33 Reports
Inspection Report — Nov 6, 2025
Renewal
Date: Nov 6, 2025
Visit Reason
The inspection was conducted as a renewal inspection combined with a complaint investigation.
Complaint Details
The inspection included a complaint investigation as indicated by the inspection reason and findings related to incident reporting and resident record confidentiality.
Findings
The facility had multiple deficiencies including delayed incident reporting, unsecured resident records, unqualified direct care staff, incomplete annual training, unsecured resident equipment, improper trash storage, combustible storage hazards, overdue medical evaluations and assessments, incomplete menus, unauthorized medication self-administration, incomplete medication administration training, and outdated resident photographs. All deficiencies had plans of correction accepted and were implemented by late December 2025.
Citations (13)
2600.16c: The home failed to report incidents to the Department within 24 hours as required, including unwitnessed falls and hospital admissions.
2600.17: Resident records were not kept confidential; a medication cart computer was left unlocked and accessible.
2600.54a: Direct care staff persons H and I lacked a high school diploma, GED, or active nurse aide registry status.
2600.65f: Staff persons C, E, F, and G did not receive required annual training on care for residents with mental illness or intellectual disability.
2600.81b: Resident #4's bedside mobility device was not secured to the bed, allowing excessive movement.
2600.85e: Trash outside the home was kept in uncovered receptacles allowing access to insects, rodents, and wild animals.
2600.125a: Combustible materials were found on a running dryer, posing a fire hazard.
2600.141b1: Several residents had overdue annual medical evaluations.
2600.162c: Menus were not posted one week in advance as required.
2600.181e: Resident #4 had medication in the apartment without assessment for self-administration capability.
2600.190a: Staff persons A, B, C, and D had not completed required Department-approved medication administration courses before administering medications.
2600.225c: Resident #3 had an overdue additional assessment.
2600.252: Resident #6's photo on file was outdated beyond two years.
Report Facts
Residents Served: 68
Hospice Residents: 7
Residents 60 Years or Older: 68
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 15
Inspection Report — Sep 23, 2025
Complaint Investigation
Date: Sep 23, 2025
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 09/23/2025 and 09/30/2025.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 77
Current Hospice Residents: 5
Residents Age 60 or Older: 77
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 16
Inspection Report — Aug 15, 2024
Complaint Investigation
Date: Aug 15, 2024
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 08/15/2024.
Complaint Details
The inspection was complaint-driven; no deficiencies or citations were substantiated.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 99
Current Residents in Hospice: 4
Residents Age 60 or Older: 98
Residents with Mobility Need: 13
Residents with Physical Disability: 1
Inspection Report — Apr 30, 2024
Date: Apr 30, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility on 04/30/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 113
Current Hospice Residents: 2
Resident Support Staff: 0
Total Daily Staff: 126
Waking Staff: 95
Residents Age 60 or Older: 112
Residents with Mobility Need: 13
Residents with Physical Disability: 2
Inspection Report — Apr 18, 2024
Follow-Up
Date: Apr 18, 2024
Visit Reason
The inspection visit on 04/18/2024 was a partial, unannounced follow-up inspection triggered by an incident to verify the implementation of a submitted plan of correction.
Findings
The submitted plan of correction related to resident personal equipment (enabler bars) was found to be fully implemented as of the inspection date. The facility corrected issues with unsecured enabler bars and established ongoing audits and staff education to maintain compliance.
Citations (1)
Residents' enabler bars were observed to have approximately a 10 x 12 inch opening and were not covered at time of inspection. The enabler bar on a resident's bed was fastened loosely and gave over 6 inches of leeway with applied pressure.
