Inspection Reports for Bethlehem Manor
815 Pennsylvania Ave, Bethlehem, PA 18018, United States, PA, 18018
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
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Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 27
Capacity: 75
Deficiencies: 4
Jun 24, 2025
Visit Reason
The visit was a partial, unannounced follow-up inspection to review the submitted plan of correction for the facility.
Findings
The inspection found that the submitted plan of correction was fully implemented. Deficiencies related to access to records, peeling paint, refrigerator temperature, and menu posting were corrected with ongoing monitoring plans in place.
Deficiencies (4)
| Description |
|---|
| Delayed access to staff and resident records, schedules, and Medication Administration Records; access was not immediate as required. |
| Peeling paint on the windowsill in the Memory Care activity unit, with multiple sections already peeled off. |
| Refrigerator temperature in the Memory Care Unit was above required 40°F, measured at 45°F and 43°F during inspection. |
| Menus for the following week were not posted as required. |
Report Facts
License Capacity: 75
Residents Served: 27
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 12
Current Hospice Residents: 6
Residents Age 60 or Older: 27
Residents with Mobility Need: 23
Residents with Physical Disability: 1
Total Daily Staff: 50
Waking Staff: 38
Inspection Report
Renewal
Census: 40
Capacity: 75
Deficiencies: 16
May 1, 2025
Visit Reason
The inspection was conducted as a renewal visit combined with a complaint investigation to review compliance and address allegations of resident abuse.
Findings
The inspection found multiple deficiencies including failure to report and investigate alleged resident abuse, inadequate staffing on third shift for safe evacuation, incomplete administrator training hours, sanitary and safety violations such as infestation, broken windows/screens, malfunctioning equipment, improper food handling, insufficient emergency water supply, smoking area hazards, medication documentation errors, and incomplete preadmission screening documentation. Plans of correction were accepted and implemented.
Complaint Details
The complaint involved alleged abuse of resident #1 by staff person A. The home failed to report, investigate, and resolve the complaint timely and adequately. The complaint was substantiated by the deficiencies noted.
Deficiencies (16)
| Description |
|---|
| Failure to immediately report suspected abuse of resident #1 and notify the Area Agency on Aging. |
| Failure to submit an incident report to the Department regarding an allegation of abuse involving staff person A and resident #1. |
| Failure to investigate and resolve a complaint regarding resident abuse with staff person A. |
| Failure to provide a status report to the complainant within 2 business days after complaint submission. |
| Inadequate staffing on 3rd shift to safely evacuate all residents during emergencies on multiple dates. |
| Administrator completed only 20 of the required 24 hours of annual training during the 2024 training year. |
| Sanitary violation: 4 fl oz spillage of chocolate ice cream found inside freezer in dining room. |
| Evidence of infestation: dead bugs and spiders observed on window sills in dining area. |
| Windows in 2nd floor common room were open with tears and bent frames in window screens. |
| Handicap elevator not functioning; exposed wires and battery at handicap door accessibility button; exposed wires in electric box for exit sign. |
| Use of a common towel found in shared bathroom without labeling; no paper towels in another shared bathroom. |
| Unlabeled leftover food (jar of salsa) found in refrigerator. |
| Insufficient emergency water supply: only 18 gallons on hand for 40 residents. |
| Cigarette butts found in multiple outdoor areas near building entrance. |
| Medication documentation errors: blood glucose readings inaccurately recorded; missed medication administration and blood sugar testing for residents #4 and #5. |
| Incomplete preadmission screening form lacking documentation if resident #3 can safely use and avoid poisonous materials. |
Report Facts
License Capacity: 75
Residents Served: 40
Residents in Secure Dementia Unit: 11
Residents with Mobility Need: 25
Residents with Physical Disability: 1
Staffing Hours: 65
Waking Staff: 49
Dates with Inadequate 3rd Shift Staffing: 5
Administrator Training Hours Completed: 20
Emergency Water Supply (gallons): 18
Emergency Water Supply After Correction (gallons): 45
Blood Glucose Reading Resident #4: 108
Blood Glucose Reading Documented Resident #4: 147
Blood Glucose Reading Resident #4: 224
Blood Glucose Reading Documented Resident #4: 109
Inspection Report
Complaint Investigation
Census: 39
Capacity: 75
Deficiencies: 0
Apr 8, 2025
Visit Reason
The inspection was conducted as a result of an incident, with an unannounced partial inspection type.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Complaint Details
The visit was incident-related and no deficiencies were found, indicating no substantiated complaints.
