Inspection Reports for
Alexandria Manor of Allentown – Bethlehem Campus
3534 LINDEN STREET,, BETHLEHEM, PA, 18017
Back to Facility Profile32 Reports
Inspection Report — Aug 4, 2026
Complaint Investigation
Date: Aug 4, 2026
Visit Reason
The inspection was conducted as a result of an incident, as indicated by the reason labeled 'Incident' in the inspection information section.
Findings
No regulatory citations or deficiencies were identified during the inspection. The report states that no deficiencies were found as a result of this inspection.
Report Facts
Residents Served: 40
Current Hospice Residents: 1
Residents Age 60 or Older: 40
Residents with Mobility Need: 1
Residents with Physical Disability: 1
Inspection Report — Jul 8, 2026
Follow-Up
Date: Jul 8, 2026
Visit Reason
The visit was an unannounced partial inspection conducted as a follow-up to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to medication administration and resident assessments. Continued compliance is required.
Citations (2)
187d - Follow Prescriber's Orders: The medication record did not indicate if the blood sugar was retaken as ordered, and there were no corresponding blood glucose levels on the resident's glucometer.
225c - Additional Assessment: The resident's Assessment and Support Plan did not indicate that the resident utilizes a wheelchair for ambulation.
Report Facts
Residents Served: 39
Current Hospice Residents: 2
Total Daily Staff: 40
Waking Staff: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rbrown | Assistant Administrator | Named in medication error finding and responsible for insulin order audits and oversight. |
| Catherine Caruso | CRNP | Contacted regarding medication error. |
Inspection Report — May 14, 2026
Complaint Investigation
Date: May 14, 2026
Visit Reason
The inspection was conducted as a complaint investigation at Alexandria Manor of Allentown - Bethlehem Campus on 05/14/2026.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 38
Current Residents in Hospice: 1
Resident Support Staff: 0
Total Daily Staff: 39
Waking Staff: 29
Inspection Report — Mar 26, 2026
Complaint Investigation
Date: Mar 26, 2026
Visit Reason
The inspection was conducted as a complaint investigation to review compliance related to medication administration and incident reporting at Alexandria Manor of Allentown - Bethlehem Campus.
Complaint Details
The inspection was complaint-related, focusing on medication errors and failure to report incidents. The plan of correction was accepted and verified as fully implemented on 03/26/2026.
Findings
The facility had medication administration errors where prescribed medications were not available or administered as prescribed, and the home failed to report these medication errors to the department. The submitted plan of correction was accepted and fully implemented as of the inspection date.
Citations (3)
16c Written Incident Report: The home failed to report medication errors to the Department of Human Services within 24 hours as required by regulation 16c.
187a Medication Record: Medication was not available or administered as prescribed, and documentation indicated residents refused or received medication inconsistently.
187d Follow Prescriber's Orders: The home did not follow prescriber directions for medication administration, resulting in medication not being administered as prescribed.
Report Facts
Residents Served: 38
Current Hospice Residents: 1
Resident Support Staff: 0
Total Daily Staff: 39
Waking Staff: 29
Inspection Report — Nov 19, 2025
Complaint Investigation
Date: Nov 19, 2025
Visit Reason
The inspection was conducted as a complaint investigation following allegations of verbal abuse and improper treatment of a resident.
Complaint Details
The complaint involved verbal abuse allegations by resident #1 against staff person A. The complaint was substantiated based on the findings during the inspection.
Findings
The investigation found that a staff member verbally abused a resident during transfer, failed to report the incident timely, and that a staff member provided unsupervised care without proper training certification. Corrective actions including staff counseling, education, and audits were implemented.
Citations (3)
16c - Written Incident Report: The home failed to report a verbally abusive incident involving staff member A and resident #1 to the Department within 24 hours as required.
42c - Treatment of Residents: Staff person A engaged in verbally abrasive and inappropriate language towards resident #1 during transfer, causing discomfort and disrespect.
65d - Initial Direct Care Training: Staff person A provided unsupervised ADL services without completing and passing the required Department-approved direct care training and competency test.
Report Facts
Residents Served: 40
Current Hospice Residents: 2
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 1
Residents with Physical Disability: 1
Inspection Report — Jun 26, 2025
Renewal
Date: Jun 26, 2025
Visit Reason
Renewal inspection of Alexandria Manor of Allentown - Bethlehem Campus to assess compliance with applicable regulations and licensing requirements.
