Bethlehem, PA

Holy Family Manor

5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle

1200 Spring Street, Bethlehem, PA

(610) 865-5595

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

208

Certified beds

Average residents

109

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1968-11-01

CMS approved date

Coverage

Medicare + Medicaid

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

0.82

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.65

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

1.85

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.32

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

2.65

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.39

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.10

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.90

CMS adjusted RN staffing hours

Adjusted total hours

3.63

CMS adjusted total nurse staffing hours

Case-mix index

1.25

Higher values indicate more complex resident acuity

RN turnover

18%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

41%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,497

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

Performance score

44.07

Composite VBP score used to determine payment impact.

Payment multiplier

0.9971

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 21.71% · Performance 23.94% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

10

Baseline 4.93% · Performance 4.76% · Measure score 10 · Achievement 10 · Improvement 9

Total nurse turnover

5.04

Baseline 43.75% · Performance 43.09% · Measure score 5.04 · Achievement 5.04 · Improvement 0

Adjusted total nurse staffing

2.59

Baseline 3.62 hours · Performance 3.81 hours · Measure score 2.59 · Achievement 2.59 · Improvement 0.41

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.22%	10.72% 0.5 pts worse	No Different than the National Rate · Eligible stays 464 · Observed rate 12.5% · Lower 95% interval 9.13%
Discharge to community	50.53%	50.57% About the same	No Different than the National Rate · Eligible stays 443 · Observed rate 43.57% · Lower 95% interval 44.34%
Medicare spending per beneficiary	0.75	1.02 0.3 pts better
Drug regimen review with follow-up	99.62%	95.27% 4.4 pts better	Numerator 261 · Denominator 262
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 262
Discharge self-care score	30.62%	53.69% 23.1 pts worse	Numerator 64 · Denominator 209
Discharge mobility score	32.54%	50.94% 18.4 pts worse	Numerator 68 · Denominator 209
Pressure ulcers or injuries, new or worsened	1.15%	2.29% 1.1 pts better	Numerator 3 · Denominator 262 · Adjusted rate 1.19%
Healthcare-associated infections requiring hospitalization	4.76%	7.12% 2.4 pts better	Better than the National Rate · Eligible stays 250 · Observed rate 2.8% · Lower 95% interval 3.01%
Staff COVID-19 vaccination coverage	3.49%	8.2% 4.7 pts worse	Numerator 6 · Denominator 172
Staff flu vaccination coverage	89.77%	42% 47.8 pts better	Numerator 193 · Denominator 215
Discharge function score	37.8%	56.45% 18.7 pts worse	Numerator 79 · Denominator 209
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 51 · Denominator 51
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 160 · Denominator 160
Resident COVID-19 vaccinations up to date	2.22%	25.2% 23 pts worse	Numerator 3 · Denominator 135

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.3	1.7 0.6 pts worse	1.9 0.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.3 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.1	1.2 0.1 pts better	1.8 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	26.6%	86.9% 60.3 pts worse	93.4% 66.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 14.4% · Q3 11.7% · Q4 64.0% · 4Q avg 26.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	95.8%	93.5% 2.3 pts better	95.5% 0.3 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 95.8%
Percentage of long-stay residents experiencing one or more falls with major injury	5.0%	3.2% 1.8 pts worse	3.3% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.4% · Q3 5.2% · Q4 5.8% · 4Q avg 5.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.0%	6.5% 4.5 pts better	11.4% 9.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 3.1% · Q4 3.3% · 4Q avg 2.0%
Percentage of long-stay residents who lose too much weight	11.0%	6.5% 4.5 pts worse	5.4% 5.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 9.2% · Q3 8.8% · Q4 12.7% · 4Q avg 11.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	27.8%	19.9% 7.9 pts worse	19.6% 8.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 26.6% · Q3 27.1% · Q4 31.6% · 4Q avg 27.8%
Percentage of long-stay residents who received an antipsychotic medication	16.9%	18.7% 1.8 pts better	16.7% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 16.7% · Q3 17.5% · Q4 13.1% · 4Q avg 16.9% · 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	20.5%	19.6% 0.9 pts worse	16.3% 4.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 21.0% · Q3 25.2% · Q4 19.8% · 4Q avg 20.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	22.3%	18.3% 4 pts worse	14.9% 7.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 25.0% · Q3 15.4% · Q4 20.8% · 4Q avg 22.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.1%	0.9% 0.2 pts worse	1.0% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	4.9%	1.7% 3.2 pts worse	1.7% 3.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 4.6% · Q3 4.0% · Q4 4.8% · 4Q avg 4.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	33.0%	26.4% 6.6 pts worse	19.8% 13.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 35.7% · Q3 34.3% · Q4 33.9% · 4Q avg 33.0%
Percentage of long-stay residents with pressure ulcers	5.0%	5.3% 0.3 pts better	5.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 6.5% · Q3 4.4% · Q4 3.8% · 4Q avg 5.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	18.9%	68.9% 50 pts worse	81.7% 62.8 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 37.4% · Q2 17.7% · Q3 10.3% · Q4 11.8% · 4Q avg 18.9%
Percentage of short-stay residents who had an outpatient emergency department visit	10.3%	9.8% 0.5 pts worse	12.0% 1.7 pts better	Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 9.6% · Expected 10.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.5%	1.5% 1 pts better	1.6% 1.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 1.4% · 4Q avg 0.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	37.2%	68.7% 31.5 pts worse	79.7% 42.5 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 37.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.8%	23.1% 2.7 pts worse	23.9% 1.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 25.2% · Expected 23.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-24 · Fire 2025-07-24

0 health deficiencies

No concentrated health issue counts in this cycle.

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-06-06 · Fire 2024-06-06

2 health deficiencies

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

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-07-20 · Fire 2023-07-20

4 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-07-24

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-08-16

E · Potential for more than minimal harm 2025-07-24

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-08-16

E · Potential for more than minimal harm 2025-07-24

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-08-16

E · Potential for more than minimal harm 2023-07-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-08-18

E · Potential for more than minimal harm 2023-07-20

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-08-18

Inspection history

Recent health citations

D · Potential for more than minimal harm 2024-06-06

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 2024-07-08

D · Potential for more than minimal harm 2024-06-06

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-07-08

D · Potential for more than minimal harm 2024-02-06

F836 · Administration Deficiencies

Health

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Corrected 2024-02-17

D · Potential for more than minimal harm 2023-07-20

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-09-08

D · Potential for more than minimal harm 2023-07-20

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2023-09-08

B · Minimal harm 2023-07-20

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 2023-09-08

Penalties and ownership