Report Facts
License Capacity: 75
Residents Served: 39
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 14
Resident Support Staff: 0
Total Daily Staff: 65
Waking Staff: 49
Residents Age 60 or Older: 39
Residents with Mobility Need: 26
Residents with Physical Disability: 1
Inspection Report
Follow-Up
Census: 34
Capacity: 75
Deficiencies: 4
Mar 19, 2025
Visit Reason
The visit was conducted as a follow-up to verify the submitted plan of correction for previous deficiencies at Bethlehem Manor.
Findings
The submitted plan of correction was determined to be fully implemented. The facility demonstrated compliance with requirements related to access to records, annual medical evaluations, medical evaluations for secured dementia care unit residents, and support plan revisions.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and was an unannounced partial inspection.
Deficiencies (4)
| Description |
|---|
| Administrator or designee did not provide immediate access to resident records; resident's support plan was locked and inaccessible at time of request. |
| Resident's medical evaluation was not completed within the required annual timeframe. |
| Resident's medical evaluation did not indicate the need for secured dementia care as required. |
| Resident Assessment Support Plan was not revised annually as required. |
Report Facts
License Capacity: 75
Residents Served: 34
Secured Dementia Care Unit Capacity: 36
Residents Served in Secured Dementia Care Unit: 11
Resident Support Staff: 0
Total Daily Staff: 51
Waking Staff: 38
Residents Age 60 or Older: 34
Residents with Mobility Need: 17
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 39
Capacity: 75
Deficiencies: 0
Dec 4, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Bethlehem Manor.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found.
Report Facts
License Capacity: 75
Residents Served: 39
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 15
Current Hospice Residents: 14
Inspection Report
Complaint Investigation
Census: 42
Capacity: 75
Deficiencies: 5
Feb 8, 2024
Visit Reason
The inspection was a complaint investigation conducted as an unannounced partial review on 02/08/2024 to assess compliance with regulations following a complaint.
Findings
The inspection found multiple deficiencies related to resident personal equipment safety, failure to follow prescriber's orders, missing annual assessments, incomplete support plan revisions, and lack of accessibility of support plans to direct care staff. Plans of correction were submitted and fully implemented by 04/05/2024.
Complaint Details
The visit was complaint-related, triggered by a complaint, with an exit conference held on 02/08/2024. The submitted plan of correction was fully implemented.
Deficiencies (5)
| Description |
|---|
| The enabler bar attached to a resident bed was not properly secured, creating a hazard. |
| Resident medication administration record lacked documentation of monthly weight for January 2024. |
| Resident did not have documentation that an annual support plan was completed in 2023. |
| Resident's support plan was not updated to reflect hospital treatments for crusted scabies. |
| Direct care staff did not have access to resident files, specifically the Resident Assessment Support Plan (RASP). |
Report Facts
License Capacity: 75
Residents Served: 42
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 15
Total Daily Staff: 76
Waking Staff: 57
Residents with Mobility Need: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christina | Nursing Supervisor | Named in medication administration and support plan findings |
| Chrissie | RASP Coordinator | Named in additional assessment and support plan findings |
Inspection Report
Census: 40
Capacity: 75
Deficiencies: 0
Jan 25, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident, with an exit conference held on 2024-02-02.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 72
Waking Staff: 54
Residents Served: 40
License Capacity: 75
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 15
Residents Age 60 or Older: 40
Residents with Mobility Need: 32
Inspection Report
Complaint Investigation
Census: 42
Capacity: 75
Deficiencies: 0
Sep 14, 2023
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related and the follow-up type was not required, indicating no substantiated deficiencies.
Report Facts
License Capacity: 75
Residents Served: 42
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 16
Current Residents in Hospice: 17
Residents Age 60 or Older: 42
Residents with Mobility Need: 38
Total Daily Staff: 80
Waking Staff: 60
Inspection Report
Complaint Investigation
Census: 42
Capacity: 75
Deficiencies: 2
Sep 7, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
Two deficiencies were identified: food was found stored in the kitchen refrigerator without being sealed, and residents reported that menu changes were often made without prior notice. Immediate corrective actions were taken and plans of correction were submitted and implemented.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The complaint involved issues with food storage and menu change notifications. The submitted plan of correction was fully implemented as of the inspection date.
Deficiencies (2)
| Description |
|---|
| A package of ham lunch meat, cheese and a bagged salad was located in the refrigerator in the kitchen without being sealed. |
| Resident interviews indicated that the menu will often change without any notice, and residents do not know about the changes until the meal is served. |
Report Facts
License Capacity: 75
Residents Served: 42
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 17
Residents 60 Years or Older: 42
Residents with Mobility Need: 38
Total Daily Staff: 80
Waking Staff: 60
Inspection Report
Complaint Investigation
Census: 53
Capacity: 75
Deficiencies: 0
Aug 4, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial licensing inspection.