Findings
Multiple deficiencies were identified including resident abuse related to elopement, medication management errors, fire safety violations, sanitary conditions, and staff training deficiencies. Corrective actions and education plans were implemented with ongoing monitoring.
Citations (26)
42b Abuse: Resident #1 eloped twice without adequate supervision, resulting in injury. Staff failed to implement required monitoring and alternative placement was not considered.
183d Prescription Current: Medication Diltiazem for resident #2 was discontinued but remained in the medication cart.
185a Implement Storage Procedures: Medication Tamsulosin blister pack was tampered with, covered with tape.
187b Date/Time of Medication Admin: Medication Diltiazem was administered but not recorded properly on the Medication Administration Record.
18 Compliance With Laws: Carbon monoxide monitor batteries were not labeled with installation dates as required.
20b1 Financial Records: Resident financial records showed a $5 deficit with no explanation or documentation.
51 Criminal Background Check: Two staff hired in 2025 did not have timely criminal background checks completed before starting work.
65a FS Orientation 1st Day: Staff person A did not receive required fire safety orientation on first day of work.
65g Annual Training Content: Staff person C and D did not receive required annual training on resident rights, fire safety, and accident prevention for 2024.
85a Sanitary Conditions: Strong urine odor detected in hallway due to carpeting; carpet was replaced with vinyl flooring.
92 Windows: Torn and detached window screens in dining areas on 2nd and 3rd floors.
103e Left Overs: Unlabeled and undated food items found in kitchen and kitchenettes.
103i Outdated Food: Expired mayonnaise and yogurt found in kitchenettes.
105g Lint Removal and Duct Cleaning: Lint accumulation behind dryer and on dryer hose.
121a Unobstructed Egress: Chair blocked egress from stairwell exit to resident smoking area.
131f Fire Extinguisher Inspection: Fire extinguishers had not been inspected annually; some were last inspected in 2023 or 2024.
132c Fire Drill Records: Fire drill record did not document that resident #2 failed to evacuate during drill.
132h Designated Meeting Place: Resident #2 did not evacuate to designated meeting place during fire drill.
144c1 Smoking Area Guidelines: Cigarette butts found on ground in staff and resident smoking areas.
144c2 Smoking Area Distance: Chair placed less than 2 feet from stairwell exit door with cigarette ashes, indicating smoking outside designated area.
183e Storing Medications: Albuterol inhaler for resident #3 expired in February 2025 but was still in medication cart.
184a Resident's Meds Labeled: Pharmacy label for resident #4's insulin did not include sliding scale order.
185a Implement Storage Procedures: Medication Meclizine for resident #5 was not available in medication cart as ordered.
187b Date/Time of Medication Admin: Resident #4's Dexamethasone was recorded as administered daily instead of only on prescribed days.
187d Follow Prescriber's Orders: Resident #6's Artificial Tears and Tamsulosin were not administered as ordered on 6/24/25.
225c Additional Assessment: Resident #7's assessment did not reflect need for mechanical soft diet.
Report Facts
Residents Served: 43
Staff Count: 46
Waking Staff: 35
Inspection Report — Mar 20, 2025
Complaint Investigation
Date: Mar 20, 2025
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced inspection on 03/20/2025 and an exit conference on 03/25/2025.
Complaint Details
The inspection was complaint-related as explicitly stated under Inspection Information with the reason noted as 'Complaint'.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 46
Total Daily Staff: 50
Waking Staff: 38
Residents with Mental Illness: 4
Residents 60 Years or Older: 38
Residents with Mobility Need: 4
Residents with Physical Disability: 2
Hospice Residents: 1
Inspection Report — Oct 10, 2024
Renewal
Date: Oct 10, 2024
Visit Reason
The inspection was conducted as a full, unannounced renewal inspection with complaint elements on 10/10/2024 to assess compliance with licensing requirements and investigate complaints.
Findings
The inspection identified multiple deficiencies including failure to post current license, missing written receipts for financial transactions, untimely criminal background checks, incomplete direct care training documentation, sanitary issues, incomplete fire drill records, smoking area hazards, medication self-administration issues, unlocked medication carts, missing medications, incomplete medication administration records, failure to follow prescriber's orders, and undated preadmission screening forms. Plans of correction were accepted and implemented with ongoing monitoring.
Citations (14)
License Inspection Summary report dated 11/2/23 for the most recent renewal inspection was not posted; current license posted expired 9/29/24.
