Inspection Report
Renewal
Census: 139
Capacity: 140
Deficiencies: 12
Jul 16, 2025
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and incident reasons, with an exit conference held on 07/23/2025.
Findings
The inspection identified multiple deficiencies including missing required postings, untimely criminal background checks, unlocked poisonous materials accessible to residents, lack of operable bedside lamps, improperly stored food, missing emergency procedure postings, routine fire drills at limited times, incomplete first aid kits, incomplete medication records, unqualified staff administering insulin, incomplete medication training records, and missing directions for key-locking devices. Plans of correction were accepted and implemented with ongoing compliance monitoring scheduled.
Deficiencies (12)
| Description |
|---|
| Telephone numbers of regulatory and protective agencies were not posted in a conspicuous and public place in the secured dementia care unit. |
| Criminal background check for a staff person was not requested timely. |
| Poisonous materials were unlocked and accessible in resident apartments without all residents assessed as capable of safe use. |
| Resident #1 did not have access to a source of light that can be turned on/off at bedside. |
| Food (ice cream) was stored unsealed in the kitchen freezer. |
| Emergency procedures were not posted in a conspicuous and public place in the home. |
| Fire drills were routinely held in the afternoon hours, not on different days and times as required. |
| First aid kit in the home’s vehicle used to transport residents did not include a thermometer. |
| Resident #2's medication record did not include a current list of medications for self-administration. |
| Staff Person C administered insulin without recent required diabetic training. |
| Medication administration training record for Staff Person D lacked signature and requalification documentation. |
| Directions for operating key-locking devices were not conspicuously posted near secure dementia care unit exits. |
Report Facts
License Capacity: 140
Residents Served: 139
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 36
Hospice Residents: 4
Residents with Mobility Need: 38
Residents with Physical Disability: 2
Total Daily Staff: 177
Waking Staff: 133
Inspection Report
Complaint Investigation
Census: 136
Capacity: 140
Deficiencies: 0
Nov 19, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility on 11/19/2024.
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
Total Daily Staff: 169
Waking Staff: 127
Resident Support Staff: 0
License Capacity: 140
Residents Served: 136
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 33
Hospice Current Residents: 3
Residents Age 60 or Older: 133
Residents with Mobility Need: 33
Residents with Physical Disability: 2
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Inspection Report
Census: 117
Capacity: 140
Deficiencies: 0
Jul 16, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident and interim reasons on 07/16/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 140
Residents Served: 117
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 33
Hospice Current Residents: 3
Residents with Mobility Need: 33
Residents with Physical Disability: 3
Total Daily Staff: 150
Waking Staff: 113
Inspection Report
Complaint Investigation
Census: 115
Capacity: 140
Deficiencies: 0
Jun 24, 2024
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 06/24/2024 and 06/26/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The visit was complaint-related, but no deficiencies were found and no follow-up was required.
Report Facts
License Capacity: 140
Residents Served: 115
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 33
Hospice Residents: 2
Residents Age 60 or Older: 115
Residents with Mobility Need: 41
Residents with Physical Disability: 1
Total Daily Staff: 156
Waking Staff: 117
Inspection Report
Renewal
Census: 118
Capacity: 140
Deficiencies: 14
May 8, 2024
Visit Reason
The inspection was conducted as part of the licensing inspections on May 8 and 9, 2024, to determine compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes and to issue a regular license.
Findings
The facility was found to be in compliance with applicable regulations after corrections were made. Several deficiencies were cited related to posting of licensing summaries, contract signatures, staff training, fire safety, medication administration, resident rights, and secured dementia care unit procedures, all of which had plans of correction implemented and verified.
