Bethlehem Manor

The refrigerator temperature in the Memory Care Unit was recorded at 45°F and 43°F, exceeding the required 40°F limit.

Large chunks of paint were peeling off a windowsill in the Memory Care activity unit.

DHS Licensing Representative was not provided immediate access to staff and resident records, schedules, and MARs.

The weekly menu for the following week was not posted in a conspicuous place.

The home failed to submit an incident report to the Department regarding an allegation of abuse within the required timeframe.

The home failed to complete an Act 13 form and notify the Area Agency on Aging regarding a written complaint of alleged resident abuse.

The home failed to provide a status report to the complainant within 2 business days of the written complaint regarding alleged abuse.

The home failed to provide adequate staffing to meet resident needs, specifically having only two staff members scheduled during 3rd shift on multiple dates.

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

Staff could not provide immediate access to a resident's support plan because the document was locked in an office to which no staff had a key.

A resident's medical evaluation did not indicate the need for services in a secured dementia care unit.

A resident's most recent medical evaluation was not completed at least annually.

The resident's Resident Assessment Support Plan (RASP) was not revised within the required annual timeframe.

The enabler bar attached to a resident's bed was not covered and was attached to an unsecured wooden board, creating a gap.

The Resident Assessment Support Plan (RASP) was not updated to reflect treatment needs following multiple hospitalizations and a diagnosis of crusted scabies.

The facility lacked documentation that an annual support plan was completed for the resident in 2023.

The resident's medication administration record lacked documentation of the required monthly weight for January 2024.