Resident #1 did not sign for cash withdrawals as required.
Criminal background check for staff person A was not obtained timely.
Staff person A lacked documentation of completing Department-approved direct care competency test.
Staff person B lacked documentation of annual training on falls and accident prevention for 2023.
Strong odor of urine detected on 2nd floor during initial walkthrough.
Fire drill records lacked complete information; evacuation times recorded only in minutes.
Cigarette butts found in staff and resident smoking areas mixed with pine needles.
Resident #2 had medication at bedside not assessed for self-administration.
Medication cart found unlocked and unattended in living room on 10/10/24.
Medications for residents #3, #4, and #5 not on hand to administer as needed per PRN orders.
Medication administration records lacked documentation of sliding scale insulin units and staff initials for resident #5.
Prescriber's order for resident #3 to hold medication if blood glucose below threshold was not followed.
Resident #6's preadmission screening form was not dated; completion date unknown.
Report Facts
Residents Served: 38
Staffing Hours: 42
Waking Staff: 32
Fire Drill Evacuation Times (minutes): 6
Fire Drill Evacuation Times (minutes): 4
Fire Drill Evacuation Times (minutes): 6
Fire Drill Evacuation Times (minutes): 7
Inspection Report — Jun 4, 2024
Complaint Investigation
Date: Jun 4, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 06/04/2024 and an exit conference on 06/20/2024.
Complaint Details
The inspection was complaint-driven, with substantiation implied by the findings of multiple violations related to resident care, privacy, and reporting requirements.
Findings
The inspection found multiple deficiencies including failure to report incidents, breaches of resident record confidentiality, inadequate assistance with activities of daily living, violations of resident privacy, incomplete medical evaluations, unsecured medications, and incomplete support plans reflecting resident behaviors. The facility submitted plans of correction which were accepted and implemented by July 2024.
Citations (8)
Failure to report an incident involving a resident's combative behavior and injury to the Department within 24 hours.
Resident records and narcotic sign-in book were left unlocked and unattended, violating confidentiality requirements.
Failure to provide assistance with toileting and changing briefs as indicated in the resident’s assessment and support plan.
Violation of resident privacy by staff recording a resident on video without consent during a combative episode.
Resident medical evaluation did not indicate the need for body positioning as required.
Prescription medication was left unattended on top of the medication cart in the common area.
Medication administration records were not signed at the time of administration due to the narcotic logbook being locked in the administrator’s office.
Resident support plan was not updated to reflect potential for aggression and combative behavior.
Report Facts
Residents Served: 40
Current Hospice Residents: 3
Residents 60 Years or Older: 47
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 4
Residents with Physical Disability: 2
Inspection Report — Jan 18, 2024
Follow-Up
Date: Jan 18, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 01/18/2024 to review the submitted plan of correction related to an incident and interim concerns.
Findings
The submitted plan of correction was found to be fully implemented and compliance was maintained. Two deficiencies were noted: lack of documentation for staff training on resident rights and fire safety in 2023, and presence of discontinued PRN medication in the medication cart.
Citations (2)
No documentation that Staff Member A received training on resident rights or fire safety in the year 2023.
Resident had a PRN prescription which was discontinued but medication was still available in the medication cart at the time of inspection.
Report Facts
Residents Served: 44
Current Hospice Residents: 3
Total Daily Staff: 47
Waking Staff: 35
Inspection Report — Nov 2, 2023
Renewal
Date: Nov 2, 2023
Visit Reason
The inspection was conducted as a full, unannounced renewal inspection with complaint components on 11/02/2023 to assess compliance with licensing regulations and complaint allegations.
Complaint Details
The inspection included complaint investigation components related to resident treatment and medication administration concerns.
Findings
The inspection identified multiple deficiencies including treatment of residents, annual training requirements, medication storage and administration issues, fire safety drills, and record-keeping deficiencies. Plans of correction were accepted and implemented by 02/05/2024.
Citations (14)
Resident #3 did not report chest pain due to feeling afraid and intimidated by Staff person F, who was observed using profanities in the dining room.
Staff person A did not complete any hours of annual training in training year 2022.
Direct care staff persons B and E did not receive the required 12 hours of annual training or training in required topics during training year 2022.
Staff person E did not receive training in Fire Safety or Emergency Preparedness during training year 2022.
Training record titled 'Proper Med Admin' on 6/13/22 did not include training length or training source.