Report Facts
Residents Served: 107
Total Daily Staff: 122
Waking Staff: 92
Residents with Mobility Need: 15
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Services Director | Named in plan of correction as responsible for covering and fastening enablers | |
| Maintenance Director | Named in plan of correction as responsible for covering and fastening enablers, conducting audits, and providing training | |
| Regional Maintenance Director | Named in plan of correction as providing education to facility leadership | |
| Regional Care Director | Named in plan of correction as providing education to facility leadership | |
| Executive Director | Named in plan of correction as receiving education and providing additional training |
Inspection Report — Feb 28, 2024
Follow-Up
Date: Feb 28, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 02/28/2024 to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to deficiencies in refrigerator/freezer temperature monitoring and medication labeling. Continued compliance is required.
Citations (2)
The thermometer in the ice cream chest showed a temperature of 4°F, exceeding the required 0°F for frozen food storage.
Insulin pens for several residents were stored in plastic bags without pharmacy labels attached.
Report Facts
Residents Served: 102
Total Daily Staff: 116
Waking Staff: 87
Residents with Mobility Need: 14
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Culinary Services | Named in plan of correction for refrigerator/freezer temperature compliance | |
| Resident Service Director | Named in plan of correction for medication labeling compliance | |
| Regional Care Director | Named in plan of correction for training related to medication controls and audits | |
| Executive Director | Named in plan of correction for training related to medication controls and audits |
Inspection Report — Jan 25, 2024
Complaint Investigation
Date: Jan 25, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Complaint Details
The inspection was complaint-related; however, no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 116
Total Daily Staff: 130
Waking Staff: 98
Residents Age 60 or Older: 115
Residents with Mobility Need: 14
Residents with Physical Disability: 2
Inspection Report — Dec 7, 2023
Renewal
Date: Dec 7, 2023
Visit Reason
The inspection was conducted as a renewal and incident review of the facility, including follow-up on previously submitted plans of correction.
Findings
The facility had multiple deficiencies including failure to post the current license inspection summary, insufficient direct care hours for residents with mobility needs, safety hazards such as non-anti-slip rugs, incomplete first aid kits, lack of accessible lighting in resident rooms, missing thermometers in refrigeration units, incomplete or missing medical evaluations and documentation for residents, expired medications, unlabeled medication containers, and incomplete resident records including missing photographs.
Citations (14)
The home did not have the License Inspection Summary dated 10/22/22 posted in the home in a conspicuous manner as required.
Insufficient direct care hours provided to immobile residents on 11/18/23 and 11/19/23.
Less than 75% of personal care service hours were available during waking hours on 11/18/23 and 11/19/23.
Room 220 had a rug in the bathroom that was not anti-slip, posing a fall hazard.
First aid kits at the reception desk and kitchen were missing protective eye wear and a thermometer.
Room 201 did not have an accessible light source that can be reached from the bedside.
The ice cream chest freezer located in the home’s kitchen did not have a thermometer.
Documentation of Medical Evaluation (DME) forms for several residents were incomplete or missing required information such as cognitive functioning assessment, temperature, and immunization history.
Annual medical evaluations for some residents were not completed within the required timeframe.
Resident #2 had an expired medication in possession.
Resident #3’s prescription medication containers did not contain the initials of the staff person who opened them.
Resident #3’s medication record contained incorrect medication orders.
Resident #5’s support plan did not identify a reason for the use of a bed enabler.
Resident records for residents #8, #10, and #11 did not contain a current photograph.
Report Facts
Residents served: 113
Immobile residents: 13
Required direct care hours: 132
Verified direct care hours: 107
Verified direct care hours: 127.5
Required waking hours: 99
Verified waking hours: 88
Verified waking hours: 92.5
Inspection Report — May 16, 2023
Date: May 16, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident.
Findings
No regulatory citations or deficiencies were identified during the inspections conducted on 05/16/2023, 05/19/2023, and 05/24/2023.
Report Facts
Residents Served: 119
Current Residents in Hospice: 2
Residents Age 60 or Older: 118
Residents with Mobility Need: 10
Residents with Physical Disability: 1
Inspection Report — Feb 7, 2023
Plan of Correction
Date: Feb 7, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident.
