Inspection Reports for
Country Meadows of Bethlehem V
4025 GREEN POND ROAD,, BETHLEHEM, PA, 18020
Back to Facility Profile35 Reports
Inspection Report — Jul 9, 2026
Complaint Investigation
Date: Jul 9, 2026
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced visit to the facility.
Complaint Details
The inspection was complaint-related as indicated by the reason 'Complaint'. No deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 63
Current Hospice Residents: 4
Resident Support Staff Hours: 76
Waking Staff Hours: 57
Residents Age 60 or Older: 63
Residents with Mobility Need: 13
Inspection Report — Oct 21, 2025
Renewal
Date: Oct 21, 2025
Visit Reason
The inspection was a renewal visit conducted to review compliance and verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have medication storage issues including unlabeled opened medications and improper storage of oxygen tanks. The submitted plan of correction was fully implemented and compliance was maintained.
Citations (2)
183e - Prescription medications and CAM were stored without dates of opening, violating manufacturer instructions for use within specified timeframes.
185a - Five oxygen tanks were stored directly on the floor in a resident room instead of in approved storage racks.
Report Facts
Residents Served: 73
Current Residents in Hospice: 6
Residents with Mobility Need: 15
Residents 60 Years or Older: 73
Residents with Physical Disability: 1
Staff Total Daily: 88
Waking Staff: 66
Inspection Report — Feb 13, 2025
Renewal
Date: Feb 13, 2025
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance with licensing requirements.
Findings
The facility was found to have several deficiencies related to fire safety drills, combustible storage, annual medical evaluations, and medication storage procedures. All deficiencies had plans of correction submitted and were determined to be fully implemented as of the follow-up date.
Citations (6)
A sock was found alongside the back of the dryer on the floor, violating combustible storage requirements.
The facility did not have an unannounced fire drill completed in August 2024.
Fire drill records were incomplete, missing critical details such as time of day, evacuation time, exit route, number of residents and staff participating, and alarm status.
The home failed to conduct a fire drill during sleeping hours within the required six-month timeframe.
Resident #1's annual medical evaluation was missing information about the ability to self-administer medications.
Medication count for Resident #2 was inaccurate due to failure to adjust the narcotics book after administration.
Report Facts
Total Daily Staff: 75
Waking Staff: 56
Residents Served: 61
Current Hospice Residents: 3
Residents 60 Years or Older: 61
Residents with Mobility Need: 14
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Associate Director of Nursing | Associate Director of Nursing | Responsible for monitoring ongoing procedure of counting narcotics by Medication Associates and Nurses. |
Inspection Report — Nov 19, 2024
Complaint Investigation
Date: Nov 19, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 11/19/2024.
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
Total Daily Staff: 78
Waking Staff: 59
Residents Served: 61
Current Residents - Hospice: 2
Residents Age 60 or Older: 61
Residents with Mobility Need: 17
Inspection Report — Sep 17, 2024
Date: Sep 17, 2024
Visit Reason
The inspection was conducted as a licensing inspection triggered by an incident, with an unannounced partial inspection type.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Staffing hours: 81
Waking staff hours: 61
Residents with mobility need: 19
Residents age 60 or older: 62
Residents with physical disability: 2
Residents with supplemental security income: 0
Residents diagnosed with mental illness: 0
Residents diagnosed with intellectual disability: 0
Hospice residents: 1
Inspection Report — Dec 12, 2023
Renewal
Date: Dec 12, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The submitted plan of correction related to discontinued medications was found to be fully implemented. Two bottles of unused medications were previously noted but were removed on the day of inspection, and staff training and audits were planned and/or completed to ensure ongoing compliance.
Citations (1)
Two bottles of unused medications, Memantine HCL 14mg and Levothyroxine 50mcg prescribed for Resident #1, were found in the medication cart and had not been discarded as required.
Report Facts
Residents Served: 59
Total Daily Staff: 75
Waking Staff: 56
Current Residents in Hospice: 1
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Notice — Oct 17, 2023
Date: Oct 17, 2023
Visit Reason
The document serves to grant a waiver for a direct care staff member at Bethlehem Community Building V-Pathways who received their high school education outside the United States, allowing them to meet qualification requirements.
Findings
The waiver is granted with conditions including documentation retention and annual review during inspections to ensure compliance. Failure to comply may result in waiver termination or licensing action.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Harman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Aug 16, 2023
Complaint Investigation
Date: Aug 16, 2023
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, 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: 83
Current Residents in Hospice: 6
Residents Age 60 or Older: 63
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 16
Inspection Report — Feb 15, 2023
Complaint Investigation
Date: Feb 15, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 02/15/2023.
Complaint Details
The inspection was triggered by a complaint and was an unannounced partial inspection.
