Cycle 1
Health 2025-08-28 · Fire 2025-08-28
0 health deficiencies
No concentrated health issue counts in this cycle.
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Bethlehem, PA
Kirkland Village
5-star overall rating with 5-star inspections with 11 fire-safety deficiencies in the latest cycle
One Kirkland Village Circle, Bethlehem, PA
(610) 691-4500
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
60
Certified beds
Average residents
42
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Presbyterian Senior Living
Operator or chain grouping
Approved since
1994-01-06
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
12 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 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
1.18
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.14
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.10
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.58
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.20
CMS adjusted RN staffing hours
Adjusted total hours
4.21
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,594
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9854
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 24.24% · Performance 25.86% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.42
Baseline 5.62% · Performance 6.81% · Measure score 3.42 · Achievement 3.42 · Improvement 0
Total nurse turnover
3.8
Baseline 58.46% · Performance 48.15% · Measure score 3.8 · Achievement 3.8 · Improvement 2.57
Adjusted total nurse staffing
4.52
Baseline 3.86 hours · Performance 4.36 hours · Measure score 4.52 · Achievement 4.52 · Improvement 2.1
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.16% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 403 · Observed rate 9.93% · Lower 95% interval 8.59% |
| Discharge to community | 57.51% |
50.57%
6.9 pts better
|
Better than the National Rate · Eligible stays 413 · Observed rate 53.27% · Lower 95% interval 52.65% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.55% |
95.27%
4.3 pts better
|
Numerator 222 · Denominator 223 |
| Falls with major injury | 0.45% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 223 |
| Discharge self-care score | 53.01% |
53.69%
0.7 pts worse
|
Numerator 88 · Denominator 166 |
| Discharge mobility score | 53.01% |
50.94%
2.1 pts better
|
Numerator 88 · Denominator 166 |
| Pressure ulcers or injuries, new or worsened | 0.9% |
2.29%
1.4 pts better
|
Numerator 2 · Denominator 222 · Adjusted rate 1.22% |
| Healthcare-associated infections requiring hospitalization | 6.81% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 224 · Observed rate 5.8% · Lower 95% interval 4.92% |
| Staff COVID-19 vaccination coverage | 11.92% |
8.2%
3.7 pts better
|
Numerator 18 · Denominator 151 |
| Staff flu vaccination coverage | 58.26% |
42%
16.3 pts better
|
Numerator 134 · Denominator 230 |
| Discharge function score | 56.63% |
56.45%
0.2 pts better
|
Numerator 94 · Denominator 166 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 62 · Denominator 62 |
| Transfer of health information to patient | 99.25% |
96.28%
3 pts better
|
Numerator 132 · Denominator 133 |
| Resident COVID-19 vaccinations up to date | 43% |
25.2%
17.8 pts better
|
Numerator 43 · Denominator 100 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.7
0.7 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.2
0.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 77.9% |
86.9%
9 pts worse
|
93.4%
15.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 76.0% · Q2 82.6% · Q3 72.7% · Q4 80.0% · 4Q avg 77.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.7% |
93.5%
1.8 pts worse
|
95.5%
3.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.2%
1 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.3% · Q3 4.5% · Q4 4.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
6.5%
3.9 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
6.5%
2.3 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.8% |
19.9%
13.9 pts worse
|
19.6%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.0% · 4Q avg 33.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.5% |
18.7%
3.2 pts better
|
16.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.5% · 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 | 29.1% |
19.6%
9.5 pts worse
|
16.3%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.1% |
18.3%
4.2 pts better
|
14.9%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.9%
0.1 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.7%
0.6 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.3% |
26.4%
5.9 pts worse
|
19.8%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 35.9% · Q3 30.8% · Q4 44.2% · 4Q avg 32.3% |
| Percentage of long-stay residents with pressure ulcers | 0.6% |
5.3%
4.7 pts better
|
5.1%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.7% |
68.9%
3.8 pts better
|
81.7%
9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 66.5% · Q2 66.7% · Q3 70.7% · Q4 86.5% · 4Q avg 72.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.9% |
9.8%
2.9 pts better
|
12.0%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.9% · Observed 6.6% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.8% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 45.5% |
68.7%
23.2 pts worse
|
79.7%
34.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 45.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.6% |
23.1%
9.5 pts worse
|
23.9%
8.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.6% · Observed 28.3% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-12 · Fire 2024-09-12
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-10-26 · Fire 2023-10-26
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-28
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-08-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-08-28
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-08-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-08-28
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-08-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-08-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-08-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-08-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-08-28
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-09-30
C · Minimal harm
2025-08-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-30
E · Potential for more than minimal harm
2024-09-12
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-09-12
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-09-12
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 2024-10-30
E · Potential for more than minimal harm
2024-09-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-09-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-30
C · Minimal harm
2024-09-12
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-10-30
E · Potential for more than minimal harm
2023-10-26
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-12-17
E · Potential for more than minimal harm
2023-10-26
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 2023-12-17
E · Potential for more than minimal harm
2023-10-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-17
D · Potential for more than minimal harm
2023-10-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-12
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 2024-10-10
D · Potential for more than minimal harm
2024-09-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-10
D · Potential for more than minimal harm
2023-10-26
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-12-17
D · Potential for more than minimal harm
2023-10-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-17
D · Potential for more than minimal harm
2023-10-26
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 2023-12-17
D · Potential for more than minimal harm
2023-10-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-12-17
Penalties and ownership
What sits behind the stars
Ownership
Birdsall, James
Corporate Director · Individual
Bowser, Nicole
Operational/Managerial Control · Individual
Chottiner, Lawrence
Corporate Director · Individual
Davis, Danny
Corporate Officer · Individual
Elliott, Brenda
Corporate Director · Individual
Goldstein, Terry
Corporate Director · Individual
Kelly, Sharon
Corporate Director · Individual
Kinard, Joseph
Corporate Director · Individual
Kinard, Joseph
Corporate Officer · Individual
Krieger, Daniel
Corporate Officer · Individual
Mcalister, Dyan
Corporate Officer · Individual
Paxton, Stuart
Corporate Director · Individual
Phi
5% Or Greater Direct Ownership Interest · Organization
Reimann, Susan
Corporate Director · Individual
Reimann, Susan
Corporate Officer · Individual
Rhodes, Cheryl
Corporate Director · Individual
Scott, William
Corporate Director · Individual
Seibert, Joseph
Corporate Director · Individual
Shropshire, Jennifer
Corporate Director · Individual
Stone, Robyn
Corporate Director · Individual
Wickline, Beverly
Corporate Officer · 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
Country Meadows Nursing Center Of Bethlehem
Bethlehem, PA
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Moravian Village Of Bethlehem
Bethlehem, PA
5-star overall rating with 5-star inspections with 1 recent health deficiencies
Jump out