Cycle 1
Health 2025-09-05 · Fire 2025-09-05
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Bethlehem, PA
Bethlehem South Skilled Nursing And Rehabilitation
3-star overall rating with 3-star inspections with 10 recent health deficiencies
2021 Westgate Drive, Bethlehem, PA
(610) 865-6077
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
227
Certified beds
Average residents
181
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1978-12-26
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
0.37
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.54
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.47
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.17
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,656
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.12
Composite VBP score used to determine payment impact.
Payment multiplier
0.9853
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.87% · Performance 21.51% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.16
Baseline 5.61% · Performance 5.70% · Measure score 7.16 · Achievement 7.16 · Improvement 0
Total nurse turnover
3.70
Baseline 47.33% · Performance 48.57% · Measure score 3.70 · Achievement 3.70 · Improvement 0
Adjusted total nurse staffing
0.79
Baseline 3.22 hours · Performance 3.30 hours · Measure score 0.79 · Achievement 0.79 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.79% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 183 · Observed rate 9.84% · Lower 95% interval 6.94% |
| Discharge to community | 42.32% |
50.57%
8.2 pts worse
|
Worse than the National Rate · Eligible stays 153 · Observed rate 32.68% · Lower 95% interval 34.81% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.32% |
95.27%
4 pts better
|
Numerator 145 · Denominator 146 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 146 |
| Discharge self-care score | 64.58% |
53.69%
10.9 pts better
|
Numerator 62 · Denominator 96 |
| Discharge mobility score | 53.13% |
50.94%
2.2 pts better
|
Numerator 51 · Denominator 96 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 146 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.7% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 3.92% · Lower 95% interval 3.51% |
| Staff COVID-19 vaccination coverage | 2.16% |
8.2%
6 pts worse
|
Numerator 4 · Denominator 185 |
| Staff flu vaccination coverage | 26.86% |
42%
15.1 pts worse
|
Numerator 76 · Denominator 283 |
| Discharge function score | 59.38% |
56.45%
2.9 pts better
|
Numerator 57 · Denominator 96 |
| Transfer of health information to provider | 98.36% |
95.95%
2.4 pts better
|
Numerator 60 · Denominator 61 |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 20 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 1.49% |
25.2%
23.7 pts worse
|
Numerator 1 · Denominator 67 |
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 1.5 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 79.1% |
86.9%
7.8 pts worse
|
93.4%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.2% · Q2 85.5% · Q3 72.2% · Q4 70.1% · 4Q avg 79.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.1% |
93.5%
2.6 pts better
|
95.5%
0.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.2%
0.1 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.5% · Q3 2.4% · Q4 2.4% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.3% |
6.5%
5.8 pts worse
|
11.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 12.1% · Q3 8.2% · Q4 10.2% · 4Q avg 12.3% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
6.5%
3.4 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.6% · Q3 2.6% · Q4 2.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.8% |
19.9%
1.1 pts better
|
19.6%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 18.7% · Q3 17.9% · Q4 16.8% · 4Q avg 18.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.1% |
18.7%
1.6 pts better
|
16.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 16.4% · Q3 18.6% · Q4 19.8% · 4Q avg 17.1% · 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 | 9.7% |
19.6%
9.9 pts better
|
16.3%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 14.2% · Q3 5.6% · Q4 13.3% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.1% |
18.3%
5.2 pts better
|
14.9%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 9.7% · Q3 12.2% · Q4 21.9% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
0.9%
0.8 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.6% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 1.9% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.5% |
26.4%
0.9 pts better
|
19.8%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 26.5% · Q3 22.0% · Q4 30.4% · 4Q avg 25.5% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
5.3%
0.2 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.7% · Q3 5.9% · Q4 5.0% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 42.0% |
68.9%
26.9 pts worse
|
81.7%
39.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 61.6% · Q2 42.9% · Q3 34.9% · Q4 29.8% · 4Q avg 42.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
9.8%
2.8 pts worse
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 12.4% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.5%
0.9 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 4.2% · Q4 3.2% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 32.2% |
68.7%
36.5 pts worse
|
79.7%
47.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 32.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
23.1%
2.6 pts worse
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 25.7% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-27 · Fire 2024-11-27
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-11-02 · Fire 2023-11-02
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-10-14
E · Potential for more than minimal harm
2025-09-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-14
D · Potential for more than minimal harm
2025-09-05
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-10-14
D · Potential for more than minimal harm
2025-09-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-14
D · Potential for more than minimal harm
2025-09-05
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 2025-10-14
D · Potential for more than minimal harm
2025-09-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-14
D · Potential for more than minimal harm
2025-09-05
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 2025-10-14
C · Minimal harm
2025-09-05
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-14
D · Potential for more than minimal harm
2025-07-25
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 2025-08-12
D · Potential for more than minimal harm
2025-07-01
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 2025-07-23
D · Potential for more than minimal harm
2024-11-27
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 2024-12-18
D · Potential for more than minimal harm
2024-11-27
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 2024-12-18
B · Minimal harm
2024-07-26
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 2024-08-20
D · Potential for more than minimal harm
2024-06-11
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-07-09
E · Potential for more than minimal harm
2023-11-02
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 2023-12-19
E · Potential for more than minimal harm
2023-11-02
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-11-02
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 2023-12-19
E · Potential for more than minimal harm
2023-11-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-11-02
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 2023-12-19
D · Potential for more than minimal harm
2023-11-02
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-11-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-11-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-11-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-19
C · Minimal harm
2023-11-02
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-12-19
C · Minimal harm
2023-11-02
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-09-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-19
Penalties and ownership
What sits behind the stars
Ownership
Genesis Pm Pa Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Aversa, Thaddeus
Operational/Managerial Control · Individual
Berg, Michael
Corporate Officer · Individual
Bridgeford, Laura
Corporate Officer · Individual
Callazo, Nancy
Operational/Managerial Control · Individual
Fc-Gen Operations Investment LLC
5% Or Greater Indirect Ownership Interest · Organization
Fishman, Steven
5% Or Greater Indirect Ownership Interest · Individual
Gen Operations I LLC
5% Or Greater Indirect Ownership Interest · Organization
Gen Operations Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Ghc Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hccf Management Group Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Mendelson, Avi
Corporate Officer · Individual
Sun Healthcare Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Sundance Rehabilitation Holdco Inc
5% Or Greater Indirect Ownership Interest · Organization
Welltower Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Whitman, Arnold
5% Or Greater Indirect Ownership Interest · Individual
Zac Properties Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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Bethlehem North Skilled Nursing And Rehabilitation
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4-star overall rating with 4-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Good Shepherd Home-Bethlehem
Bethlehem, PA
5-star overall rating with 5-star inspections with 1 recent health deficiencies
#3
Riverton Rehabilitation And Healthcare Center
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5-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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