Findings
The facility was found to have not completed an annual medical evaluation for Resident #1 for the year 2022. A plan of correction was submitted and determined to be fully implemented as of 02/07/2023.
Citations (1)
Resident #1’s most recent annual medical evaluation was not completed for 2022.
Report Facts
Residents served: 124
Resident with physical disability: 2
Resident with mobility need: 15
Resident age 60 or older: 123
Hospice current residents: 1
Inspection Report — Dec 21, 2022
Follow-Up
Date: Dec 21, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 12/21/2022 to review the submitted plan of correction for the facility.
Findings
The facility had repeat violations related to insufficient direct care staffing hours, including failure to meet required direct care hours per resident and mobility needs, inadequate staffing during waking hours, and insufficient first aid/CPR trained staff. The submitted plan of correction was accepted and determined to be fully implemented as of the follow-up date.
Citations (4)
Direct care staff persons were not available to provide at least 1 hour per day of personal care services to each mobile resident on 12/9/2022 and 12/10/2022.
Direct care staff persons were not available to provide at least 2 hours per day of personal care services to each resident with mobility needs on 12/9/2022, 12/10/2022, and 12/11/2022.
At least 75% of the personal care service hours specified in subsections (b) and (c) were not available during waking hours on 12/9/2022, 12/10/2022, and 12/11/2022.
At least one staff person for every 50 residents trained in first aid and certified in obstructed airway techniques and CPR was not present at all times on 12/9/2022 and 12/10/2022.
Report Facts
Residents Served: 129
Residents with Mobility Needs: 19
Direct Care Hours Required: 126
Direct Care Hours Staffed: 112
Direct Care Hours Required: 145
Direct Care Hours Staffed: 128
Daytime Direct Care Hours Required: 108.75
Daytime Direct Care Hours Staffed: 88
Daytime Direct Care Hours Staffed: 104
First Aid/CPR Certified Staff: 2
Inspection Report — Oct 18, 2022
Renewal
Date: Oct 18, 2022
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing regulations, including follow-up on a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies including staffing hours below required levels, failure to post current license inspection summary, uncovered trash receptacles, inadequate lighting, food storage violations, incomplete medical evaluations, medication labeling errors, delayed resident assessments and support plans, and obstructed egress routes. All deficiencies were addressed with plans of correction and were noted as repeat violations in some cases.
Citations (23)
The most current Licensing Inspection Summary was not posted at the time of inspection.
Direct care staff hours were below the required minimum for mobile residents on multiple days.
Direct care staff hours were below the required minimum for residents with mobility needs on multiple days.
Less than 75% of required personal care service hours were provided during waking hours on multiple days.
Insufficient number of staff trained in first aid and CPR present during shifts.
Trash receptacles in kitchens and bathrooms were uncovered, allowing penetration of insects and rodents.
Dumpster lids outside the home were left open, violating regulations.
No lighting found outside the exit on the 1st floor leading to the gazebo area.
Food was stored on the floor in the walk-in refrigerator, freezer, and dry storage areas.
A dented can of food was observed in the kitchen storage area.
Lint was observed on the lint screen of the dryer in the main laundry room.
A wheelchair was blocking an exit door leading to the outside patio.
Notification letter to the local fire department contained inaccurate immobile resident list.
Fire drill record indicated not all residents evacuated; no reason given for missing residents.
Medical evaluation for Resident 2 was incomplete; body positioning section left blank.
Annual medical evaluations for Residents 3, 4, and 5 were outdated or missing dates.
Medication cart had a bottle with a pharmacy label that was spilled and illegible.
Blood sugar levels for Resident 7 were inaccurately documented in the MAR.
Medication record for Resident 8 incorrectly indicated dosage.
Initial assessments for Residents 9 and 10 were completed late beyond 15 days of admission.
Support plans for Residents 9 and 10 were completed late beyond 30 days of admission.
