Inspection Reports for Alexandria Manor of Allentown – Bethlehem Campus
3534 LINDEN STREET,, PA, 18017
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
12.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
172% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
79% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 46
Capacity: 58
Deficiencies: 0
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.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related as explicitly stated under Inspection Information with the reason noted as 'Complaint'.
Report Facts
License Capacity: 58
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
Renewal
Census: 38
Capacity: 58
Deficiencies: 14
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.
Deficiencies (14)
| Description |
|---|
| 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
License Capacity: 58
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
Complaint Investigation
Census: 40
Capacity: 58
Deficiencies: 8
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.
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.
Complaint Details
The inspection was complaint-driven, with substantiation implied by the findings of multiple violations related to resident care, privacy, and reporting requirements.
Deficiencies (8)
| Description |
|---|
| 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
License Capacity: 58
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
Follow-Up
Census: 44
Capacity: 58
Deficiencies: 2
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 58
Residents Served: 44
Current Hospice Residents: 3
Total Daily Staff: 47
Waking Staff: 35
Inspection Report
Renewal
Census: 46
Capacity: 58
Deficiencies: 14
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.
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.
Complaint Details
The inspection included complaint investigation components related to resident treatment and medication administration concerns.
Deficiencies (14)
| Description |
|---|
| 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
License Capacity: 58
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
Complaint Investigation
Census: 45
Capacity: 58
Deficiencies: 0
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.
Findings
No regulatory citations or deficiencies were identified as a result of the inspections conducted 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.
Report Facts
License Capacity: 58
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
Follow-Up
Census: 48
Capacity: 58
Deficiencies: 2
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.
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.
Complaint Details
The visit was incident-related, indicating a complaint or allegation triggered the inspection. The plan of correction was accepted and fully implemented.
Deficiencies (2)
| Description |
|---|
| 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
Licensed Capacity: 58
Residents Served: 48
Current Resident with Mental Illness: 3
Residents 60 Years or Older: 47
Residents with Mobility Need: 4
Inspection Report
Complaint Investigation
Census: 35
Capacity: 58
Deficiencies: 3
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.
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.
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.
Deficiencies (3)
| Description |
|---|
| 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
License Capacity: 58
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
Renewal
Census: 36
Capacity: 58
Deficiencies: 8
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.
Deficiencies (8)
| Description |
|---|
| 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
License Capacity: 58
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
Complaint Investigation
Census: 36
Capacity: 58
Deficiencies: 2
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.
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.
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 58
Residents Served: 36
Current Residents in Hospice: 3
Total Daily Staff: 39
Waking Staff: 29
Notice
Capacity: 58
Deficiencies: 0
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
Maximum licensed capacity: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 28
Capacity: 58
Deficiencies: 11
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.
Deficiencies (11)
| Description |
|---|
| 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
License Capacity: 58
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
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