Bethlehem Manor.

“On 06/24/2025, the home had posted menus for one week, but menus for the following week were not posted in a conspicuous and public place as required.”

“DHS Licensing Representative requested immediate access to staff and resident records, schedules, and Medication Administration Records on 06/24/2025 at 10:50 a.m., but these records were not provided until 11:57 a.m., violating the requirement for immediate access.”

“On 06/24/2025 at 10:04 a.m., a resident was observed peeling off large chunks of paint from the windowsill in the Memory Care activity unit, with multiple other sections of the sill already showing peeling paint, creating a hazard.”

“On 06/24/2025 at 10:11 a.m., the refrigerator temperature in the Memory Care Unit was 45 degrees Fahrenheit (above the required maximum of 40°F); a second check at 12:15 p.m. showed 43 degrees Fahrenheit, still exceeding the required temperature.”

“The home received a written complaint of alleged abuse of a resident by a staff member but failed to complete an Act 13 form and notify the Area Agency on Aging as required.”

“The home failed to submit an incident report to the Department regarding an allegation of abuse involving a staff member and resident when made aware of it.”

“The home failed to investigate and resolve a complaint filed by a resident's family regarding resident abuse with a staff member.”

“The home did not schedule an adequate number of staff persons on 3rd shift (11pm to 7am) to safely evacuate all residents, including 11 residents in the secure dementia unit and 2 residents requiring two-person assists, in the event of an emergency. Only two staff persons were scheduled on multiple dates.”

“The home's administrator completed only 20 of the required 24 hours of annual administrator training during the 2024 training year.”

“Approximately 4 fluid ounces of chocolate ice cream spillage was found on the bottom of the freezer in the dining room on the 2nd floor, indicating sanitary conditions were not maintained.”

“Three windows located in the 2nd floor common room were observed open 2 to 3 inches with tears in the window screens. One screen had a large tear across the bottom, another had a large tear to the right, and another had a bent frame creating a gap between the windowsill and screen.”

“Staff were unable to provide immediate access to a resident's most recent Resident Assessment Support Plan during a licensing inspection. The support plan was locked in an office with no staff having a key, and it took until 2:48 p.m. to retrieve the document via email.”

“A resident's most recent medical evaluation was overdue and did not meet the annual evaluation requirement, with a significant gap between the evaluation date and the previous evaluation date.”

“A resident admitted to the secured dementia care unit had a medical evaluation that did not document the resident's diagnosis of dementia or the need for placement in the secured dementia care unit as required.”

“A resident's Resident Assessment Support Plan was not revised within the required annual timeframe, with a significant gap between the most recent and previous support plans.”

“Direct care staff interviews determined they did not have access to resident files, specifically the Resident Assessment Support Plan (RASP), which must be accessible to direct care staff at all times.”

“An enabler bar attached to a resident's bed was not covered and was attached to an unsecured wooden board, allowing the bar to slide out of place and create a gap between the bar and the mattress, creating a hazard.”

“A resident's medication administration record indicated monthly weighing was required, but documentation of weight for January 2024 was not present in the resident's records.”

“A resident's most current support plan did not have documentation that an annual support plan was completed in 2023, as required by annual assessment requirements.”

“A resident was hospitalized 3 times for irritated and itchy skin, including an admission with a diagnosis of crusted scabies, but the Resident Assessment Support Plan (RASP) was not updated to reflect the need for treatment related to these hospitalizations.”

“Food items (ham lunch meat, cheese, and bagged salad) were found in the kitchen refrigerator without being sealed or in closed containers.”

“Menu changes were not posted in a conspicuous and public place in advance of meals. Residents reported being unaware of meal changes until food was being served.”