Findings
Two deficiencies were identified: a resident's wheelchair was found very dirty with food crumbs and grime, and a resident's bedroom carpet had heavy black staining requiring cleaning or replacement. Both issues were corrected promptly with cleaning and scheduled audits to ensure ongoing compliance.
Citations (2)
Resident #1's wheelchair was very dirty with a buildup of food crumbs, dirt and grim along the seat and wheels.
Resident #1's bedroom carpet had heavy black staining and needed cleaning or replacement.
Report Facts
Residents Served: 83
Current Residents in Hospice: 5
Residents Age 60 or Older: 63
Residents with Mobility Need: 16
Total Daily Staff: 99
Waking Staff: 74
Inspection Report — Jan 6, 2023
Plan of Correction
Date: Jan 6, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with multiple review dates including on-site and off-site visits between 01/06/2023 and 02/03/2023.
Complaint Details
The visit was complaint-related and incident-based. The plan of correction was accepted and fully implemented, indicating compliance with corrective actions.
Findings
The report found that four residents experienced delays of more than half an hour on multiple occasions before staff responded to their call bells for assistance with activities of daily living. A plan of correction was submitted and fully implemented by 02/27/2023.
Citations (1)
Four residents indicate that it takes staff more than a half an hour on multiple occasions before a staff member responds to their call bell to assist them with their ADLs.
Report Facts
Residents served: 70
Current residents in hospice: 5
Residents with mobility need: 17
Residents age 60 or older: 79
Residents indicating delayed call bell response: 4
Staff total daily: 87
Staff waking: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Re-educated care staff on call bell timing and needs of residents as part of plan of correction |
Inspection Report — Sep 7, 2022
Renewal
Date: Sep 7, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, with an unannounced full inspection on 09/07/2022 and 09/08/2022.
Findings
The submitted plan of correction was found to be fully implemented. Deficiencies related to medication labeling, storage procedures, and following prescriber's orders were identified and corrected with education and process improvements.
Citations (3)
Resident #1's PRN albuterol HFA inhaler and Resident #2's PRN glucagon kit did not have a pharmacy label attached.
Resident #3's PRN Tylenol 325mg was not available at the time of the inspection.
Resident #4 had an order for digoxin .125mg tablet daily, hold for pulse rate less than 60. On 8/26/22 the pulse rate was 60, the medication was held and should have been administered.
Report Facts
Residents Served: 81
Current Hospice Residents: 5
Resident Mobility Need: 18
Resident Physical Disability: 6
Resident Age 60 or Older: 81
Inspection Report — May 23, 2022
Routine
Date: May 23, 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 — Mar 1, 2022
Routine
Date: Mar 1, 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 — Feb 10, 2022
Complaint Investigation
Date: Feb 10, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation following reports of resident abuse and medication errors.
Complaint Details
The complaint involved alleged abuse of resident #1 by staff person A, who reportedly threw the resident face down on the bed. The incident was not reported immediately as required. Additionally, medication errors involving resident #2 were investigated, including incorrect medication administration and improper medication storage.
Findings
The investigation found multiple violations including failure to immediately report suspected resident abuse, improper treatment of a resident, medication administration errors involving incorrect medications given to a resident, and improper medication storage with medications found in a resident's room without current prescriptions. Plans of correction were accepted and staff retraining was mandated.
Citations (5)
Failure to immediately report suspected abuse of resident #1 to the Area Agency on Aging and Department’s regional office.
Resident #1 was thrown face down on the bed by staff person A rather than being given time to turn and pivot, causing distress.
Resident #2 had a weekly pill storage box with several pills stored in different compartments despite being unable to self-administer medications.
Staff person B incorrectly administered 5 medications to resident #2 that were prescribed to another resident.
Medications found in resident #2’s room were not current prescriptions and staff could not identify all pills in the pill box.
Report Facts
Residents Served: 61
Current Hospice Residents: 4
Residents with Mobility Need: 19
Residents with Physical Disability: 2
Medications Incorrectly Administered: 5
Staffing Hours: 80
Waking Staff Hours: 60
Inspection Report — Dec 8, 2021
Renewal
Date: Dec 8, 2021
Visit Reason
The document is related to the renewal application and issuance of a license to operate the Personal Care Home 'Country Meadows of Bethlehem V'. The Department will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
A regular license is being issued in response to the renewal application. The Department advises that an annual inspection will be conducted within the next twelve months and enforcement action will be taken if noncompliance is found.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed letter regarding renewal application and licensing |
Inspection Report — Oct 19, 2021
Renewal
Date: Oct 19, 2021
Visit Reason
The inspection was conducted as a renewal visit for the facility's license.
Findings
The inspection found three deficiencies related to uncovered trash receptacles, lack of thermometer in a refrigerator, and incomplete updates to a resident's support plan reflecting hospice care. All deficiencies were corrected promptly with plans of correction accepted and implemented.
