Cycle 1
Health 2025-07-31 · Fire 2025-07-31
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Construction (2 deficiencies)
Bethlehem, PA
Country Meadows Nursing Center Of Bethlehem
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
4025 Green Pond Road, Bethlehem, PA
(610) 882-4110
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-06-04
CMS approved date
Coverage
Medicare
Participation flags
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
1.16
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.21
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.11
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.59
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.74
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.15
CMS adjusted RN staffing hours
Adjusted total hours
4.17
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
475
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
69.20
Composite VBP score used to determine payment impact.
Payment multiplier
1.0220
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.18
Baseline 21.01% · Performance 17.64% · Measure score 8.18 · Achievement 8.18 · Improvement 7.97
Healthcare-associated infections
6.64
Baseline 3.68% · Performance 5.85% · Measure score 6.64 · Achievement 6.64 · Improvement 0
Total nurse turnover
8.28
Baseline 27.12% · Performance 29.85% · Measure score 8.28 · Achievement 8.28 · Improvement 0
Adjusted total nurse staffing
4.58
Baseline 4.52 hours · Performance 4.38 hours · Measure score 4.58 · Achievement 4.58 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.62% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 603 · Observed rate 11.28% · Lower 95% interval 9.39% |
| Discharge to community | 66.46% |
50.57%
15.9 pts better
|
Better than the National Rate · Eligible stays 590 · Observed rate 59.83% · Lower 95% interval 62.51% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 41.7% |
95.27%
53.6 pts worse
|
Numerator 186 · Denominator 446 |
| Falls with major injury | 0.67% |
0.77%
0.1 pts better
|
Numerator 3 · Denominator 446 |
| Discharge self-care score | 50.4% |
53.69%
3.3 pts worse
|
Numerator 188 · Denominator 373 |
| Discharge mobility score | 40.21% |
50.94%
10.7 pts worse
|
Numerator 150 · Denominator 373 |
| Pressure ulcers or injuries, new or worsened | 0.9% |
2.29%
1.4 pts better
|
Numerator 4 · Denominator 446 · Adjusted rate 0.94% |
| Healthcare-associated infections requiring hospitalization | 5.85% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 403 · Observed rate 4.71% · Lower 95% interval 4.1% |
| Staff COVID-19 vaccination coverage | 2.68% |
8.2%
5.5 pts worse
|
Numerator 4 · Denominator 149 |
| Staff flu vaccination coverage | 46.05% |
42%
4 pts better
|
Numerator 70 · Denominator 152 |
| Discharge function score | 52.28% |
56.45%
4.2 pts worse
|
Numerator 195 · Denominator 373 |
| Transfer of health information to provider | 81.87% |
95.95%
14.1 pts worse
|
Numerator 140 · Denominator 171 |
| Transfer of health information to patient | 98.65% |
96.28%
2.4 pts better
|
Numerator 219 · Denominator 222 |
| Resident COVID-19 vaccinations up to date | 12.28% |
25.2%
12.9 pts worse
|
Numerator 28 · Denominator 228 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.3 |
1.7
1.4 pts better
|
1.9
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.2
0.9 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
86.9%
8.6 pts better
|
93.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 95.2% · 4Q avg 95.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.2%
0.2 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
6.5%
1.6 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 10.0% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 42.6% |
19.9%
22.7 pts worse
|
19.6%
23 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 50.0% · 4Q avg 42.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 46.0% |
18.7%
27.3 pts worse
|
16.7%
29.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 46.0% · 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 · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.2% |
18.3%
6.1 pts better
|
14.9%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 3.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.9% |
26.4%
3.5 pts better
|
19.8%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.9% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.3%
0.5 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 8.6% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
68.9%
27.5 pts better
|
81.7%
14.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 95.9% · Q3 97.5% · Q4 97.1% · 4Q avg 96.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
9.8%
0.5 pts better
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 8.5% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 3.2% · Q4 2.4% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.7% |
68.7%
25 pts better
|
79.7%
14 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.9% |
23.1%
5.2 pts better
|
23.9%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 15.6% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-18 · Fire 2024-06-18
0 health deficiencies
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-08-24 · Fire 2023-08-24
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Construction (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-31
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-09-10
E · Potential for more than minimal harm
2025-07-31
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-09-10
E · Potential for more than minimal harm
2025-07-31
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-09-10
C · Minimal harm
2025-07-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-10
C · Minimal harm
2025-07-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-10
E · Potential for more than minimal harm
2024-06-18
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-07-12
E · Potential for more than minimal harm
2024-06-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-12
E · Potential for more than minimal harm
2024-06-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-12
C · Minimal harm
2024-06-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-12
C · Minimal harm
2024-06-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-12
C · Minimal harm
2024-06-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-12
E · Potential for more than minimal harm
2023-08-24
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-08-24
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-08-24
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-08-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-08-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-31
C · Minimal harm
2023-08-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-31
C · Minimal harm
2023-08-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-07-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-07-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-17
Penalties and ownership
What sits behind the stars
Ownership
Country Meadows Of Northampton Associates LP
Limited Partnership Interest · Organization
Fistner, Christopher
Operational/Managerial Control · Individual
G. Michael Leader 3d Tr Udt 06172004
Limited Partnership Interest · Organization
George M. Leader Family Corp.
Limited Partnership Interest · Organization
George M. Leader Family Corp.
Operational/Managerial Control · Organization
Guerrisi, Louisa
Operational/Managerial Control · Individual
Jane L. Janeczek Deed Tr
Limited Partnership Interest · Organization
Janeczek, Jane
Limited Partnership Interest · Individual
Leader Holdings, LP
Limited Partnership Interest · Organization
Leader, David
Limited Partnership Interest · Individual
Leader, G
Limited Partnership Interest · Individual
Mills, Meredith
Corporate Officer · Individual
Orix Real Estate Capital LLC
5% Or Greater Mortgage Interest · Organization
Palkovitz, John
Operational/Managerial Control · Individual
Potluri, Sunitha
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Advanced Health Care Of Hanover
Bethlehem, PA
3-star overall rating with 3-star inspections with $3,387 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Kirkland Village
Bethlehem, PA
5-star overall rating with 5-star inspections with 11 fire-safety deficiencies in the latest cycle
#3
Northampton Post Acute
Easton, PA
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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