Resident support plans for Residents 1 and 10 did not indicate use of bed rails as required.
Resident 9's record did not indicate identifying marks as required.
Report Facts
Residents served: 113
Direct care hours required: 112
Direct care hours staffed: 109.86
Direct care hours required: 136
Direct care hours staffed: 115.02
Direct care hours during waking hours required: 102
Direct care hours during waking hours staffed: 91.71
Residents with mobility needs: 25
First aid/CPR trained staff: 2
Residents in fire drill: 115
Residents evacuated in fire drill: 111
Inspection Report — Apr 25, 2022
Routine
Date: Apr 25, 2022
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 — Aug 24, 2021
Renewal
Date: Aug 24, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the ATRIA BETHLEHEM facility to assess compliance with state regulations and licensing requirements.
Findings
The inspection identified multiple deficiencies related to incident reporting, staffing levels, staff training, sanitary conditions, food storage, unobstructed egress, medical evaluations, smoking area safety, medication storage, preadmission screening, and support plan documentation. Plans of correction were accepted for most deficiencies with evidence of implemented corrective actions and ongoing monitoring.
Citations (15)
Incident report for resident fall was not submitted within required 24 hours.
Resident family did not receive an accurate refund after resident death and move-out.
Insufficient direct care staff scheduled to provide minimum required personal care hours on multiple dates.
Insufficient staff with first aid and CPR certification present for census size on multiple shifts.
Administrator did not complete required competency-based training test prior to employment.
Glucometer was contaminated with dried blood and used on multiple residents without cleaning.
Food items stored uncovered or unsealed in kitchen and pantry areas.
Exit door required heavy force to open due to obstruction at bottom of door.
Medical evaluation form missing resident height and weight information.
Cigarette butts found in mulch and asphalt areas near staff smoking area, posing fire hazard.
Blood glucose reading inaccurately documented on medication administration record; loose pills found in medication cart.
Missing preadmission screening form for resident admitted to facility.
Support plan for resident completed late, beyond 30 days of admission.
Resident support plan did not document need for bed enabler bar.
Support plan not signed by assessor or resident.
Report Facts
Inspection dates: 3
Residents served: 62
Direct care hours required: 89
Direct care hours provided: 82
Direct care hours provided: 86.5
Direct care hours provided: 68.5
Residents with mobility needs: 27
Residents with physical disability: 1
Refund amount: 6245
Staffing hours: 89
Waking staff hours: 67
Residents on hospice: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Named in deficiency for not completing required competency-based training test |
| Resident Services Director | Named in multiple findings related to incident reporting, staffing, training, and compliance monitoring | |
| Executive Director | Executive Director | Named in multiple findings related to training, compliance monitoring, and corrective actions |
Inspection Report — Jun 14, 2021
Renewal
Date: Jun 14, 2021
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 — Jun 1, 2021
Renewal
Date: Jun 1, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing for the facility Atria Bethlehem.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — Sep 9, 2020
Date: Sep 9, 2020
Visit Reason
This document serves as a certificate of compliance and notification of license renewal for the Personal Care Home 'Atria Bethlehem'. It informs the facility that an annual 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 issuance of a regular license following the renewal application and outlines the Department's requirement to conduct an annual inspection.
Report Facts
Inspection Report — Apr 24, 2020
Renewal
Date: Apr 24, 2020
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing for the facility Atria Bethlehem.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Mar 25, 2020
Complaint Investigation
Date: Mar 25, 2020
Visit Reason
The inspection was conducted as a complaint investigation to review compliance at Atria Bethlehem.
Complaint Details
The inspection was complaint-driven. The deficiency involved missing medical evaluation data for a resident. The submitted plan of correction was approved and fully implemented.
Findings
The submitted plan of correction was found to be fully implemented following the review. The deficiency involved missing medical evaluation documentation for a resident.
Citations (1)
The documentation of medical evaluation form dated 11/12/2019 for resident #1 was missing weight, pulse, blood pressure, and temperature information.
