Inspection Reports for Kirkland Village
1 Kirkland Village Cir, Bethlehem, PA 18017, United States, PA, 18017
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% better than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
47% occupied
Based on a May 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 28, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Kirkland Village following a survey completed on 2025-08-28.
Findings
No health deficiencies were found during the survey.
Inspection Report
Census: 30
Capacity: 64
Deficiencies: 0
May 20, 2025
Visit Reason
The inspection was conducted as a licensing inspection due to an incident, with an unannounced partial inspection type.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 30
License Capacity: 64
Current Hospice Residents: 2
Residents Age 60 or Older: 30
Residents with Mobility Need: 1
Inspection Report
Renewal
Census: 30
Capacity: 64
Deficiencies: 2
Mar 27, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the Kirkland Village facility to assess compliance with licensing requirements.
Findings
The submitted plan of correction was determined to be fully implemented. Two deficiencies were noted related to fire safety inspection and medication administration course completion, both of which had corrective actions accepted and implemented.
Deficiencies (2)
| Description |
|---|
| The most recent fire safety inspection and fire drill conducted by a fire safety expert was conducted on 12/20/24; the previous one was conducted on 7/20/23, indicating a lapse in annual inspection timing. |
| The annual practicum for staff person A only included one of the required two medication administration record reviews and one of the medication administration observations. |
Report Facts
License Capacity: 64
Residents Served: 30
Total Daily Staff: 30
Waking Staff: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Environmental Services | Named in fire safety inspection deficiency and plan of correction | |
| PC Administrator | Involved in re-education and auditing related to fire safety and medication administration deficiencies | |
| Medication Administration Trainer | Completed additional medication administration record review and observation for staff person A |
Inspection Report
Census: 29
Capacity: 64
Deficiencies: 0
Jan 8, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Resident Support Staff: 0
Total Daily Staff: 29
Waking Staff: 22
Residents Served: 29
License Capacity: 64
Current Hospice Residents: 0
Residents Age 60 or Older: 29
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 0
Residents with Physical Disability: 0
Inspection Report
Complaint Investigation
Deficiencies: 4
Sep 12, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to notify a resident's responsible party of significant weight loss, failure to implement physician's orders, inadequate monitoring of significant weight changes, and failure to implement infection prevention and control measures.
Findings
The facility was found to have multiple deficiencies including failure to notify a resident's responsible party of significant weight loss, failure to implement physician's orders for daily weights, inadequate monitoring and assessment of significant weight changes, and failure to implement required COVID-19 droplet precautions and PPE use for infected residents.
Complaint Details
The visit was complaint-related, triggered by allegations of failure to notify responsible parties of significant weight loss, failure to implement physician's orders, inadequate nutritional monitoring, and failure to follow infection control protocols. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to notify a resident's responsible party of a significant weight loss for one of 12 sampled residents (Resident 11). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure that physician's orders were implemented for one of 12 sampled residents (Resident 20), specifically daily weights were not documented on four dates. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to adequately monitor and assess a significant weight change for one of 12 sampled residents (Resident 11), with no documented evidence that the dietitian addressed the weight loss. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement transmission based droplet precautions and use of personal protective equipment (PPE) to prevent the spread of infection for two of 12 sampled residents (Residents 15, 23). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Weight loss percentage: 14
Dates weights not documented: 4
Residents sampled: 12
Residents affected: 2
Inspection Report
Census: 30
Capacity: 64
Deficiencies: 0
Jul 17, 2024
Visit Reason
The inspection was conducted as a licensing inspection with a partial, unannounced visit due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 30
License Capacity: 64
Current Residents in Hospice: 3
Total Daily Staff: 30
Waking Staff: 23
Inspection Report
Census: 24
Capacity: 64
Deficiencies: 0
Nov 16, 2023
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 24
License Capacity: 64
Current Residents in Hospice: 3
Inspection Report
Complaint Investigation
Deficiencies: 4
Oct 26, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to timely complete quarterly Minimum Data Set assessments, assess and treat wounds, implement safety interventions for residents at risk for falls, and maintain accurate and complete clinical records.