Trash can in main kitchen was uncovered with waste at time of inspection.
No overnight fire drill conducted since 8/31/22.
Resident #4's medical evaluation and additional assessment were not completed within the annual timeframe.
Resident #2 stored medications in an unlocked nightstand accessible to other residents.
Med Techs B, C, D, E, and F were administering medications without current certification and documentation.
Resident #1's medication label was incorrect, stating twice daily instead of once daily administration.
Staff Person B signed narcotic count before completing the count; narcotic count discrepancy found.
Resident #1's medication record was incomplete and did not reflect actual administration or holding of medication per parameters.
Resident #5's record did not address if Resident #3 had any identifiable marks.
Report Facts
Residents Served: 46
Total Daily Staff: 49
Waking Staff: 37
Current Hospice Residents: 3
Deficiencies Cited: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Did not complete annual training in 2022 | |
| Staff person B | Administering medications without certification; narcotic count discrepancy | |
| Staff person E | Did not receive required training in 2022 including fire safety and emergency preparedness | |
| Staff person F | Observed using profanities and abrupt behavior towards resident |
Inspection Report — Jun 1, 2023
Complaint Investigation
Date: Jun 1, 2023
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 06/01/2023 and 06/14/2023.
Complaint Details
The inspection was complaint-related as indicated by the reason 'Complaint' and was unannounced. No deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of the inspections conducted on 06/01/2023 and 06/14/2023.
Report Facts
Residents Served: 45
Current Residents in Hospice: 2
Resident Support Staff Hours: 0
Total Daily Staff Hours: 48
Waking Staff Hours: 36
Residents Age 60 or Older: 45
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Physical Disability: 1
Residents with Mobility Need: 3
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Intellectual Disability: 0
Inspection Report — Jan 31, 2023
Follow-Up
Date: Jan 31, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Complaint Details
The visit was incident-related, indicating a complaint or allegation triggered the inspection. The plan of correction was accepted and fully implemented.
Findings
The submitted plan of correction was determined to be fully implemented. Two deficiencies were addressed: one involving mistreatment of a resident by staff and another regarding failure to complete a required initial assessment within 15 days of admission.
Citations (2)
Staff A yelled and cursed at Resident #1 and threatened physical harm; Staff A was suspended and removed from the facility.
An initial assessment was not completed for Resident #1 within 15 days of admission as required.
Report Facts
Residents Served: 48
Current Resident with Mental Illness: 3
Residents 60 Years or Older: 47
Residents with Mobility Need: 4
Inspection Report — Aug 17, 2022
Complaint Investigation
Date: Aug 17, 2022
Visit Reason
The inspection was conducted as a complaint investigation with multiple on-site and off-site review dates between 08/17/2022 and 10/07/2022 to assess compliance with state regulations.
Complaint Details
The inspection was complaint-driven as indicated by the inspection information section. The plan of correction was accepted and fully implemented, indicating resolution of the complaint issues.
Findings
The facility was found to have deficiencies related to resident record confidentiality, securing preventative medical care, and medication storage security. The submitted plan of correction was accepted and fully implemented by 01/06/2023.
Citations (3)
Administrator's office was unlocked and accessible, containing confidential resident records.
Failure to secure preventative medical care by not arranging pickup of a prescription from a different pharmacy.
Medication cart located in the lobby was unlocked and accessible.
Report Facts
Residents Served: 35
Total Daily Staff: 38
Waking Staff: 29
Current Residents in Hospice: 3
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 3
Residents Aged 60 or Older: 35
Residents with Physical Disability: 1
Inspection Report — Jul 6, 2022
Renewal
Date: Jul 6, 2022
Visit Reason
The inspection visit occurred as a renewal inspection of the Alexandria Manor of Allentown - Bethlehem Campus facility on 07/06/2022.
Findings
The inspection identified multiple deficiencies including failure to complete an annual quality management plan review, delayed refund of resident funds, unaccredited high school diploma of direct care staff, incomplete direct care training for staff, lack of operable bedside lamp in a resident room, failure to evacuate hospice residents properly during fire drills, incomplete medical evaluation documentation, and failure to administer prescribed medication due to unavailability.
Citations (8)
The home did not complete an annual quality management plan review within the past 12 months.
Resident #1's estate refund was not made within 30 days of discharge.
Direct care staff person A has a high school diploma not accredited by the Pennsylvania Department of Education or other states.
Direct care staff persons A and B provided unsupervised ADL services without completing and passing the Department-approved direct care training and competency test.
Resident room #201 did not have access to a source of light that can be turned on/off at bedside.
During fire drills, hospice residents did not evacuate to a designated meeting place away from the building or within the fire-safe area as required.
Medical evaluation for resident #2 did not indicate the resident's height.
Resident #2 was prescribed medication that was not administered due to unavailability in the home.
Report Facts
Residents Served: 36
Resident Support Staff: 3
Total Daily Staff: 42
Waking Staff: 32
Current Hospice Residents: 1
Residents Age 60 or Older: 35
Residents with Mobility Need: 3
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Harold | Direct Care Staff | Named in relation to unaccredited diploma and transfer to dietary department. |
Inspection Report — Jun 2, 2022
Complaint Investigation
Date: Jun 2, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation, as indicated by the reason stated in the inspection information section.
Complaint Details
The visit was complaint-related, investigating an incident where Resident #1 was stockpiling medication instead of taking it as administered. Staff person A confirmed not observing the resident taking medication at administration.
Findings
The inspection found deficiencies related to medication administration and medication technician training. Staff persons A, B, and C lacked proper or documented medication administration training, and a resident was found stockpiling medication rather than taking it as administered.
Citations (2)
Staff persons A, B, and C are medication technicians who pass medications but lacked current or documented medication administration training.
Resident #1 was stockpiling medication rather than taking it at administration time, and staff person A failed to observe proper medication administration.
Report Facts
Residents Served: 36
Current Residents in Hospice: 3
Total Daily Staff: 39
Waking Staff: 29
Notice — Aug 30, 2021
Date: Aug 30, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Alexandria Manor of Allentown - Bethlehem Campus, a Personal Care Home. It informs the facility that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It is a certificate of compliance and renewal license issuance indicating the facility is authorized to operate with a maximum capacity of 58 residents.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Inspection Report — Jun 22, 2021
Renewal
Date: Jun 22, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection found multiple deficiencies related to food storage, fire safety, medical evaluations, medication administration, and documentation. All deficiencies were corrected at the time of inspection or have plans of correction in place with follow-up dates. The submitted plan of correction was determined to be fully implemented.
Citations (11)
Uncovered cherry pie stored in freezer in dry storage room.
No thermometer in the freezer in the dry storage room.
Dented #10 cans of Cheddar cheese sauce and Mandarin Oranges found on can shelf in dry storage room.
Fire exit door leading to rear patio does not close without being forcefully pulled.
Fire extinguisher in entire building not inspected by fire safety expert since April 2020.
Fire drill records for 10/12/19 and 11/13/19 missing number of residents in home and number evacuated.
Resident #1 and #2 medical evaluations not completed timely.
Narcotics not properly locked in medication cart; medication administration records (MAR) inaccurately transcribed blood glucose test results and glucometers not calibrated correctly.
Medication administration records included initials on days medication was not prescribed, indicating inaccurate documentation.
Resident #9 preadmission screening form completed after admission date.
Resident #1 additional assessment not completed timely.
Report Facts
Residents Served: 28
Total Daily Staff: 28
Waking Staff: 21
Hospice Residents: 1
Residents Diagnosed with Mental Illness: 2
Residents 60 Years or Older: 28
Notice — Aug 10, 2020
Date: Aug 10, 2020
Visit Reason
The document serves as a renewal notification and license issuance for Alexandria Manor of Allentown - Bethlehem Campus Personal Care Home. It informs the facility that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Apr 6, 2020
Renewal
Date: Apr 6, 2020
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Jan 3, 2020
Plan of Correction
Date: Jan 3, 2020
Visit Reason
The document is a review of the plan of correction submitted by Carbon County Children and Youth Services following a prior inspection related to child protective services compliance.
Findings
The review determined that the submitted plan of correction is implemented and continued compliance must be maintained. The prior inspection identified multiple deficiencies related to GPS reports, supervisory oversight, risk assessments, and notification procedures.
Citations (6)
The county agency received 6 GPS reports regarding the victim child and sibling in the 10 months preceding the near fatality report but did not assess the need for services or conduct interviews with referral sources and medical professionals.
The county agency did not ensure that the safety of the children was assessed within the response time assigned when receiving reports and assessing the need for services.
Review of prior GPS reports revealed the county agency did not provide supervisory oversight as required.
The county agency received the 6th GPS report on 5/15/19 but did not notify the Department of this outcome until 7/15/19, and the report was never reviewed by a supervisor despite serious allegations of child maltreatment.
The county agency screened out 2 of 6 prior GPS reports without clear explanation and made no initial assessment of safety or risk.
The county agency did not assess risk or safety at required intervals, did not assess characteristics of a parent, and documentation did not support the identified level of risk.
Report Facts
GPS reports received: 6
Date of 6th GPS report: May 15, 2019
Notification delay days: 61
Prior GPS reports screened out: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gerry Lynn Butler | Human Services Program Representative | Signed letter reviewing plan of correction and conducted inspection |
Inspection Report — Aug 1, 2019
Renewal
Date: Aug 1, 2019
Visit Reason
The inspection was a renewal visit conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Ch. 2600 for the Alexandria Manor of Allentown - Bethlehem Campus.
Findings
Multiple violations of state regulations were found, including missing carbon monoxide monitors, incomplete financial transaction records, failure to provide quarterly financial statements, lack of criminal background check completion before unsupervised work, missed annual staff training, inadequate fire department notification, improper smoking area safeguards, and uncalibrated medical equipment.
Citations (9)
2600.18: The home lacked a carbon monoxide monitor in the main kitchen as required by the Care Facilities Carbon Monoxide Standard Act.
2600.20b1: The financial transaction sheet for resident #1 did not include the current balance for the previous three withdrawals.
2600.20b8: The home did not provide a quarterly statement of financial transactions to resident #1 or the resident’s designated person for 2018 and 2019.
2600.28f: Resident #2 was discharged on 3/21/2019, but the home did not provide a refund to the resident’s family until 6/14/2019.
2600.51: A direct care staff member hired on 7/10/19 had an incomplete Pennsylvania State Police Criminal Background Check and worked unsupervised.
2600.65g: Ancillary staff member B hired in 2010 did not receive required annual training in resident rights and the Older Adult Protective Services Act for 2018.
2600.124: The home’s notice to the fire department did not specify the level of assistance residents require in an emergency.
2600.144c: Approximately 10 extinguished cigarette butts were found near the dumpster smoking area, and a fireproof receptacle was not provided in the designated smoking area.
2600.185a: The glucometer for resident #3 was not calibrated to the correct date and time; it showed 9/27/2018 during the inspection.
Report Facts
Residents Served: 32
Current Residents in Hospice: 7
Residents Diagnosed with Mental Illness: 7
Residents with Mobility Need: 7
Residents 60 Years or Older: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Clarissa DeGroff | Administrator | Named in multiple findings and plans of correction as responsible party |
Notice — Jun 27, 2019
Date: Jun 27, 2019
Visit Reason
The document serves as a renewal notice confirming the approval of the June 17, 2019 renewal application to operate the Personal Care Home facility Alexandria Manor of Allentown - Bethlehem Campus.
Findings
No inspection findings are reported. The notice states that the Department will conduct an annual onsite inspection within the next twelve months as required by regulation.
Report Facts
Inspection Report — Oct 25, 2018
Complaint Investigation
Date: Oct 25, 2018
Visit Reason
The inspection was conducted as a complaint investigation at Alexandria Manor of Allentown Bethlehem Campus on October 25, 2018.
Complaint Details
The inspection was triggered by a complaint, as explicitly stated under 'Reason(s) for Inspection(s)' on page 2.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including deficiencies in fire drill procedures, smoking policy compliance, medication management, and resident support plans. Plans of correction were submitted and approved.
Citations (6)
55 Pa.Code §2600.132(e) - The home did not conduct overnight sleeping hours fire drills requiring residents to get out of bed as required every six months.
55 Pa.Code §2600.144(c)(1) - An employee was observed smoking outside the designated smoking area near the dumpster.
55 Pa.Code §2600.183(d) - Resident #4's humalog quickpen was not dated when opened.
55 Pa.Code §2600.186(c) - Resident #3's medication administration record (MAR) noted oxybutynin 5mg daily, but the medication label indicated twice daily.
55 Pa.Code §2600.187(a) - Resident #2's medications were not initialed as administered on multiple dates and times in October 2018.
55 Pa.Code §2600.227(d) - Resident #1's support plan did not reflect the required 2-person assist for transfer and ADL; Resident #2's plan incorrectly noted independence with transfers.
