was at risk for falls due to impaired mobility and a right hip fracture. The interventions included that staff encourage the resident to use the call bell for assistance. In an interview with Resident 58 on August 4, 2026, at 2:00 p.m., Resident 58 stated that she sometimes had to wait over 30 minutes for staff to answer call bells which had affected her ability to receive care and services in a timely manner.

Review of the facility form entitled, "Tek-CARE Report," for Resident 54 revealed that from July 27, 2026, through August 5, 2026, there were six occurrences when the call bell response time was from 22 to 60 minutes. From July 21, 2026, through August 5, 2026, for Resident 58, there were 12 occurrences when the call bell response time was from 22 to 43 minutes.

During interviews on August 5, 2026, at 8:46 a.m. and 10:45 a.m., the Administrator confirmed the expected call bell response time was 15 minutes and that the previously mentioned residents waited more than the expected response time of 15 minutes.

CFR 483.10(a)(1) Residents Rights

Previously cited 7/31/25.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 09/16/2026

- The Director of Nursing or designee will audit the specific cases mentioned in this deficient practice to identity if there are any trends of patterns relative to assignments and provide directed education.
- Education will be given to all staff on effective strategies for managing call bells, such as teamwork, purposeful rounding, and acceptable call bell response time.
- A call bell response subcommittee will be established to track and trend call bell use, such as locations, time of day, response times, etc. If any patterns are identified, new interventions will be rolled out as appropriate.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of eight sampled residents. (Resident 4)

Findings include:

Clinical record review revealed that Resident 4 was admitted to the facility on May 16, 2026, and had diagnoses that included retention of urine. Review of the Minimum Data Set assessment dated May 23, 2026, indicated that the resident was alert and was frequently incontinent of urine. The Care Area Assessment summary dated May 23, 2026, noted that the resident's urinary incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident's 4's urinary incontinence were included in the care plan.

In an interview on August 5, 2026, at 8:37 a.m., the Administrator confirmed there was no documented evidence that the identified care area was addressed in the care plan.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 09/16/2026

- Care plans for resident 4 was updated immediately on 8/4/2026 to reflect the care areas that the MDS summaries stated should be addressed in the care plans and all resolved areas were removed from the care plans.
- An initial one-time audit of 15 random care plans will be conducted by the LPNAC or designee as all residents have the potential to be affected. Any identified care area updates/changes will be made and any items needing to be resolved will be resolved.
- Assessment Coordinator team will be educated on care planning.
- A random audit of 5 residents' comprehensive care plans will be conducted x 4 weeks. This plan of correction will be monitored at the monthly Quality Assurance meeting until consistent substantial compliance has been meet.

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2) REQUIREMENT Discharge Process:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:

(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's responsible party or the legal representative with a written notice of transfer that included all required information, including a statement of the resident's appeal rights and the Ombudsman information in writing upon discharge from the facility for two of eight sampled residents. Additionally, it was determined that 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 two of eight sampled residents who were transferred out of the facility. (Residents 2 and 4)

Findings include:

Clinical record review revealed that Resident 2 was discharged to the hospital on March 24 and March 29, 2026, after changes in condition. There was no documented evidence that the resident and resident's responsible party, or the legal representative, were provided information regarding appeal rights and State Long-Term Care Ombudsman information or that the facility provided copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman.

Clinical record review revealed that Resident 4 was discharged to the hospital on June 5, 2026, after a change in condition. There was no documented evidence that the resident and resident's responsible party, or the legal representative, were provided information regarding appeal rights and State Long-Term Care Ombudsman information, or that the facility provided copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman.

In an interview on August 5, 2026, at 8:40 a.m., the Administrator confirmed that the transfer notice did not include the required information and notification of discharge was not provided to a representative of the Office of the State Long-Term Care Ombudsman.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(1)(2) Management.

28 Pa. Code 201.29(a)(c.3)(2) Resident rights.

Plan of Correction - To be completed: 09/16/2026

- New transfer letters with the information regarding appeal rights will be sent to residents 2 and 4 on 8/14/26. The transfer information for residents 2 and 4 was sent to the Long-Term Care Ombudsman on 8/5/26 immediately upon realizing the non-compliance.
- The Director of Medical Records will conduct a one-time audit of all transfer letters sent over the past 30 days to identify additional letters needing to be corrected. If any are identified, new letters will be resent with the correct appeal rights listed. The Director of Social Services conducted a onetime audit of all ombudsman notifications on 8/4/26, noting that transfer information was not sent to the ombudsman for the past 12 months. Therefore, the transfer information for all transfers from 08/01/2025-07/31/2026.
- The Administrator provided education to the Medical Records Director and the Director of Social Services regarding transfer and discharge notifications on 8/4/26.
- A new standard transfer/discharge letter has been created, that lists the correct appeal information and nursing department will be educated on the process and new form at the next department meeting on 8/19/26. Moving forward, a new process has been established for the Director of Social Services to send the notification to the Long-Term Care Ombudsman monthly, outlining the previous month's transfers. For auditing purposes, the Director of Social Services will copy/forward the notification to the Administrator.

§ 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, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratio for four of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from June 1 through 7, 2026, June 29 through July 5, 2026, and July 29, through August 4, 2026, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on July 3, 4, and 5, 2026, and August 1, 2026.

During an interview on August 5, 2026, at 9:40 a.m., the Administrator confirmed that the facility did not meet the required NA to resident ratio on the dates identified.

Plan of Correction - To be completed: 09/16/2026

- The staffing coordinator or designee 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, the facility utilizes staffing agencies as needed to cover vacancies and call offs.
- The current day's projected ratios and HPPD and the previous days' (on Monday's review the weekend) performance are reported to the whole team in the daily stand-up meeting that occurs every Monday-Friday. Interim scheduling meetings are called if gaps are identified during this meeting and actions are taken as necessary.
- Education on staffing ratios and call off procedures will be given to the nursing department at the next department meeting on 8/19/26 and also to the managers on duty.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement