The Birches of Lehigh Valley.

“A resident's glucometer device had a blood glucose reading at 12:20 p.m. that was not noted on the medication administration record. Additionally, blood sugar readings taken at 6 a.m. and 4 p.m. were noted in the medication administration record but were not found in the glucometer device.”

“A resident prescribed tablets every 4 hours as needed did not have the initials of the staff person who administered a PRN medication documented on the medication administration record for an administration at 2:32 p.m. in January 2026.”

“A resident prescribed blood sugar checks twice daily did not have blood sugar readings completed at 6 a.m. and 4 p.m. as ordered by the prescriber. This was a repeat violation.”

“The first aid kit in the vehicle used to transport residents did not include a thermometer as required.”

“The written notification to the local fire department, dated 5/8/24, did not include current location of bedrooms, assistance needed to evacuate in an emergency, and current census of residents with mobility needs.”

“Criminal background checks were not completed before hiring staff. Staff person A and Staff person B were hired before their Pennsylvania State Police Criminal Background Checks were requested.”

“Resident #1's record did not include a current list of medications. The list did not include new prescriptions of Trospium Chloride 20mg tab and Lisinopril 10mg tab, and included 5 discontinued medications.”

“Resident #2's prescribed Clearlax polyethylene glycol 3350 had expired on 11/20/25 and was stored in the medication cart. This was a repeat violation from 8/6/24.”

“Staff person initialed medication administration record indicating a resident took a tablet prior to actually administering it. When approached, the resident refused the medication, but documentation falsely reflected administration.”

“Discrepancies in medication destruction documentation and controlled substance records for two residents' discontinued medications. Documentation dates for destruction did not match between destruction log and staff interviews; narcotic count sheets showed discrepancies between pills remaining and destruction records.”

“Medication administration record documented that a PRN medication dose was administered at 8:42 a.m., but staff interviews determined the resident was not actually administered the medication at that time.”

“The resident-home contract for Resident #1 was not signed by the resident or payor.”

“A resident exited the facility without adequate supervision and wandered to a nearby pharmacy, becoming lost for approximately 1 hour before police returned them. The preadmission screening indicated the resident required attendance in unfamiliar places, but the facility failed to provide the necessary supervision, creating potential for resident harm.”

“Resident's wheelchair was in poor repair (wobbly) prior to an incident. The facility failed to ensure the resident's equipment was maintained in good repair at all times.”

“Direct care staff person A was found unresponsive on the floor after consuming a THC-infused gummy provided by staff person B during their shift, rendering the staff member unfit for duty and unable to provide necessary care to residents with reasonable skill and safety.”

“Resident Assessment and Support Plan dated 7-8-24 was not updated to reflect the resident's current mobility needs, incontinence needs, or that the resident receives hospice services.”

“A resident was found unresponsive on a concrete patio in below-freezing temperatures wearing only a nightshirt, fleece cardigan, and underwear after staff failed to respond to a door opening notification for over 3.5 hours. The resident had exited through an unmonitored door at 10:04 p.m. and was not discovered until 7:00 a.m. the next morning by another resident. This constitutes neglect and failure to protect the resident from harm.”

“Direct care staff members consumed THC gummies during their shift, with one staff member distributing the gummies to two other staff members. One staff member became unresponsive on the facility floor at 6:30 p.m. and was unable to provide necessary personal care services with reasonable skill and safety. This violates requirements that direct care staff be free from drug addiction or medical conditions limiting their ability to safely provide care.”

“A resident in the memory care neighborhood was found engaging in a sexual act with another resident on 1/7/2025 at approximately 11:52am. The incident was not reported in accordance with the Older Adults Protective Services Act as required.”

“An incident in which a resident was found engaging in a sexual act with another resident on 1/7/2025 at approximately 11:52am was not reported to the Department within 24 hours as required.”

“On 1/7/2025 at 7:30am, a resident in the Secured Dementia Care Unit was found with a hand on the private area of another resident. Subsequently at 11:52am on the same date, the resident was found engaging in a sexual act with the other resident. These incidents constitute mistreatment and potential abuse.”

“The facility failed to report an incident to the Department's Personal Care Home Regional Office within 24 hours. A resident threw a bowl of hot soup at another resident in the dining room, and this reportable incident was not documented with the Department.”

“Resident-to-resident abuse occurred in the Secured Dementia Care Unit when one resident hit another resident in the dining room and subsequently struck another resident on the cheek, leaving a red mark. Additionally, a staff person witnessed a resident touching another resident underneath clothing.”

“The facility failed to document in a resident's Assessment and Support Plan that the resident was receiving 1:1 monitoring as a medical/behavioral care service, despite implementing this intervention in response to the resident's aggressive verbal and physical altercations.”

“Electronic Medication Administration Record was unlocked and accessible on top of medication cart near Room #115, compromising resident record confidentiality.”

“A tube of A&D ointment labeled with poison control warning was found in Room #24's bathroom. Resident #4 in the memory care unit is not assessed to safely handle and identify poisons.”

“A handful of lint was located in the lint trap of the far-right dryer in the laundry room closest to the dining room, posing a possible fire hazard.”

“An orange rag was located behind the dryer near the dryer duct of the far-right dryer in the laundry room closest to the dining room, posing a possible fire hazard. This was a repeat violation from 05/08/2024.”

“Multiple medication storage violations: Resident #1 had a Lantus Solostar pen opened 48 days prior (should be disposed after 28 days); Resident #2 had two pens (Lantus Solostar and Lispro Kwikpen) without documented opening dates as required by manufacturer's instructions.”

“Directions for operating the magnetic locks near Room #24 were not conspicuously posted; the codes had been removed by a resident.”

“A PVC Primer container, a combustible material, was located next to the natural gas hot water heater, posing a fire hazard.”

“The community restroom outside the Director of Wellness' office did not have a covered garbage can, failing to prevent the penetration of insects and rodents.”

“The telephone located in the entrance of the home did not have emergency telephone numbers posted on or near the phone.”

“Exit #3 had cardboard on the ground outside the exit door that was catching on the door and slowing immediate egress from the building, and also posed a tripping hazard. Additionally, the exit doors to the porch off the first-floor dining room did not note that this is not an exit.”