Report Facts
Number of Residents Served: 41
Number of Current Hospice Residents: 7
Number of Hospice Residents in Past Year: 13
Staff Counts: 43
Waking Staff: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaqueline Burns | Administrator | Named as facility administrator responsible for ongoing compliance and plan of correction signatures. |
| Ryan Novak | Inspector | Department representative conducting the inspection. |
| Kristin De Vries | Inspector | Department representative conducting the inspection. |
Inspection Report — Jul 10, 2018
Renewal
Date: Jul 10, 2018
Visit Reason
The inspection was a renewal visit conducted by the Department of Human Services Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found, including unsigned resident contracts, uncovered bed rails, open trash receptacle lids, combustible materials near heat sources, and unsigned resident assessment plans. All violations were corrected at the time of inspection or had plans of correction with partial implementation progress.
Citations (5)
55 Pa.Code 2600.25(b) - The contract dated 2/28/2018 for resident #1 was not signed by the resident and there is no indication the resident refused to sign.
55 Pa.Code 2600.81(b) - The bed in room 208 had an approximately 6 inch side rail attached to it that was not covered.
55 Pa.Code 2600.85(e) - The home's large commercial trash receptacle lid was left open on 7/10/18 at 10am.
55 Pa.Code 2600.125(a) - Behind two dryers in the laundry room there were a crumpled napkin, a dryer sheet, and a tissue near heat sources.
55 Pa.Code 2600.227(h) - Resident Assessment and Support Plans dated 02/13/2018 and 04/29/2018 for resident #2 were not signed by the resident.
Report Facts
Number of Residents Served: 38
Total Daily Staff: 41
Waking Staff: 31
Number of Current Hospice Residents: 4
Number of Hospice Residents in past year: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Burns | Administrator | Named in relation to plan of correction and signature on violation pages. |
| Jason Harvey | Department representative conducting inspection. | |
| Amy Deluca | Department representative conducting inspection. |
Notice — Jun 14, 2018
Date: Jun 14, 2018
Visit Reason
The document serves as a renewal notification for the Personal Care Home license of Alexandria Manor of Allentown - Bethlehem Campus, confirming the renewal application received on June 14, 2018.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and outlines the requirement for annual onsite inspections.
Report Facts
Inspection Report — Nov 17, 2017
Complaint Investigation
Date: Nov 17, 2017
Visit Reason
The inspection was conducted as a complaint investigation at Alexandria Manor of Allentown Bethlehem Campus on November 17, 2017.
Complaint Details
The inspection was complaint-driven. Specific substantiation status is not stated.
Findings
The facility was found to have violations related to the failure to include a written initial assessment for a resident within 15 days of admission. The plan of correction included updating the assessment and support plan and ensuring home care agencies are properly added to resident plans.
Citations (1)
Regulation 55 Pa.Code §2600 requires a written initial assessment within 15 days of admission. The home did not include resident #1's assessment dated 11/8/17, missing referral documentation for home health agency wound care.
Report Facts
Number of Residents Served: 40
Total Daily Staff: 41
Waking Staff: 31
Number of Current Hospice Residents: 4
Number of Hospice Residents in past year: 10
Number of Residents 60 Years or Older: 39
Number of Residents with a Mobility Need: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacquelyn Burns | Administrator | Named as facility administrator and legal entity representative who signed plan of correction |
| Gerald Dumas | Department representative on-site during inspection |
Inspection Report — Jul 13, 2017
Renewal
Date: Jul 13, 2017
Visit Reason
The inspection was conducted as an annual licensing renewal inspection for Alexandria Manor of Allentown Bethlehem Campus.
Findings
Several violations of 55 Pa.Code Chapter 2600 were found, including unsupervised ADL services by untrained staff, lack of handrails on exit steps, prohibited portable space heaters, and incomplete resident records. Plans of correction were submitted and partially implemented as of early August 2017.
Citations (4)
Regulation 55 Pa.Code §2600.65(d) - Direct care staff hired after April 24, 2006 may not provide unsupervised ADL services until completing required training and competency testing. A direct care staff person hired on 5/21/17 began providing unsupervised ADL services without completing the online direct care test by 6/5/17.
Regulation 55 Pa.Code §2600.93(a) - Each ramp, interior stairway and outside steps must have a well-secured handrail. The home's courtyard exit steps lacked a handrail for the four steps to ground level.
Regulation 55 Pa.Code §2600.127(a) - Portable space heaters are prohibited. A portable space heater was observed in the recreation room entertainment console with a blower temperature of 163 degrees.
