Inspection Report
Complaint Investigation
Census: 77
Capacity: 150
Deficiencies: 0
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.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 150
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
Complaint Investigation
Census: 99
Capacity: 150
Deficiencies: 0
Aug 15, 2024
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 08/15/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-driven; no deficiencies or citations were substantiated.
Report Facts
License Capacity: 150
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
Census: 113
Capacity: 150
Deficiencies: 0
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
License Capacity: 150
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
Follow-Up
Census: 107
Capacity: 150
Deficiencies: 1
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.
Deficiencies (1)
| Description |
|---|
| 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
License Capacity: 150
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
Follow-Up
Census: 102
Capacity: 150
Deficiencies: 2
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 150
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
Complaint Investigation
Census: 116
Capacity: 150
Deficiencies: 0
Jan 25, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related; however, no deficiencies were found and no follow-up was required.
Report Facts
License Capacity: 150
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
Renewal
Census: 119
Capacity: 150
Deficiencies: 14
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.
Deficiencies (14)
| Description |
|---|
| 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
License capacity: 150
Census: 119
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
Census: 119
Capacity: 150
Deficiencies: 0
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
License Capacity: 150
Current Residents in Hospice: 2
Residents Age 60 or Older: 118
Residents with Mobility Need: 10
Residents with Physical Disability: 1
Inspection Report
Plan of Correction
Census: 124
Capacity: 150
Deficiencies: 1
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.
Deficiencies (1)
| Description |
|---|
| Resident #1’s most recent annual medical evaluation was not completed for 2022. |
Report Facts
Residents served: 124
License capacity: 150
Resident with physical disability: 2
Resident with mobility need: 15
Resident age 60 or older: 123
Hospice current residents: 1
Inspection Report
Follow-Up
Census: 129
Capacity: 150
Deficiencies: 4
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.
Deficiencies (4)
| Description |
|---|
| 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
License Capacity: 150
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
Renewal
Census: 113
Capacity: 150
Deficiencies: 23
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.
Deficiencies (23)
| Description |
|---|
| 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
License capacity: 150
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
Routine
Deficiencies: 0
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
Renewal
Census: 62
Capacity: 150
Deficiencies: 15
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.
Deficiencies (15)
| Description |
|---|
| 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
License capacity: 150
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
Renewal
Deficiencies: 0
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
Renewal
Deficiencies: 0
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
Capacity: 150
Deficiencies: 0
Aug 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
Maximum licensed capacity: 150
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