Findings
The facility was found to have multiple deficiencies including failure to complete timely quarterly assessments for one resident, failure to assess and treat wounds for another resident, failure to implement fall prevention interventions for a resident at risk, and failure to maintain accurate and complete clinical records for two residents. All deficiencies were cited with minimal harm or potential for actual harm affecting few residents.
Complaint Details
The visit was complaint-related, investigating issues including untimely MDS assessments, inadequate wound care, lack of fall prevention measures, and incomplete clinical documentation. The deficiencies were substantiated based on clinical record reviews, interviews, and observations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to timely complete a quarterly Minimum Data Set (MDS) assessment for one of 13 sampled residents (Resident 21). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assess and treat wounds for one of 13 sampled residents (Resident 94). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement safety interventions for one of three sampled residents at risk for falls (Resident 11). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain clinical records that were accurate and complete for two of 13 sampled residents (Residents 7, 42). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Sampled residents: 13
Falls documented: 4
Medication documentation errors: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Stated that the MDS quarterly assessment had not been completed in a timely manner | |
| Director of Nursing | Confirmed lack of wound assessment and treatment documentation for Resident 94; confirmed improper documentation of insulin administration and lack of documentation for Resident 42 and Resident 11 | |
| Registered Nurse 1 | Stated there was no documented evidence that fall mats were in place during Resident 11's falls |
Inspection Report
Follow-Up
Census: 32
Capacity: 64
Deficiencies: 1
Jul 18, 2022
Visit Reason
The visit was a follow-up review conducted on 07/18/2022 to verify that the submitted plan of correction was fully implemented following a prior incident-related inspection.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. The deficiency involved an incomplete preadmission screening form missing a determination about the resident's ability to safely use and avoid poisonous materials.
Deficiencies (1)
| Description |
|---|
| Resident #1's preadmission screening form did not include a determination under Section II that the resident can safely use and avoid poisonous materials; the yes or no boxes were left blank. |
Report Facts
License Capacity: 64
Residents Served: 32
Current Hospice Residents: 3
Resident Support Staff: 1
Total Daily Staff: 34
Waking Staff: 26
Residents 60 Years or Older: 32
Residents with Mobility Need: 1
Inspection Report
Follow-Up
Census: 32
Capacity: 64
Deficiencies: 4
May 19, 2022
Visit Reason
The visit was a partial, unannounced inspection conducted due to an incident, with follow-up on a previously submitted plan of correction.
Findings
The inspection identified medication management deficiencies including discontinued medications remaining in carts, incorrect medication labeling, transcription errors in medication records, and failure to follow prescriber's orders. The facility submitted and implemented a plan of correction addressing these issues.
Deficiencies (4)
| Description |
|---|
| Resident #1's discontinued medication was still present in the medication cart at the time of inspection. |
| Resident #2's medication label did not match the directions on the medication record. |
| Resident #1's medication order was transcribed incorrectly onto the medication record. |
| Resident #1 was administered medication outside the prescribed dates due to transcription error. |
Report Facts
License Capacity: 64
Residents Served: 32
Resident Support Staff: 33
Total Daily Staff: 33
Waking Staff: 25
Inspection Report
Renewal
Census: 33
Capacity: 64
Deficiencies: 4
Jan 25, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection found deficiencies related to incomplete medical evaluation documentation, medication record discrepancies, and incomplete support plans for residents. Plans of correction were accepted and fully implemented.
Deficiencies (4)
| Description |
|---|
| The documentation of medical evaluation (DME) forms for resident #1 were missing height, weight, and pulse information. |
| Resident #2 had a medication order discrepancy where the pharmacy label did not match the physician's order regarding systolic blood pressure thresholds. |
| Resident #3's support plan was not updated to reflect 1:1 private duty aide care on all shifts. |
| Resident #3's support plan was not signed by the resident or the staff person who completed the plan. |
Report Facts
License Capacity: 64
Residents Served: 33
Current Residents in Hospice: 1
Total Daily Staff: 34
Waking Staff: 26
Notice
Capacity: 64
Deficiencies: 0
Jan 22, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Kirkland Village Personal Care Home, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported; the document confirms issuance of a regular license following the renewal application and outlines the Department's obligation to conduct an annual inspection.
Report Facts
Maximum capacity: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
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