Regulation 55 Pa.Code §2600.252 - Each resident's record must include required information. Resident records #1 and #2 did not include color of eyes and hair respectively.
Report Facts
Number of Current Hospice Residents: 3
Number of Hospice Residents in Past Year: 10
Staffing - Total Daily Staff: 41
Staffing - Waking Staff: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacquelyn Burns | Administrator | Named as administrator and legal entity representative signing plans of correction. |
| Kimberli Foulkes | Department representative present on-site during inspection. | |
| Gerald Dumas | Department representative present on-site during inspection. |
Inspection Report — Jun 15, 2017
Renewal
Date: Jun 15, 2017
Visit Reason
This document is a renewal notification and license issuance for Alexandria Manor of Allentown - Bethlehem Campus to operate as a Personal Care Home. The Department of Human Services will conduct an onsite inspection at least once every twelve months as required by state code.
Findings
The document does not report inspection findings but confirms the renewal of the facility's license and states that inspections will be conducted annually to ensure compliance with applicable laws and regulations.
Report Facts
Inspection Report — Jul 19, 2016
Renewal
Date: Jul 19, 2016
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of Alexandria Manor of Allentown Bethlehem Campus.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to personal care home regulations were found, including issues with resident confidentiality, contract signatures, staff training, emergency procedures, and documentation of care. Plans of correction were partially implemented with adequate progress noted.
Citations (11)
55 Pa.Code §2600.17 - Resident records were not kept confidential as paperwork on bulletin boards revealed confidential resident information.
55 Pa.Code §2600.25(b) - The contract for Resident #1 was not signed by the payer as required.
55 Pa.Code §2600.65(f) - Annual training for direct care staff did not include required topics such as meeting needs of residents with mental illness or intellectual disability.
55 Pa.Code §2600.66(b) - The 2016 staff training plan did not include required elements for meeting needs of residents with mental illness or intellectual disability.
55 Pa.Code §2600.107(b) - Emergency procedures lacked required elements including confidentiality of medical information, transportation means, and alternate means for utility outages.
55 Pa.Code §2600.123(b) - Emergency procedures were not posted in a conspicuous and public place in the facility.
55 Pa.Code §2600.124 - Notification to local fire department did not include a general description of mobility needs or total facility capacity.
55 Pa.Code §2600.187(d) - Resident #2's insulin administration did not follow physician's sliding scale order; resident received fewer units than required.
55 Pa.Code §2600.221(g) - A current weekly activity calendar was not posted; scheduled entertainment was changed without notifying residents.
55 Pa.Code §2600.225(a) - Resident #3's initial assessment was not completed within 15 days of admission as required.
55 Pa.Code §2600.227(a) - Resident #3's written support plan was completed prior to admission date, not within 30 days after admission as required.
Report Facts
Units of insulin required: 4
Units of insulin received: 3
Hospice Residents Current: 2
Hospice Residents Past Year: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Burns | Administrator | Named in multiple plans of correction and signature on violation pages |
Inspection Report — Jun 16, 2016
Renewal
Date: Jun 16, 2016
Visit Reason
The document is a renewal application and license issuance for Alexandria Manor of Allentown – Bethlehem Campus to operate as a Personal Care Home. The Department will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and certificate of compliance.
Report Facts
Inspection Report — May 18, 2016
Complaint Investigation
Date: May 18, 2016
Visit Reason
The inspection was conducted as a complaint investigation at Alexandria Manor of Allentown Bethlehem Campus on May 18, 2016.
Complaint Details
The inspection was complaint-driven. The complaint was substantiated as violations were found regarding dietary needs not being met.
Findings
The inspection found violations related to the facility not meeting residents' special dietary needs as prescribed by physicians. Specifically, the home was not providing residents with meals as prescribed by their physicians, including serving high sodium meals contrary to dietary requirements.
Citations (1)
Regulation 55 Pa.Code §2600 requires that a resident's special dietary needs be met as prescribed by a physician or qualified practitioner. The facility failed to provide meals as prescribed, serving high sodium meals despite a resident's prescribed low sodium diet.
Report Facts
Number of Residents Served: 47
Total Daily Staff: 49
Waking Staff: 37
Number of Current Hospice Residents: 4
Number of Hospice Residents in past year: 4
Number of Residents 60 Years or Older: 47
Number of Residents with a Mobility Need: 2
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