Bethlehem, PA

Bethlehem North Skilled Nursing And Rehabilitation

4-star overall rating with 4-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

2029 Westgate Drive, Bethlehem, PA

(610) 861-0100

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

217

Certified beds

Average residents

202

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Genesis Healthcare

Operator or chain grouping

Approved since

1982-05-22

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

193 facilities

Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.42

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.94

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.08

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.44

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.36

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.16

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.21

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.42

CMS adjusted RN staffing hours

Adjusted total hours

3.44

CMS adjusted total nurse staffing hours

Case-mix index

1.37

Higher values indicate more complex resident acuity

RN turnover

57%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

55%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,164

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

30.57

Composite VBP score used to determine payment impact.

Payment multiplier

0.9860

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.98

Baseline 18.07% · Performance 19.59% · Measure score 3.98 · Achievement 3.98 · Improvement 0

Healthcare-associated infections

5.43

Baseline 6.10% · Performance 6.21% · Measure score 5.43 · Achievement 5.43 · Improvement 0

Total nurse turnover

2.82

Baseline 47.48% · Performance 52.15% · Measure score 2.82 · Achievement 2.82 · Improvement 0

Adjusted total nurse staffing

0

Baseline 3.38 hours · Performance 3.21 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	7.75%	10.72% 3 pts better	No Different than the National Rate · Eligible stays 213 · Observed rate 5.16% · Lower 95% interval 5.18%
Discharge to community	46.06%	50.57% 4.5 pts worse	No Different than the National Rate · Eligible stays 195 · Observed rate 37.95% · Lower 95% interval 41.08%
Medicare spending per beneficiary	0.75	1.02 0.3 pts better
Drug regimen review with follow-up	97.06%	95.27% 1.8 pts better	Numerator 132 · Denominator 136
Falls with major injury	1.47%	0.77% 0.7 pts worse	Numerator 2 · Denominator 136
Discharge self-care score	47.31%	53.69% 6.4 pts worse	Numerator 44 · Denominator 93
Discharge mobility score	31.18%	50.94% 19.8 pts worse	Numerator 29 · Denominator 93
Pressure ulcers or injuries, new or worsened	2.21%	2.29% 0.1 pts better	Numerator 3 · Denominator 136 · Adjusted rate 2.2%
Healthcare-associated infections requiring hospitalization	6.21%	7.12% 0.9 pts better	No Different than the National Rate · Eligible stays 109 · Observed rate 5.5% · Lower 95% interval 4.2%
Staff COVID-19 vaccination coverage	0.59%	8.2% 7.6 pts worse	Numerator 1 · Denominator 169
Staff flu vaccination coverage	13.98%	42% 28 pts worse	Numerator 39 · Denominator 279
Discharge function score	37.63%	56.45% 18.8 pts worse	Numerator 35 · Denominator 93
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 29 · Denominator 29
Transfer of health information to patient	97.87%	96.28% 1.6 pts better	Numerator 46 · Denominator 47
Resident COVID-19 vaccinations up to date	1.41%	25.2% 23.8 pts worse	Numerator 1 · Denominator 71

