Inspection Reports for Lehigh Commons
1680 SPRING CREEK ROAD,, MACUNGIE, PA, 18062
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
11.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
143% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
88% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Follow-Up
Census: 70
Capacity: 80
Deficiencies: 4
Date: Jun 17, 2025
Visit Reason
The inspection was an interim, unannounced full review conducted on 06/17/2025 to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing multiple deficiencies related to resident personal equipment, medication storage and administration, medication documentation, following prescriber's orders, and records storing. Continued compliance and ongoing staff education were emphasized.
Deficiencies (4)
Resident beds had bed canes that were not securely fastened, posing a hazard.
Blood glucose readings for resident #1 were not recorded on the Medication Administration Record or treatment sheet.
Medication administration records lacked initials of staff administering medications and did not document insulin units given according to sliding scale for resident #2.
Resident records and therapy notes were found unattended and unsecured in common areas.
Report Facts
License Capacity: 80
Residents Served: 70
Secured Dementia Care Unit Capacity: 14
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 4
Resident Support Staff: 0
Total Daily Staff: 88
Waking Staff: 66
Residents Age 60 or Older: 70
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rehab Director | Involved in assessing and securing resident bed mobility devices and staff education. | |
| Maintenance Director | Assessed and tightened bed canes and involved in staff education and ongoing compliance. | |
| Director of Health and Wellness | Implemented blood glucose tracking form, conducted audits, and led staff education on medication administration. | |
| Executive Director | Oversaw quality assurance meetings, staff education, and corrective actions related to deficiencies. | |
| Administrator | Conducted review of record storing policies and staff education. | |
| Rehabilitation Director | Reminded staff of policies regarding protected health information and record storing. |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 80
Deficiencies: 3
Date: Jan 8, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with licensing requirements at the facility.
Complaint Details
The visit was complaint-related with the reason stated as 'Complaint'. The plan of correction was reviewed and found to be fully implemented as of the inspection date.
Findings
The inspection found deficiencies related to preadmission screening and assessment processes, including incorrect completion of preadmission screening forms by unauthorized staff and failure to complete initial resident assessments within 15 days of admission. The submitted plan of correction was determined to be fully implemented.
Deficiencies (3)
Preadmission screening was completed incorrectly indicating the facility can meet the resident’s needs although the resident does 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.
An assessment was not completed within 15 days of admission for a resident.
Report Facts
License Capacity: 80
Residents Served: 63
Secured Dementia Care Unit Capacity: 14
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 8
Total Daily Staff: 86
Waking Staff: 65
Inspection Report
Complaint Investigation
Census: 74
Capacity: 80
Deficiencies: 0
Date: Oct 16, 2024
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial on-site and off-site visits on 10/16/2024 and 10/21/2024.
Complaint Details
The inspection was complaint-related as explicitly stated under Inspection Information with reason 'Complaint'. No deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 80
Residents Served: 74
Secured Dementia Care Unit Capacity: 14
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 5
Resident Mobility Need: 43
Residents Age 60 or Older: 74
Inspection Report
Plan of Correction
Census: 74
Capacity: 80
Deficiencies: 2
Date: Sep 5, 2024
Visit Reason
The inspection was conducted as a follow-up review of a submitted plan of correction related to complaints and incidents at the facility, including medication administration and resident support plan documentation.
Complaint Details
The inspection was complaint-related, triggered by complaints and incidents. Substantiation status is not explicitly stated.
Findings
The facility was found to have deficiencies in medication administration documentation and in documenting resident behavioral support plans. The submitted plan of correction was fully implemented and compliance was maintained.
Deficiencies (2)
Resident medication administration record was not documented to verify the administration of medications on specified dates and times.
Resident behavioral issues and the home's plan to address these behaviors were not documented in the resident's assessment and support plan dated 4/3/24.
Report Facts
License Capacity: 80
Residents Served: 74
Secured Dementia Care Unit Capacity: 14
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 5
Total Daily Staff: 117
Waking Staff: 88
Inspection Report
Complaint Investigation
Census: 73
Capacity: 80
Deficiencies: 0
Date: Jul 2, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Complaint Details
The inspection was complaint-related and incident-related; no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
License Capacity: 80
Residents Served: 73
Secured Dementia Care Unit Capacity: 14
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 12
Residents Age 60 or Older: 73
Residents with Mobility Need: 35
Total Daily Staff: 108
Waking Staff: 81
Inspection Report
Complaint Investigation
Census: 76
Capacity: 80
Deficiencies: 2
Date: Jun 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation at Lehigh Commons on 06/11/2024.