Report Facts
Residents Served: 72
Current Hospice Residents: 4
Residents with Mobility Need: 30
Residents Age 60 or Older: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Caruso | Executive Director | Named in plan of correction signature and related to the medical evaluation deficiency |
Inspection Report — Jul 16, 2019
Renewal
Date: Jul 16, 2019
Visit Reason
The inspection was an unannounced renewal inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Violations of 55 Pa. Code Chapter 2600 were found during the inspection. The facility submitted plans of correction addressing issues such as lack of bedside lighting, uncovered food in the kitchen refrigerator, and incomplete resident records.
Citations (3)
Resident bedroom #345 did not have bedside lighting available for resident use. A lighting source was immediately added to correct this finding.
A large container of garden salad in the kitchen refrigerator was not covered or sealed. The lid was reattached immediately to seal the container.
Resident records for Residents #1, #2, and #3 did not indicate if the residents had any identifiable marks. Records were updated accurately immediately.
Report Facts
Residents Served: 69
Current Hospice Residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ann O'Haire | Department Representative | On-site inspector during the inspection visit. |
| Jason Harvey | Department Representative | On-site inspector during the inspection visit. |
| Kevin Caruso | Contact person listed in the report. | |
| Kevin Caruso | Executive Director | Signed the plans of correction. |
Notice — Jun 28, 2019
Date: Jun 28, 2019
Visit Reason
The document serves as a renewal approval for the Personal Care Home license for Atria Bethlehem and notifies that an onsite inspection will be conducted within the next twelve months as required by state code.
Findings
No inspection findings are reported in this document. It confirms receipt of the renewal application and issuance of the license.
Inspection Report — Oct 30, 2018
Date: Oct 30, 2018
Visit Reason
The inspection was a partial, unannounced visit triggered by an incident at the personal care home.
Findings
The inspection identified citations related to compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes. The facility submitted a Plan of Correction addressing issues such as staff training, incident reporting, and resident care documentation.
Citations (6)
Staff person B performed unsupervised direct care without completing the required initial trainings under the regulation.
Staff member A was suspended immediately pending investigation of an abuse allegation, and was retrained on resident rights and sensitivity before returning to work.
The home failed to submit a final incident report for an incident involving Resident #3 from 11-28-17 until 10-30-18.
Resident #4 had expired DME and was not assessed for self-administering medications; audits and retraining were conducted to ensure compliance.
Resident #5 was admitted and moved out without a completed pre-admission screening; audits and retraining were completed to ensure compliance.
Resident #5's charts were audited to ensure photos were taken upon admission and uploaded to electronic records; staff were retrained accordingly.
Report Facts
Number of Residents Served: 90
Number of Current Hospice Residents: 4
Number of Residents with Mobility Need: 22
Number of Residents 60 Years or Older: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Caruso | Administrator | Named as the facility administrator responsible for compliance and Plan of Correction approval. |
Notice — Sep 27, 2018
Date: Sep 27, 2018
Visit Reason
The document responds to a waiver request for qualifications of direct care staff persons under 55 Pa.Code § 2600.54(a)(2) for Atria Bethlehem.
Findings
The Department determined that a waiver is not needed as the educational credits obtained meet the requirements. The Department recommends keeping documentation in personnel files.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Licensing Manager | Signed the waiver response letter. |
Inspection Report — Sep 11, 2018
Complaint Investigation
Date: Sep 11, 2018
Visit Reason
The inspection was conducted as a complaint investigation with unannounced visits on September 11 and 18, 2018, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
The visit was complaint-related, triggered by medication administration errors. The report does not explicitly state substantiation status.
Findings
The inspection found multiple medication administration errors including failure to notify the Department within 24 hours of medication errors, improper documentation on medication administration records, and failure to follow prescriber directions. The facility submitted plans of correction and retraining to address these issues.