Citations (3)
The home had a large trash container in the main dining room that did not have a lid.
The GE brand refrigerator located in the country kitchen activity room did not have a thermometer.
Resident #1's Resident Support Plan was not updated to reflect the change to hospice care in a timely manner.
Report Facts
Residents Served: 62
Staffing Hours: 79
Waking Staff: 59
Hospice Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chris Swope | Administrator | Named as facility administrator |
| Ann O'Haire | Lead Inspector | Lead inspector for the renewal inspection |
| Michele Moskalczyk | Human Services Licensing Supervisor | Reviewer and licensing supervisor involved in follow-up and document submission |
Inspection Report — Oct 1, 2021
Renewal
Date: Oct 1, 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 — Jul 23, 2021
Renewal
Date: Jul 23, 2021
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing licensing inspections on 07/23/2021 and 07/30/2021.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Nov 12, 2020
Follow-Up
Date: Nov 12, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a submitted plan of correction.
Findings
The submitted plan of correction was fully implemented, addressing an abuse allegation involving a resident being restrained improperly. Staff training on abuse prevention was completed and documented, and monitoring procedures were established.
Citations (1)
42b - Abuse: Resident 1’s wrists were bruised from being restrained by staff during brief changing. The responsible staff member was suspended and later terminated, and staff received re-training on managing resident behaviors and abuse regulations.
Report Facts
Residents Served: 60
Current Residents in Hospice: 2
Resident Age 60 or Older: 60
Residents with Mobility Need: 10
Residents with Physical Disability: 3
Notice — Oct 21, 2020
Date: Oct 21, 2020
Visit Reason
The document serves as a license renewal approval and notification for Country Meadows of Bethlehem V, a Personal Care Home, and informs 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 renewal license notification and certificate issuance.
Report Facts
Inspection Report — Aug 26, 2020
Renewal
Date: Aug 26, 2020
Visit Reason
The inspection was conducted as part of the licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of the inspection conducted on multiple dates between 08/26/2020 and 09/11/2020.
Inspection Report — Apr 17, 2020
Routine
Date: Apr 17, 2020
Visit Reason
The inspection visits were conducted as part of licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on multiple dates in April and May 2020.
Findings
No regulatory citations were identified as a result of these inspections.
Inspection Report — Nov 14, 2019
Renewal
Date: Nov 14, 2019
Visit Reason
The inspection was conducted as a renewal inspection to review compliance and verify the submitted plan of correction.
Findings
Two violations were found related to lint removal and combustible storage in the laundry room. Both plans of correction were fully implemented as of January 16, 2020.
Citations (2)
Regulation 2600 105.g requires lint removal from dryer lint traps and ducts. Two dryers had lint build-up beneath the dryer screens.
Regulation 2600 125.a prohibits combustible materials near heat sources. Lint was found behind dryers' heat sources in the laundry room.
Report Facts
Residents Served: 60
Current Hospice Residents: 2
Total Daily Staff: 70
Waking Staff: 53
Notice — Aug 20, 2019
Date: Aug 20, 2019
Visit Reason
The document serves as a renewal notification and license issuance for Country Meadows of Bethlehem V, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is a license renewal notice with no deficiencies or compliance issues mentioned.
Report Facts
Notice — Dec 17, 2018
Date: Dec 17, 2018
Visit Reason
The document is a response to a waiver request concerning qualifications for direct care staff persons at Country Meadows of Bethlehem V.
Findings
The Department determined that the submitted high school diploma is equivalent to a U.S. high school diploma and that a waiver is not needed for the individual in question.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Licensing Manager | Signed the waiver determination letter. |
Notice — Oct 29, 2018
Date: Oct 29, 2018
Visit Reason
This document is a renewal application and license issuance notice for Country Meadows of Bethlehem V, a Personal Care Home, confirming the facility's licensed capacity and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of future inspection requirements.
Report Facts
Notice — Oct 11, 2018
Date: Oct 11, 2018
Visit Reason
The document serves as a Certificate of Compliance issued to Country Meadows of Bethlehem V for operating a Personal Care Home and a letter explaining the rescission of a consolidated Certificate of Compliance due to independent operation of multiple personal care homes.
Findings
The Certificate of Compliance was issued in error because the personal care homes operate independently with separate services and certificates. The consolidated certificate is rescinded and previous certificates with separate capacities are reinstated.
Inspection Report — Sep 11, 2018
Renewal
Date: Sep 11, 2018
Visit Reason
The inspection was conducted as a renewal licensing inspection of the Country Meadows of Bethlehem V personal care home.
Findings
Violations of 55 Pa. Code Chapter 2600 were found related to staff training and fire extinguisher maintenance. Plans of correction were submitted addressing medication self-administration training and fire extinguisher inspection delays.
Citations (2)
55 Pa.Code §2600.65(b) - The home's annual training plan did not include required medication self-administration training for all direct care staff.