Complaint Details
The visit was complaint-related with the reason stated as 'Complaint'. The plan of correction was accepted and fully implemented as of 06/11/2024.
Findings
The inspection found deficiencies related to medication administration records not being properly documented and failure to follow prescriber's orders for medication administration. The submitted plan of correction was fully implemented.
Deficiencies (2)
Medication administration record was not documented to indicate that certain medications were administered at specified times.
The home failed to follow the directions of the prescriber as a resident did not receive a prescribed tablet at 2pm.
Report Facts
License Capacity: 80
Residents Served: 76
Secured Dementia Care Unit Capacity: 15
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 12
Total Daily Staff: 102
Waking Staff: 77
Inspection Report
Follow-Up
Census: 70
Capacity: 80
Deficiencies: 5
Date: May 16, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident reported by the home, with the purpose of reviewing the submitted plan of correction and verifying compliance.
Findings
The facility was found to have multiple deficiencies including failure to provide immediate access to resident records, neglect of a resident who eloped and was found unattended for hours, incomplete medical evaluation documentation, improper use of physical restraints, and missing documentation for resident transfer to the secured dementia care unit. The submitted plan of correction was accepted and fully implemented by the follow-up dates.
Deficiencies (5)
Failure to provide immediate access to the home, residents, and records to Department agents upon request.
Resident neglect: a resident was found lying outside unattended for 5 hours after eloping from the building.
Medical evaluation documentation did not indicate resident allergies or body positioning needs despite medication indicating allergies.
Use of manual physical restraints on combative residents by holding their arms to provide care.
Resident record lacked documentation that the resident or designated person did not object to transfer to the secured dementia care unit.
Report Facts
License Capacity: 80
Residents Served: 70
Secured Dementia Care Unit Capacity: 14
Residents Served in Secured Dementia Care Unit: 14
Hospice Residents: 6
Residents with Mobility Need: 28
Total Daily Staff: 99
Waking Staff: 74
Resident Unattended Time: 5
Inspection Report
Follow-Up
Census: 72
Capacity: 80
Deficiencies: 11
Date: Apr 9, 2024
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction, as well as for renewal, complaint, and incident reasons.
Complaint Details
The inspection included complaint-related reasons. One complaint involved an incident where resident #2 pushed resident #3 causing injury, which was substantiated with corrective actions implemented.
Findings
The facility was found to have fully implemented the submitted plan of correction. Several deficiencies were identified related to posting of current license, financial management, abuse incidents, medication storage and administration, fire drill compliance, medical evaluations, and support plan documentation, all of which had corrective actions accepted and implemented.
Deficiencies (11)
The home did not have the inspection binder with current license inspection summaries posted conspicuously as required.
Resident #1's quarterly financial statements were outdated, last dated 3/31/21.
Resident #2 was observed pushing resident #3 causing injury.
The rabies vaccination for the cat Delilah expired on 2/4/24.
Fire drills during sleeping hours were not conducted within the required 6-month interval.
Resident #4's medical evaluation form did not indicate ability to self-administer medications.
Resident #5's Novolog insulin pen was not dated and initialed when opened; medication improperly stored for resident #6.
Resident #6's medication label indicated an incorrect dosage of Myrbetriq.
Resident #7's PRN medication Ondansetron was not available in the medication cart.
Medications administered to residents #3, #6, #8, and #9 were not properly initialed or administered as ordered.
Support plans for residents #1, #5, and #10 did not include required details about enabler bars used.
Report Facts
License Capacity: 80
Residents Served: 72
Secured Dementia Care Unit Capacity: 15
Residents Served in Dementia Unit: 12
Current Hospice Residents: 12
Residents with Mobility Need: 28
Total Daily Staff: 100
Waking Staff: 75
Inspection Report
Census: 68
Capacity: 80
Deficiencies: 0
Date: Nov 28, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
License Capacity: 80
Residents Served: 68
Secured Dementia Care Unit Capacity: 15
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 10
Residents with Mobility Need: 15
Residents 60 Years or Older: 68
Inspection Report
Follow-Up
Census: 68
Capacity: 80
Deficiencies: 1
Date: Aug 3, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, to review the submitted plan of correction and verify its implementation.
Findings
The submitted plan of correction was found to be fully implemented, with no errors detected in medication administration records after auditing. The facility has established a two-step verification process for new medication orders to ensure accuracy.