Citations (3)
55 Pa.Code §2600.16(c) - The home failed to notify the Department within 24 hours of medication errors involving residents not receiving proper insulin coverage and missed narcotic doses.
55 Pa.Code §2600.187(a) - Staff did not properly sign or initial medication administration records for a resident, including incorrect documentation of eye drop administration.
55 Pa.Code §2600.187(d) - Staff altered a resident's insulin order time resulting in missed doses for three days, and the home failed to follow prescriber directions properly.
Report Facts
Staff Count: 98
Walking Staff: 74
Current Hospice Residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Harvey | Inspector | Named as the Department representative conducting the inspection on September 11 and 18, 2018. |
| Kevin Caruso | Administrator | Facility administrator mentioned in the report and responsible for conducting audits and retraining. |
Inspection Report — Jul 17, 2018
Renewal
Date: Jul 17, 2018
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 Chapter 2600 for the personal care home Atria Bethlehem.
Findings
The inspection found multiple violations related to resident privacy, direct care staff hours, staff training, fire safety notification, medication administration, and documentation. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (11)
55 Pa.Code §2600.17 - Resident records were not kept confidential as the License Inspection Summary contained resident privacy coding exposing confidential information.
55 Pa.Code §2600.57(b) - The home provided 92 hours of direct care services on 7/14/2018, less than the required 100 hours.
55 Pa.Code §2600.65(f) - Annual training for direct care staff in 2017 did not include infection control.
55 Pa.Code §2600.65(g) - Annual training for ancillary staff in 2017 did not include Resident Rights or the Older Adult Protective Services Act.
55 Pa.Code §2600.124 - The home's notification to the local fire department was incomplete, lacking total capacity and general layout description.
55 Pa.Code §2600.182(b) - Staff scheduled during the 11pm to 7am shift on 7/14/2018 lacked required medication administration training and no licensed nurse was scheduled.
55 Pa.Code §2600.182(c) - Medication Administration Record (MAR) was not initialed by staff administering medications on specified dates and times.
55 Pa.Code §2600.183(d) - An Advair Disk was not labeled with the date it was opened, contrary to manufacturer instructions.
55 Pa.Code §2600.185(a) - Resident #3's blood glucose monitoring documentation was inconsistent; readings did not match the MAR.
55 Pa.Code §2600.187(a) - Resident #1's medication order for Lumigan Drops was labeled incorrectly as .01% instead of .03%.
55 Pa.Code §2600.187(d) - Resident #3's insulin administration did not follow the prescriber's directions, with incorrect units given on multiple dates.
Report Facts
Number of Residents Served: 75
Direct Care Hours Provided: 92
Number of Residents with Mental Illness: 2
Number of Residents with Mobility Need: 25
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Caruso | Executive Director | Named as Legal Entity Representative signing plans of correction and involved in corrective actions. |
Notice — Jul 2, 2018
Date: Jul 2, 2018
Visit Reason
The document serves as a renewal notice and license issuance for the Personal Care Home facility Atria Bethlehem following receipt of the renewal application.
Findings
No inspection findings are reported in this document. It confirms the license issuance and states that an onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Inspection Report — Jan 26, 2018
Complaint Investigation
Date: Jan 26, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident at the facility.
Complaint Details
The visit was complaint-related due to an incident. The report does not explicitly state substantiation status.
Findings
Multiple violations related to sanitary conditions, medication administration, and safe storage and handling of medical equipment were found. The facility submitted a plan of correction and was partially implementing corrective actions at the time of the report.
Citations (4)
55 Pa.Code §2600.85(a) - Sanitary conditions were not maintained as Resident #1's finger pen was used on Resident #2's finger and Resident #3's glucometer had dried blood on the machine.
55 Pa.Code §2600.185(a) - The home failed to develop and implement procedures for safe storage, access, security, distribution, and use of medications and medical equipment by trained staff.
