Bethlehem South Skilled Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Bethlehem South Skilled Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 9, 2026

  Based on facility policy review, clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to ensure that residents were free from abuse that resulted in actual physical harm for one of seven sampled residents (Resident 2) This failure resulted in an Immediate Jeopardy situation. The incident has been identified as past non-compliance.Findings include: Review of the facility policy entitled, Abuse Prohibition, last reviewed on November 14, 2025, revealed that Center staff were to do all that was within their control to prevent occurrences of abuse for all patients. Actions to prevent abuse would include identifying, correcting, and intervening in situations in which abuse was more likely to occur. […]

• No harm, potential for more than minimal, patternF607Sep 5, 2025

  Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to verify professional license/registration status prior to the start of employment for three of five newly hired employees. (Employees 1, 2, 3)Findings include: A review of the facility policy entitled, Abuse Prohibition, last reviewed February 27, 2025, revealed that the facility would implement an abuse prohibition program through screening of potential hires. The process included screening potential employees for a history of abuse, neglect, or mistreatment of patients which would have included checking with the appropriate licensing boards and registries. […]

• No harm, potential for more than minimal, patternF695Sep 5, 2025

  Based on review of facility policy, clinical record review and resident and staff interview, it was determined that the facility failed to provide adequate treatment and services for respiratory therapy and failed to maintain respiratory equipment in a sanitary manner for four of six sampled residents who utilized respiratory equipment. (Residents 1, 7, 12, 104)Findings include: Review of the facility policy entitled, Respiratory Equipment/Supply Cleaning/Disinfecting, last reviewed February 27, 2025, revealed that the schedule for supply changes for oxygen humidifiers was to be every seven days and as needed for soiling and nebulizer equipment was to be changed daily. Clinical record review revealed that Resident 1 had diagnoses that included pneumonia, asthma, and respiratory failure. […]

• No harm, potential for more than minimal, patternF623Nov 2, 2023

  Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify the resident's representative(s) of transfer and the reasons for the move in writing for seven of 11 sampled residents who were transferred to the hospital. (Residents 37, 77, 90, 91, 137, 154, 159 ) Findings include: Review of the facility policy entitled, Discharge and Transfer, last reviewed November 11, 2022, revealed that the facility must notify the resident and resident representative in writing prior to the transfer or discharge in a language and manner they understand. Clinical record review revealed that Resident 37 was transferred and admitted to the hospital on July 16, 2023, after a change in condition. […]

• No harm, potential for more than minimal, patternF625Nov 2, 2023

  Based on clinical record review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident or resident representative at the time of transfer for seven of 11 sampled residents who were transferred to the hospital. (Residents 37, 77, 90, 91, 137, 154, 159) Findings include: Clinical record review revealed that Resident 37 was transferred and admitted to the hospital on July 16, 2023, after a change in condition. […]