Deficiencies (1)
Staff failed to follow the prescriber’s order due to incorrect transcription of medication dosage, resulting in a resident being sent to the ER for evaluation.
Report Facts
License Capacity: 80
Residents Served: 68
Total Daily Staff: 95
Waking Staff: 71
Inspection Report
Renewal
Census: 75
Capacity: 80
Deficiencies: 6
Date: Apr 4, 2023
Visit Reason
The inspection was conducted as a full, unannounced renewal inspection with an incident review on 04/04/2023 and 04/05/2023.
Findings
The facility was found to have multiple deficiencies including unqualified direct care staff, improper scheduling of fire drills, lack of medication administration training for staff, inadequate medication storage procedures, insufficient dementia care training, and incomplete resident records. Plans of correction were accepted and implemented by June 13, 2023.
Deficiencies (6)
Staff person 'A' does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
The home routinely holds fire drills during the last week of the month, not on different days and times as required.
Staff Person B lacked documentation of training for administration of oral, topical, eye, nose, and ear drop prescription medications, insulin injections, and epinephrine injections.
Resident #1's glucometer had a blood glucose test reading discrepancy and the home's MAR had inconsistent blood glucose test records.
Direct care staff working on the secured dementia care unit did not receive the required 6 hours of annual training related to dementia care and services for training year 2022.
Resident #2 and #3's records did not include any identifiable marks; the response was left blank.
Report Facts
License Capacity: 80
Residents Served: 75
Secured Dementia Care Unit Capacity: 15
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 10
Total Daily Staff: 90
Waking Staff: 68
Residents 60 Years or Older: 73
Residents with Mobility Need: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Zurl | Human Resources Director | Named in plan of correction for auditing staff qualifications. |
| Lori Simons | Director of Nursing | Responsible for auditing medication storage containers monthly. |
Inspection Report
Follow-Up
Census: 70
Capacity: 80
Deficiencies: 1
Date: Jul 15, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted off-site on 07/15/2022 to review the submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented. The incident involved a staff member retaliating against a resident who hit them, resulting in the staff member's termination. The facility maintains policies and procedures to prevent abuse and trains staff yearly on abuse prevention.
Deficiencies (1)
On 5/13/22 Resident #1 hit direct care staff member A. Staff member A retaliated and struck the resident back in the shoulder and made a threatening statement.
Report Facts
License Capacity: 80
Residents Served: 70
Secured Dementia Care Unit Capacity: 14
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 10
Resident Mobility Need: 15
Resident Age 60 or Older: 70
Resident Supplemental Security Income: 0
Resident Diagnosed with Mental Illness: 0
Resident Diagnosed with Intellectual Disability: 0
Resident with Physical Disability: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Graziano | Signed the letter confirming plan of correction implementation | |
| Staff member A | Direct care staff member involved in abuse incident and terminated |
Inspection Report
Renewal
Census: 70
Capacity: 80
Deficiencies: 16
Date: Mar 8, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection identified multiple deficiencies related to contract signatures, staff orientation, emergency telephone numbers, lighting, toilet paper availability, food labeling, emergency management procedures, unobstructed egress, resident assessments, support plan signatures, medical evaluations, preadmission screening, and non-objection statements. Plans of correction were submitted and accepted with follow-up dates.
Deficiencies (16)
Residents #1, #2, #3, #4, and #5 did not sign their contracts.
Staff A did not receive orientation on evacuation procedures, staff duties, fire safety, and emergency preparedness on the first day.
Staff A did not complete training on resident rights, emergency medical plan, mandatory abuse reporting, and reportable incidents within 40 hours.
No emergency telephone numbers posted on or by the telephone in room 103.
Residents in rooms 254, 138, and 100 did not have a bedside lamp within reach of their beds.
No toilet paper in the bathroom located in room 138.
Frozen pizza dough and dinner rolls in the walk-in freezer were not labeled with a date.
Written emergency procedures were not submitted annually to the local emergency management agency; last submission was 12/16/2020.
Linens were blocking egress from emergency doors in the dining room; emergency exit door required excessive force to open.
Resident #6’s initial assessment was not completed within 15 days of admission.
Resident #7’s last assessment had errors including incorrect dates and signatures.
Resident #2 participated in the support plan development but did not sign the support plan.
Resident #2’s medical evaluation was not completed within 60 days prior to admission to the secured dementia care unit.
