F 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review it was determined that the facility failed to notify the resident's representative in four of
five residents sampled who were transferred to the hospital. (Residents 19, 56, 61, 112)
Findings include:
Clinical record review revealed that Resident 19 was transferred and admitted to the hospital on [DATE],
after a change in condition. There was no documented evidence that the resident's responsible party or
legal representative was provided written information regarding the resident's transfer to the hospital.
Clinical record review revealed that Resident 56 was transferred and admitted to the hospital on [DATE],
after a change in condition. There was no documented evidence that the resident, the resident's
responsible party or legal representative was provided written information regarding the resident's transfer
to the hospital.
Clinical record review revealed that Resident 61 was transferred to the hospital on April 24 and June 1,
2023, after changes in condition. There was no documented evidence that the resident's responsible party
or legal representative was provided written information regarding the resident's transfers to the hospital.
Clinical record review revealed that Resident 112 was transferred and admitted to the hospital on [DATE],
after a change in condition. There was no documented evidence that the resident's responsible party or
legal representative was provided written information regarding the resident's transfer to the hospital.
28 Pa. Code 201.29(c.3)(2) Resident rights.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
395250
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395250
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Holy Family Manor
1200 Spring Street
Bethlehem, PA 18018
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to
ensure physician's orders were implemented for one of 24 sampled residents. (Resident 20)
Residents Affected - Few
Findings include
Clinical record review revealed that Resident 20 had diagnoses that included spina bifida, paraplegia,
muscle weakness, and debility. A physician's order dated November 1, 2019, directed staff to apply a knee
abduction cushion and check for alignment throughout the day. Review of the care plan revealed that the
resident was at risk for skin breakdown. The intervention was for staff to apply a knee abduction cushion
per the orders. Multiple observations on July 19, 2023, between 11:10 a.m., and 1:28 p.m., revealed
Resident 20 sitting in a wheelchair, the knee abduction cushion was not in place.
In an interview on July 20, 2023, at 8:20 a.m., the Director of Nursing confirmed that staff did not apply the
knee abduction cushion and that it should have been applied per the care plan and physician's order.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395250
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395250
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Holy Family Manor
1200 Spring Street
Bethlehem, PA 18018
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based on facility policy review, clinical record review, and observation, it was determined that the facility
failed to ensure that proper care was provided for one of two sampled residents who used a urinary
catheter (a flexible tube that drains urine from the bladder). (Resident 20)
Findings include:
Review of facility policy entitled, Urinary Catheters, last reviewed January 2023, revealed that a catheter
drainage bag was never to be elevated to or above bladder level.
Clinical record review revealed that Resident 20 had diagnoses that included paraplegia, spina bifida,
dementia, and dysfunction of the bladder. Review of the care plan revealed that the resident had an
indwelling catheter. The intervention was for staff to position the catheter bag and tubing below the level of
the bladder. Multiple observations on July 18, 2023, between 11:30 a.m. and 1:13 a.m., revealed Resident
20 was seated in a wheelchair. The tubing of the catheter was arranged such that it extended down the
resident's pants leg and out the bottom to the drainage bag. The catheter bag was positioned inside the
seat of the wheelchair, between the arm rest and the resident's hip. Neither the tubing nor the drainage bag
were maintained below the level of the resident's bladder. Urine was observed in the tubing.
28 Pa. Code 211.10(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395250
If continuation sheet
Page 3 of 3