55 Pa.Code §2600.187(a) - Medication records lacked required details; Resident #1 received insulin per a sliding scale but MAR did not include units given per scale on specified dates.
55 Pa.Code §2600.187(d) - The home did not follow prescriber directions; Resident #1 received incorrect sliding scale insulin doses on multiple dates.
Report Facts
Number of Residents Served: 108
Total Daily Staff: 123
Waking Staff: 92
Number of Hospice Residents in Past Year: 3
Number of Residents Age 60 or Older: 108
Number of Residents with Mobility Need: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Caruso | Executive Director | Named as Legal Entity Representative signing plans of correction and involved in findings. |
| Ryan Novak | Department Representative on-site during inspection. |
Inspection Report — Jul 27, 2017
Renewal
Date: Jul 27, 2017
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the Atria Bethlehem Personal Care Home.
Complaint Details
The inspection included a complaint investigation as indicated by the reason for inspection and findings related to medication administration, sanitary conditions, and emergency preparedness.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including issues with contract signing, staff training, sanitary conditions, emergency egress, medical evaluations, medication storage, and documentation of blood glucose monitoring. Plans of correction were submitted for each violation.
Citations (14)
55 Pa.Code §2600.25(b) - Resident contracts were not signed by residents upon admission as required.
55 Pa.Code §2600.65(f) - Annual training for direct care staff did not include all mandatory topics such as medication self-administration and care for residents with dementia.
55 Pa.Code §2600.85(a) - Glucometers used by residents had dried blood on the machines, indicating unsanitary conditions.
55 Pa.Code §2600.121(a) - An event stand blocked an emergency egress route, preventing immediate exit in case of emergency.
55 Pa.Code §2600.124 - The home failed to notify the local fire department in writing of the address and assistance needs for residents requiring help in emergencies.
55 Pa.Code §2600.133(a)(1) - Exit signs were missing at required locations in stairwells for homes serving nine or more residents.
55 Pa.Code §2600.141(a)(2) - Medical evaluations for several residents lacked required information including height, temperature, immunization history, and ability to self-administer medications.
55 Pa.Code §2600.141(b)(1) - Residents did not have current annual medical evaluations as required.
55 Pa.Code §2600.181(d) - Medications were not properly secured in resident rooms; one resident self-administered medications without locking the door.
55 Pa.Code §2600.183(d) - Several residents had expired medications in their medication carts.
55 Pa.Code §2600.185(a) - Glucometers were not calibrated to the correct date for some residents.
55 Pa.Code §2600.187(a) - Medication records lacked required information such as administration times and staff initials for residents receiving medications.
55 Pa.Code §2600.187(d) - The home failed to follow prescriber directions for blood glucose monitoring and insulin administration for several residents.
55 Pa.Code §2600.224(a) - Pre-admission screening forms were incomplete for several residents, lacking documentation of personal care and medical needs.
Report Facts
Number of Residents Served: 116
Number of Residents 60 Years or Older: 116
Number of Residents with Mental Illness: 1
Number of Residents with Mobility Need: 8
Number of Current Hospice Residents: 0
Number of Hospice Residents in Past Year: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arielle Allen | Executive Director | Named as the legal entity representative and involved in plans of correction. |
| Cindy Yellenic | Department representative conducting the inspection. | |
| Ryan Novak | Department representative conducting the inspection. |
Notice — Jul 7, 2017
Date: Jul 7, 2017
Visit Reason
The document serves as a renewal approval for the Personal Care Home license for Atria Bethlehem and notifies the facility of the requirement for an annual onsite inspection within the next twelve months.
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 — Jan 15, 2017
Complaint Investigation
Date: Jan 15, 2017
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving suspected abuse at the facility.
Complaint Details
The complaint investigation was substantiated as the facility did not timely report suspected abuse following an incident on 11/4/16 involving Resident #1 pushing Resident #2, resulting in a fall.
Findings
The facility failed to immediately report suspected abuse of a resident as required by regulation. A resident pushed another resident causing a fall, and the home did not send the required report to the local area agency on aging until several weeks later.