Resident #4 was admitted to the secured dementia care unit without a written cognitive preadmission screening.
Residents #2, #3, and #4 did not sign non-objection documents for transfer to the secured dementia care unit.
Residents #6, #7, and #3 had medical evaluations missing vital signs such as blood pressure, pulse, and weight.
Report Facts
License Capacity: 80
Residents Served: 70
Secured Dementia Care Unit Capacity: 14
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 6
Staffing Hours: 99
Waking Staff: 74
Deficiency Completion Dates: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MM | Responsible for monitoring ongoing compliance and plan of correction updates. | |
| KP | Maintenance Director | Oversaw installation of door hinges and monthly door inspections. |
| DON | Director of Nursing | Responsible for ensuring completeness of assessments and support plans. |
| Memory Director | Responsible for assessments and medical evaluations related to secured dementia care unit. | |
| Executive Director | Oversaw emergency management submissions, non-objection documentation, and compliance monitoring. |
Inspection Report
Follow-Up
Census: 73
Capacity: 80
Deficiencies: 2
Date: Jan 3, 2022
Visit Reason
The inspection was a partial, unannounced follow-up review conducted off-site on 01/03/2022 and 01/14/2022 to verify the implementation of a previously submitted plan of correction related to regulatory compliance issues.
Findings
The submitted plan of correction was determined to be fully implemented, demonstrating compliance with regulations regarding timely resident assessments and support plan revisions. Continued compliance must be maintained.
Deficiencies (2)
Resident #1's initial assessment was not completed within 15 days of admission.
Resident #1's support plan was not updated within 30 days following a fall to reflect changes in care needs.
Report Facts
License Capacity: 80
Residents Served: 73
Secured Dementia Care Unit Capacity: 14
Residents Served in Dementia Unit: 14
Hospice Current Residents: 7
Resident Mobility Need: 30
Resident Age 60 or Older: 73
Resident Support Staff Hours: 73
Total Daily Staff Hours: 176
Waking Staff Hours: 132
Inspection Report
Renewal
Deficiencies: 0
Date: Dec 1, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing for the facility LEHIGH COMMONS.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 21, 2021
Visit Reason
The inspection was conducted as a licensing inspection of the facility on 10/21/2021 and 10/25/2021.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 4, 2021
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report
Renewal
Deficiencies: 0
Date: May 5, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 05/05/2021 and 05/07/2021 for the facility Lehigh Commons.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Routine
Deficiencies: 0
Date: Apr 20, 2021
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Notice
Capacity: 80
Deficiencies: 0
Date: Mar 19, 2021
Visit Reason
This document serves as a renewal notification and issuance of a regular license for the Personal Care Home 'Lehigh Commons' following receipt of the renewal application dated December 2, 2020.
Findings
The Department advises that an onsite inspection will be conducted within the next twelve months as required by regulation, and enforcement action will be taken if noncompliance is found during that inspection.
Report Facts
Maximum capacity: 80
Secure Dementia Care Unit capacity: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Inspection Report
Renewal
Census: 62
Capacity: 80
Deficiencies: 4
Date: Feb 18, 2021
Visit Reason
The inspection was conducted as a renewal review of the facility license for Lehigh Commons on 02/18/2021 and 02/23/2021.
Findings
The inspection identified several deficiencies including unlocked poisonous materials accessible to residents, staff not knowing the location of first aid kits, incomplete medication administration documentation, and delayed completion of a resident's support plan. The facility submitted plans of correction which were accepted and fully implemented.
Deficiencies (4)
Housekeeping closet in the secure dementia unit was found unlocked and accessible to residents, containing poisonous materials.
Staff person could not identify the locations of the home's emergency first aid kits.
Medication administration for Resident #1 did not include recording the heart rate as ordered before administering Digoxin.
Resident #2's support plan was not completed until more than 72 hours after admission to the secure dementia unit.
Report Facts
License Capacity: 80
Residents Served: 62
Capacity of Secured Dementia Care Unit: 14
Residents in Secured Dementia Care Unit: 11
Current Hospice Residents: 6
Total Daily Staff: 90
Waking Staff: 68
Inspection Report
Routine
Deficiencies: 0
Date: Feb 5, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the inspection report |
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 20, 2021
Visit Reason
The inspection was conducted as part of licensing inspections on 01/20/2021 and 02/04/2021 for the facility LEHIGH COMMONS.
Findings
No regulatory citations were identified as a result of this inspection.
Viewing
Loading inspection reports...
