Lehigh Commons.

“A resident's medical evaluation was missing a response in Section 8 regarding whether the resident can self-administer medication and what type of assistance is needed.”

“Wheelchairs, walkers, prosthetic devices and other apparatus used by residents must be clean, in good repair and free of hazards. At 11:25 a.m., resident #3 and resident #4's queen size bed had bed canes located on left and right side of the bed that shifted back and forth when pulled and were not securely fastened to the bed frame. At 11:36 a.m. resident #5's bed had a bed cane attached but was not securely fastened, with the base pulled out from under the mattress approximately 3 ½ inches.”

“The home shall develop and implement procedures for the safe storage, access, security, distribution and use of medications and medical equipment by trained staff persons. Blood glucose readings for resident #1 (readings of 258, 394, 211, and 210) were not recorded on the Medication Administration Record or treatment sheet on four separate occasions in June 2025.”

“The information regarding date and time of medication administration shall be recorded at the time the medication is administered. Resident #1's medication administration record does not include the initials of the staff person who administered Mag Oxide tablets 400mg and Metformin tablets 1000mg on 6/13/25 at 9:00 A.M. Resident #2's record does not indicate the units of Admelog insulin administered or the initials of the staff person on four separate dates (6/5/25, 6/6/25, 6/7/25, and 6/14/25), with discrepancies between documented and prescribed sliding scale doses. This is a repeat violation from 9/5/24.”

“The home shall follow the directions of the prescriber. Resident #2's sliding scale insulin documentation indicates medication administration that does not align with the prescribed scale on multiple dates, suggesting prescriber orders were not followed accurately.”

“Preadmission screening was completed incorrectly, indicating the facility could meet a resident's needs when the resident did not meet the admittance requirements in the home's description of services.”

“Preadmission screening was completed by Staff A, who is not the Administrator, Administrator's designee, or a representative of a referral agency, in violation of requirements.”

“A resident was admitted to the home but an initial assessment was not completed within 15 days of admission as required.”

“Resident medication administration records were not documented at the time of administration for multiple medications on 8/20/24 (6am and 2pm), 8/21/24 (10pm), and 8/19/24 (9am and 9pm). Documentation is required to verify when medications are actually administered.”

“Resident's support plan dated 4/3/24 did not document repeatedly displayed paranoid behaviors (falsely accusing staff of refusing care, verbal abuse, theft) and agitation toward staff, nor did it document the home's plan to address these behaviors, despite the resident's physician determining the necessity of mental health or behavioral care services.”

“Medication administration records were not documented to indicate that prescribed medications were administered to residents on specified dates and times.”

“The home did not follow the prescriber's orders when a resident did not receive a prescribed tablet at 2pm as ordered, which was verified by the medication administration record showing the medication was not administered.”

“Department representative was not provided immediate access to the facility, residents, and records upon arrival. Staff stated the administrator and designee were unavailable, and the representative was initially prevented from entering the Secured Unit. Access to resident records was delayed approximately 45 minutes until a Med Tech was located.”

“A resident was found lying face down unattended in the grass for approximately 5 hours after exiting the building at 12:30 am. Staff Person C admitted they did not check on the resident after the previous evening because they were too busy. The resident, who should have been monitored, was left without supervision.”

“A resident's dated medical evaluation did not document whether the resident has allergies or requires body positioning, despite the resident's medication administration record indicating PRN Claritin for allergy symptoms.”

“Staff members routinely held the arms of combative residents to restrict their movement during care activities. Staff were instructed by a supervisor to "do whatever it takes" to change clothes and briefs of a combative resident, constituting manual restraint which is prohibited.”

“A resident's record did not contain documentation that the resident or their designated person acknowledged or did not object to the resident's transfer to the Secured Dementia Care Unit.”

“Resident #2 pushed resident #3, causing resident #3 to fall and suffer a laceration to the forehead.”

“The rabies vaccination for Delilah the cat residing in the home expired on 2/4/24; no current certificate of rabies vaccination was maintained.”

“The facility did not post the current license inspection summary in a conspicuous public place; the inspection binder was stored behind the receptionist's desk instead of being visible.”

“Resident #1 who utilizes the facility's financial management had not received quarterly statements of financial transactions; the most current documentation was dated 3/31/21.”

“Fire drill logs indicate sleeping hour drills were conducted in March 2023 and November 2023, more than six months apart, violating the requirement for drills once every six months.”

“Resident #4's Documentation of Medical Evaluation form did not indicate the resident's ability to self-administer medications.”

“Resident #5's Novolog insulin pen was not dated and initialed when opened for use despite pharmacy label indicating 28-day discard requirement. Additionally, a half pill of Myrbetriq 50mg prescribed to resident #6 was improperly stored in a cup in the medication cart drawer instead of being properly disposed of after administration.”

“The home failed to follow the prescriber's order for Resident #1's medication. A medication order for 2 tablets was incorrectly transcribed as 3 tablets daily, resulting in medication administration error that caused the resident to become lethargic and require emergency room evaluation.”