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.2	1.7 0.5 pts better	1.9 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.8	1.2 0.4 pts better	1.8 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	80.1%	86.9% 6.8 pts worse	93.4% 13.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 77.3% · Q2 80.5% · Q3 80.9% · Q4 81.6% · 4Q avg 80.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	84.7%	93.5% 8.8 pts worse	95.5% 10.8 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 84.7%
Percentage of long-stay residents experiencing one or more falls with major injury	3.2%	3.2% About the same	3.3% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.9% · Q3 3.3% · Q4 5.0% · 4Q avg 3.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	7.1%	6.5% 0.6 pts worse	11.4% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 9.0% · Q3 5.6% · Q4 4.6% · 4Q avg 7.1%
Percentage of long-stay residents who lose too much weight	8.4%	6.5% 1.9 pts worse	5.4% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 8.3% · Q3 6.5% · Q4 10.9% · 4Q avg 8.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.2%	19.9% 0.7 pts better	19.6% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 21.4% · Q3 16.4% · Q4 17.0% · 4Q avg 19.2%
Percentage of long-stay residents who received an antipsychotic medication	17.5%	18.7% 1.2 pts better	16.7% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 18.8% · Q3 15.5% · Q4 15.6% · 4Q avg 17.5% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	33.6%	19.6% 14 pts worse	16.3% 17.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 32.0% · Q3 34.0% · Q4 45.4% · 4Q avg 33.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	29.0%	18.3% 10.7 pts worse	14.9% 14.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 26.5% · Q3 27.4% · Q4 40.1% · 4Q avg 29.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.6%	0.9% 0.3 pts better	1.0% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 0.5% · Q4 1.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.9%	1.7% 0.8 pts better	1.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.7% · Q3 0.0% · Q4 0.6% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	27.1%	26.4% 0.7 pts worse	19.8% 7.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 31.1% · Q3 26.7% · Q4 26.2% · 4Q avg 27.1%
Percentage of long-stay residents with pressure ulcers	6.3%	5.3% 1 pts worse	5.1% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 6.5% · Q3 6.6% · Q4 5.5% · 4Q avg 6.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	60.6%	68.9% 8.3 pts worse	81.7% 21.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 38.5% · Q2 61.1% · Q3 74.9% · Q4 67.6% · 4Q avg 60.6%
Percentage of short-stay residents who had an outpatient emergency department visit	6.8%	9.8% 3 pts better	12.0% 5.2 pts better	Short Stay · 20240701-20250630 · Adjusted 6.8% · Observed 6.4% · Expected 10.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.9%	1.5% 0.4 pts worse	1.6% 0.3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.4% · Q3 2.8% · Q4 1.0% · 4Q avg 1.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	58.2%	68.7% 10.5 pts worse	79.7% 21.5 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 58.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.5%	23.1% 2.6 pts better	23.9% 3.4 pts better	Short Stay · 20240701-20250630 · Adjusted 20.5% · Observed 21.1% · Expected 24.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-06 · Fire 2025-03-06

9 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-02-16 · Fire 2024-02-16

1 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-03-30 · Fire 2023-03-30

3 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

3 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-03-06

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2025-05-10

E · Potential for more than minimal harm 2025-03-06

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2025-05-10

D · Potential for more than minimal harm 2025-03-06

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-05-10

E · Potential for more than minimal harm 2024-02-16

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-03-21

E · Potential for more than minimal harm 2024-02-16

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-03-21

E · Potential for more than minimal harm 2024-02-16

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-03-21

E · Potential for more than minimal harm 2024-02-16

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2024-03-21

E · Potential for more than minimal harm 2023-03-30

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2023-05-08

E · Potential for more than minimal harm 2023-03-30

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2023-05-08

E · Potential for more than minimal harm 2023-03-30

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-05-08

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-03-06

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-04-30

D · Potential for more than minimal harm 2025-03-06

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-04-30

D · Potential for more than minimal harm 2025-03-06

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-04-30

D · Potential for more than minimal harm 2025-03-06

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2025-04-30

D · Potential for more than minimal harm 2025-03-06

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-04-30

D · Potential for more than minimal harm 2025-03-06

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-04-30

D · Potential for more than minimal harm 2025-03-06

F810 · Nutrition and Dietary Deficiencies

Health

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Corrected 2025-04-30

D · Potential for more than minimal harm 2025-03-06

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-04-30

C · Minimal harm 2025-03-06

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2025-04-30

D · Potential for more than minimal harm 2024-02-16

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-03-05

D · Potential for more than minimal harm 2023-12-28

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2024-02-13

F · Potential for more than minimal harm 2023-03-30

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-05-15

D · Potential for more than minimal harm 2023-03-30

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2023-05-15

Penalties and ownership

What sits behind the stars

Ownership

Genesis Pm Pa Operations LLC

5% Or Greater Direct Ownership Interest · Organization

100% 22 facilities 2022-11-15

Berg, Michael

Corporate Officer · Individual

0% 175 facilities 2022-11-15

Bridgeford, Laura

Corporate Officer · Individual

0% 150 facilities 2024-04-01

Callazo, Nancy

Operational/Managerial Control · Individual

0% 2 facilities 2024-01-29

Fc-Gen Operations Investment LLC