Deficiencies (14)
| Description |
|---|
| Licensing Inspection Summaries were not posted in a conspicuous location. |
| Resident home contract for resident #3 was not signed by the resident. |
| No signed statement acknowledging resident #3's receipt of resident rights due to unsigned contract. |
| Ancillary and direct care staff did not complete required orientation and training within specified timeframes. |
| Direct care staff members lacked documentation of supervised practice for ADL services. |
| Accumulation of lint in dryer lint trap in secured dementia care unit. |
| Combustible materials found near heat sources behind dryers in secured dementia care unit. |
| Fire drill records incomplete for multiple drills, missing key information such as number of residents evacuated and problems encountered. |
| Fire drill during sleeping hours not held within required six-month interval. |
| Residents #1 and #2 assessed as unable to self-administer medications but medications were stored for self-administration. |
| Resident #4 was administered medication despite prescriber’s parameters to hold medication based on blood pressure readings. |
| Resident #3 was not educated or documented on the right to refuse medication due to unsigned contract. |
| No documentation that resident #3 or designated person objected to admission or transfer to secured dementia care unit. |
| Key-locking devices in secured dementia care unit were inoperable or had incorrect codes posted, preventing immediate egress. |
Report Facts
License Capacity: 140
Residents Served: 118
Secured Dementia Care Unit Capacity: 36
Residents Served in Secured Dementia Care Unit: 33
Current Hospice Residents: 2
Staffing Hours: 159
Waking Staff Hours: 119
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and report cover letter. |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 140
Deficiencies: 15
Dec 7, 2023
Visit Reason
The inspection was conducted as a complaint investigation and incident review following multiple licensing inspections on September 12, 2023, September 13, 2023, December 7, 2023, and December 12, 2023.
Findings
The inspection identified multiple deficiencies including failure to timely report incidents, incomplete resident contracts, inadequate staff training and certifications, food storage violations, fire safety deficiencies, medication administration errors, incomplete medical evaluations, and incomplete or unsigned resident support plans. Plans of correction were accepted but many were not implemented as of the report date.
Complaint Details
This inspection was complaint-related, triggered by incidents and complaints regarding resident care, safety, and regulatory compliance. The report includes substantiated violations with plans of correction.
Deficiencies (15)
| Description |
|---|
| Failure to report incidents to the Department within 24 hours including injury requiring hospital visit, fire alarm activations, and gas leak. |
| Resident home contract not signed by resident without notation of refusal or inability. |
| Insufficient staff certified in First Aid and CPR for resident census on specified dates. |
| Food storage violations including unlabeled and undated opened food containers. |
| Combustible materials stored near heat sources posing fire hazard. |
| No documentation of fire drill conducted in November 2023. |
| Medical evaluations for residents missing required information or completed outside required timeframes. |
| Medication storage and administration errors including missing medications, incorrect administration per prescriber orders, repackaging medications outside original containers, and expired medications in use. |
| Resident support plans not updated to reflect changes in condition or incidents, missing signatures, or incomplete documentation. |
| Failure to post required regulations, emergency procedures, and emergency telephone numbers in conspicuous locations. |
| Fire alarm system inoperable for extended period without proper fire watch documentation. |
| Failure to conduct monthly fire drills and incomplete fire drill records. |
| Staff training deficiencies including lack of fire safety orientation, resident rights, abuse reporting, and direct care staff qualifications. |
| Key-locking device code not posted correctly. |
| Resident in secured dementia care unit without dementia diagnosis did not know how to operate keypad exit device. |
Report Facts
License Capacity: 140
Residents Served: 85
Secured Dementia Care Unit Capacity: 36
Residents Served in Secured Dementia Care Unit: 33
Total Daily Staff: 148
Waking Staff: 111
Deficiency Count: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the provisional license letter. |
| Christina Price | Residence Director | Named in multiple findings related to monitoring compliance and training. |
| Health Care Director | Named in multiple findings related to education, audits, and corrective actions for medical and medication deficiencies. | |
| Maintenance Director | Named in findings related to fire safety and facility maintenance. | |
| Senior Vice President | Provided education on contracts and resident signature requirements. |
Inspection Report
Enforcement
Census: 85
Capacity: 140
Deficiencies: 14
Dec 7, 2023
Visit Reason
The inspection was conducted due to incidents and complaints, including interim exit conference, to investigate violations and compliance with Personal Care Homes regulations.