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 substantiated issues were found.
Report Facts
License Capacity: 75
Residents Served: 53
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 16
Total Daily Staff: 89
Waking Staff: 67
Residents 60 Years or Older: 51
Residents with Mobility Need: 36
Inspection Report
Routine
Deficiencies: 0
Mar 10, 2022
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the inspection report letter. |
Inspection Report
Renewal
Census: 57
Capacity: 75
Deficiencies: 6
Mar 1, 2022
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements at Bethlehem Manor.
Findings
The inspection identified several deficiencies related to resident record confidentiality, resident personal equipment, trash management, medication administration, medication security, and key-locking devices. All deficiencies were corrected at the time of inspection or addressed through plans of correction and training.
Deficiencies (6)
| Description |
|---|
| Medication carts were found unlocked and unattended with resident information visible, violating resident record confidentiality. |
| Resident room #112 had an enabler bar without a cover. |
| Exterior trash dumpster lid was propped open allowing insect and rodent infestation. |
| Medications were prepared in advance and not administered one resident at a time. |
| Medication carts were found unlocked and unattended in the dining room, allowing access to residents' medications. |
| Secured unit stairwell did not have directions posted near the locking mechanism device. |
Report Facts
License Capacity: 75
Residents Served: 57
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 16
Hospice Residents: 15
Residents with Mobility Need: 26
Residents with Physical Disability: 1
Total Daily Staff: 83
Waking Staff: 62
Inspection Report
Follow-Up
Census: 43
Capacity: 75
Deficiencies: 1
Oct 14, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 10/14/2021 to review the submitted plan of correction related to an incident at Bethlehem Manor.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. A deficiency was noted regarding the resident support plan not accurately reflecting a resident's transferring needs, which was corrected through staff training and administrative review.
Deficiencies (1)
| Description |
|---|
| The Resident Assessment and Support Plan for Resident 1 did not indicate the resident’s transferring needs accurately; it listed the resident as independent, but staff stated assistance was required. |
Report Facts
License Capacity: 75
Residents Served: 43
Current Residents in Hospice: 5
Residents with Mobility Need: 20
Total Daily Staff: 63
Waking Staff: 47
Inspection Report
Follow-Up
Census: 43
Capacity: 75
Deficiencies: 1
Oct 14, 2021
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
The submitted plan of correction was reviewed and determined to be fully implemented. A deficiency was noted regarding the resident support plan not accurately reflecting a resident's transferring needs, which was corrected through staff training and administrative review.
Deficiencies (1)
| Description |
|---|
| The Resident Assessment and Support Plan for Resident 1 did not indicate the resident’s transferring needs accurately; it listed the resident as independent, but staff stated assistance was required. |
Report Facts
License Capacity: 75
Residents Served: 43
Current Residents in Hospice: 5
Total Daily Staff: 63
Waking Staff: 47
Residents with Mobility Need: 20
Residents 60 Years or Older: 43
Inspection Report
Renewal
Deficiencies: 0
Aug 5, 2021
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing's licensing inspections of the facility.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Follow-Up
Census: 36
Capacity: 75
Deficiencies: 4
Mar 30, 2021
Visit Reason
The inspection was a full, unannounced review conducted on 03/30/2021 and 03/31/2021 to verify that the facility's submitted plan of correction was fully implemented.
Findings
The facility was found to have implemented the plan of correction fully. Deficiencies related to fire drill record keeping, fire drill scheduling, smoking area safety, and medication administration were addressed with corrective actions accepted and documented.
Deficiencies (4)
| Description |
|---|
| Fire drill record did not include the time taken to evacuate all residents to fire safe areas. |
| Fire drills were routinely held at the end of the month rather than on different days and times. |
| Extinguished cigarette butts were observed outside the designated smoking area near the front entrance walkway. |
| Medication Metoprolol was administered to a resident when it should have been held due to low heart rate as per physician's orders. |
Report Facts
License Capacity: 75
Residents Served: 36
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 0
Hospice Current Residents: 2
Fire Drill Dates Count: 10
Extinguished Cigarette Butts: 8
Medication Administration Incident: 1
Notice
Capacity: 75
Deficiencies: 0
May 7, 2021
Visit Reason
The document serves as a certificate of compliance and a renewal notice for Bethlehem Manor to operate as a Personal Care Home. 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 based on the renewal application and advises that future inspections will be conducted to ensure compliance.
Report Facts
Maximum licensed capacity: 75
Secure Dementia Care Unit capacity: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notice letter. |
| Nimita Kapoor-Atiyeh | President | Recipient of the renewal notice letter. |
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