Citations (1)
55 Pa.Code §2600.15(a) requires immediate reporting of suspected abuse. The home failed to send the Act 13 report to the local area agency on aging until 11/16/16, weeks after the incident on 11/4/16.
Report Facts
Number of Residents Served: 108
Total Daily Staff: 112
Waking Staff: 84
Number of Current Hospice Residents: 1
Number of Hospice Residents in past year: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ariel Allen | Administrator | Named as facility administrator on violation report |
| John Maylor | Head of Services at Northampton AAA | Involved in training and follow-up related to incident reporting |
Inspection Report — Jul 20, 2016
Renewal
Date: Jul 20, 2016
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services for Atria Bethlehem Personal Care Home.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found related to staff training, food storage, fire safety, medication management, and resident support plans. Plans of correction were submitted with partial implementation and ongoing monitoring.
Citations (13)
55 Pa.Code 2600.65(f) - Direct care staff did not receive annual training on meeting residents' needs as described in preadmission screening, assessment, medical evaluation, and support plan during 2015.
55 Pa.Code 2600.65(g) - Direct care staff and ancillary personnel did not receive annual training in resident rights and the Older Adult Protective Services Act during 2015.
55 Pa.Code 2600.65(i) - Training records for staff did not include date, source, content, length of each course, or copies of certificates for 2015.
55 Pa.Code 2600.103(g) - Food items in the main kitchen were not stored in closed or sealed containers.
55 Pa.Code 2600.103(h) - Frozen salmon was thawing improperly at room temperature, posing a risk of bacterial growth.
55 Pa.Code 2600.103(i) - Food items were not stored in original packaging and were unlabeled or undated in the kitchen walk-in refrigerator and freezer.
55 Pa.Code 2600.132(d) - Fire drill exceeded maximum evacuation time of 13 minutes; one resident refused to evacuate during drill on 3/13/16.
55 Pa.Code 2600.132(b) - During fire drill on 3/13/16, 78 residents were present but only 77 evacuated.
55 Pa.Code 2600.183(b) - Prescription medications and syringes were not kept in locked areas; unlocked medications were accessible in resident rooms.
55 Pa.Code 2600.183(d) - Resident medication was not dated or labeled properly, and expired medication could not be determined.
55 Pa.Code 2600.184(a) - Prescription medication labels lacked required pharmacy label information including resident name, medication name, prescription date, dosage instructions, and prescriber name.
55 Pa.Code 2600.185(a) - Procedures for safe storage, access, security, distribution, and use of medications and medical equipment were not implemented by trained staff.
55 Pa.Code 2600.227(g) - Residents did not participate in the development of their support plans or sign the plans within required timeframes.
Report Facts
Number of Residents Served: 79
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 6
Number of Residents 60 Years or Older: 79
Number of Residents with Mental Illness: 3
Number of Residents with Mobility Need: 4
Number of Residents Present During Fire Drill: 78
Number of Residents Evacuated During Fire Drill: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arielle Allen | Executive Director | Named as facility administrator and signer of plans of correction. |
| Jesse Hummel | Department Representative | Inspector conducting the inspection. |
| Ryan Novak | Department Representative | Inspector conducting the inspection. |
Inspection Report — Jul 1, 2016
Renewal
Date: Jul 1, 2016
Visit Reason
The document is a renewal license issued in response to the June 30, 2016 renewal application to operate the Personal Care Home 'Atria Bethlehem'. The Department advises that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It is a license renewal certificate and accompanying letter confirming the renewal and outlining future inspection requirements.
Report Facts
Notice — August 31, 2021
Date: August 31, 2021
Visit Reason
The document serves as a certificate of compliance and a license renewal notification for the Personal Care Home 'Atria Bethlehem'. 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 an administrative notice confirming license renewal and outlining the requirement for a future annual inspection.
Report Facts
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