55 Pa.Code §2600.131(f) - Fire extinguishers in multiple buildings had an expiration date beyond the allowable annual timeframe.
Report Facts
Number of Residents Served: 75
Total Daily Staff: 87
Waking Staff: 65
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 12
Number of Residents Age 60 or Older: 75
Number of Residents with a Mobility Need: 12
Notice — Aug 15, 2018
Date: Aug 15, 2018
Visit Reason
Notification from the facility that the license for Country Meadows of Bethlehem V is no longer operated at this location as it has been consolidated with another license.
Findings
The document confirms the consolidation of the facility license and cessation of operation under the specified license number at the given location.
Inspection Report — Jun 1, 2018
Complaint Investigation
Date: Jun 1, 2018
Visit Reason
The inspection was conducted due to an incident as a partial, unannounced inspection.
Complaint Details
The visit was complaint-related due to an incident. The report does not state substantiation status.
Findings
A medication administration record (MAR) was incorrectly documented regarding the resident's pulse rate when administering medication. The responsible staff member documented a pulse of 6 instead of 60 or more.
Citations (1)
REGULATION 55 Pa.Code §2600: The medication administration record was incorrectly documented with a pulse of 6 instead of 60 or more when administering medication to a resident.
Report Facts
Number of Residents Served: 75
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 10
Residents Age 60 or Older: 75
Residents with Mobility Need: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Novak | Department representative on-site during inspection | |
| Melissa Clementoni | Administrator | Facility administrator named in report header |
| Patty Rohrbach | VP of Operations | Signed plan of correction |
Notice — Feb 22, 2018
Date: Feb 22, 2018
Visit Reason
This letter responds to a request for a waiver of 55 Pa.Code § 2600.54(a) relating to qualifications for direct care staff persons at a personal care home.
Findings
The Department of Human Services determined that a specific educational credential is equivalent to a U.S. high school diploma and that a waiver is not needed for that individual.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Licensing Manager | Signed the waiver determination letter. |
Inspection Report — Sep 6, 2017
Renewal
Date: Sep 6, 2017
Visit Reason
The inspection was conducted as a renewal licensing inspection of the Country Meadows of Bethlehem V facility on September 6, 2017.
Findings
Two violations of 55 Pa.Code Chapter 2600 were found related to fire safety notification and storage of combustible materials. Plans of correction were submitted to address these issues.
Citations (2)
55 Pa.Code §2600.124 requires the home to notify the local fire department in writing of the home's total capacity. The home's notification did not include the total capacity of the home.
55 Pa.Code §2600.125(a) prohibits combustible and flammable materials near heat sources. A twin mattress with a blue nylon-like covering was stored directly behind the dryer in the resident laundry room.
Report Facts
Number of Residents Served: 74
Number of Hospice Residents in past year: 15
Number of Residents 60 Years or Older: 74
Number of Residents with Mobility Need: 5
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Clementoni | Administrator | Named in facility header information |
| Michelle Hamilton | Chief of Senior Living Operations | Signed plan of correction documents |
Notice — Aug 25, 2017
Date: Aug 25, 2017
Visit Reason
This document serves as a renewal notification and license issuance for Country Meadows of Bethlehem V, confirming the facility's compliance and informing about 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 — Sep 21, 2016
Renewal
Date: Sep 21, 2016
Visit Reason
The inspection was conducted as a renewal licensing inspection for the personal care home facility on September 21, 2016 and November 10, 2016.
Findings
Violations related to Personal Care Homes under 55 Pa.Code Chapter 2600 were found during the inspection. The violations included failure to obtain informed consent for hospice residents and improper medication management.
Citations (2)
Regulation 55 Pa.Code §2600.29a(b)(2): The facility failed to obtain written informed consent for a hospice resident regarding exemption from evacuation during fire drills. The resident was not evacuated during a fire drill conducted on 9/19/16 at 12:08 a.m.
Regulation 55 Pa.Code §2600.183(f): The home failed to date resident #1's Advair inhaler when it was opened, contrary to medication manufacturer directions allowing use up to 30 days after opening.
Report Facts
Number of Residents Served: 85
Total Daily Staff: 93
Waking Staff: 70
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 6
Number of Residents Age 60 or Older: 85
Number of Residents with Mobility Need: 8
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Hamilton | Chief of Senior Living Operations | Named as legal entity representative signing plan of correction |
| Gerald Dumas | Department representative on-site during inspection | |
| Anne O'Haire | Department representative on-site during inspection |
Notice — Aug 18, 2016
Date: Aug 18, 2016
Visit Reason
This document serves as a renewal license issued in response to the facility's renewal application to operate a Personal Care Home. It also notifies the facility of the Department's requirement to conduct an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a licensing renewal notice with no deficiencies or compliance issues stated.
Report Facts
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