Health inspection·September 12, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to notify a resident's responsible party of a significant weight loss for one of 12 sampled residents. (Resident 11) Findings include: Review of the facility policy entitled, Change in Medical Condition, dated August 29, 2024, revealed that staff were to provide timely notification to the resident's representative of significant changes to the resident's physical status. Clinical record review revealed that Resident 11 had diagnoses that included dementia, adult failure to thrive, and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive impairment. Review of the resident's weights revealed that on July 4, 2024, the resident weighed 146 pounds (lbs). On August 13, 2024, Resident 11 weighed 124.6 lbs, which was confirmed with a reweigh. On August 19, 2024, Resident 11 weighed 125 lbs. This reflected a 14 percent weight loss in one month. There was no documented evidence that Resident 11's responsible party was notified of the significant weight loss. In an interview on September 12, 2024, at 12:07 p.m., the Administrator confirmed that there was no documented evidence that Resident 11's responsible party was notified of the significant weight loss. Pa. Code 201.29(c) 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 4 Event ID: 395916 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 395916 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkland Village One Kirkland Village Circle Bethlehem, PA 18017 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)