Findings
Multiple violations were found including failure to report incidents timely, incomplete resident contracts, insufficient CPR certified staff, improper food storage, combustible storage hazards, missing fire drills, incomplete medical evaluations, medication storage and administration errors, incomplete support plans, and issues with emergency procedures and fire safety equipment.
Complaint Details
The inspection was complaint-related, triggered by incidents and interim exit conference. Specific substantiation status is not stated.
Deficiencies (14)
| Description |
|---|
| Incident reports were not submitted within 24 hours for injuries, fire alarm activations, and gas leak. |
| Resident home contract was unsigned without notation of refusal or inability. |
| Insufficient staff certified in CPR and First Aid for resident census. |
| Food items in kitchen storage were open and not dated. |
| Combustible materials found near heat sources in laundry room. |
| No documentation of fire drill conducted in November 2023. |
| Medical evaluations missing required information or completed outside required timeframe. |
| Medications not available in medication cart as prescribed. |
| Medication administration did not follow prescriber's orders. |
| Support plans missing documentation of medical, dental, vision, mental health services and signatures. |
| Cognitive preadmission screening not completed within 72 hours prior to admission to secured dementia care unit. |
| Resident without dementia diagnosis residing in secured dementia care unit without knowledge of keypad operation. |
| Electronic keypad code not posted correctly. |
| Support plans not revised timely to reflect changes in resident condition or incidents. |
Report Facts
License Capacity: 140
Residents Served: 85
Secured Dementia Care Unit Capacity: 36
Residents Served in Secured Dementia Care Unit: 33
Total Daily Staff: 148
Waking Staff: 111
Deficiency Counts: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed enforcement letter regarding provisional license. |
| Christina Price | Residence Director | Named in multiple findings related to training, monitoring, and compliance. |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 140
Deficiencies: 2
Oct 17, 2023
Visit Reason
The inspection was conducted as a complaint investigation and incident review at THE VERO AT BETHLEHEM on 10/17/2023.
Findings
The facility was found to have deficiencies related to failure to immediately submit a plan of supervision for a staff member involved in an abuse allegation and a direct care staff member lacking a valid high school diploma or equivalent. Plans of correction were accepted and fully implemented by 01/05/2024.
Complaint Details
The visit was complaint-related involving an allegation of abuse by Resident #1 against a staff member. The staff member was suspended pending investigation and returned to work after the home completed its internal investigation. The home failed to notify the Department immediately about the plan of supervision. The complaint was addressed with accepted plans of correction.
Deficiencies (2)
| Description |
|---|
| Failure to immediately submit to the Department a plan of supervision or notice of suspension for a staff member involved in an abuse allegation. |
| Direct care staff person did not have a valid high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
Report Facts
License Capacity: 140
Residents Served: 82
Secured Dementia Care Unit Capacity: 34
Residents Served in Dementia Unit: 34
Resident Mobility Need: 45
Residents 60 Years or Older: 82
Residents Diagnosed with Mental Illness: 5
Residents with Physical Disability: 2
Resident Support Staff: 45
Total Daily Staff: 172
Waking Staff: 129
Inspection Report
Plan of Correction
Capacity: 36
Deficiencies: 2
May 17, 2023
Visit Reason
The inspection was a partial, announced visit conducted as a new review of the facility on 05/17/2023, with follow-up related to plan of correction submissions.
Findings
Two deficiencies were identified: insufficient exterior lighting at a stair exit door and missing posted codes for key-locking devices on the secured dementia care unit courtyard gate. Both violations were corrected promptly with plans for ongoing monitoring to ensure compliance.
Deficiencies (2)
| Description |
|---|
| The stair 2 exit door does not have sufficient lighting outside of the door which exits to the parking lot. |
| The keypads located in the secured dementia care unit courtyard do not have a code posted to operate the key locking devices. |
Report Facts
License Capacity: 36
Residents Served: 0
Plan of Correction Completion Date: May 25, 2023
Plan of Correction Implementation Date: May 30, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Ennis | Maintenance Director | Named in lighting deficiency correction and ongoing monitoring |
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