Inspection Reports for
Lehigh Commons
1680 SPRING CREEK ROAD,, MACUNGIE, PA, 18062
Back to Facility Profile48 Reports
Inspection Report — May 20, 2026
Renewal
Date: May 20, 2026
Visit Reason
The inspection was conducted as a renewal review of the facility's license and compliance with applicable regulations.
Findings
The inspection identified multiple deficiencies related to food storage, emergency egress, emergency procedures posting, fire department notification, fire drills, medication administration, medication storage, medication documentation, and key-locking device instructions. All deficiencies were corrected or had plans of correction accepted with ongoing compliance measures established.
Citations (9)
103f Food requiring refrigeration was stored without a thermometer in the ice cream chest freezer in the kitchen.
121a The dining room exit door was blocked by a chair and laundry cart, preventing immediate egress in an emergency.
123b The local municipality’s emergency procedures were not posted in a conspicuous public area of the home.
124 The home's notice to the fire department incorrectly noted 21 residents needing evacuation assistance, while 19 residents actually required assistance.
132g Fire drills were routinely held during overnight shifts with low staff presence, not meeting requirements for varied days and times.
182c Medication administration errors occurred when staff administered medication without reviewing the medication administration record first.
185a The facility failed to properly store medications and medical equipment; missing PRN medications and incorrect blood glucose documentation were noted.
187b Medication administration records were initialed before medication was administered to residents.
233c Directions for operating key-locking devices were not posted in the secured dementia care unit.
Report Facts
Residents served: 72
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 10
Residents needing assistance to evacuate: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in medication administration and medication record initialing findings | |
| Facility's Market President | RN | In-serviced all staff authorized to administer medications on medication documentation requirements |
Inspection Report — Nov 17, 2025
Follow-Up
Date: Nov 17, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to medical evaluations. Ongoing compliance measures were established including audits and staff training.
Citations (1)
2600.141.a: The resident's medical evaluation did not include a response on whether the resident can self-administer medication or the type of assistance needed.
Report Facts
Residents Served: 72
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 4
Resident Support Staff: 19
Total Daily Staff: 110
Waking Staff: 83
Inspection Report — Nov 6, 2025
Complaint Investigation
Date: Nov 6, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 73
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 4
Inspection Report — Jun 17, 2025
Follow-Up
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.
Citations (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
Residents Served: 70
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 — Jan 8, 2025
Complaint Investigation
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.
Citations (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
Residents Served: 63
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 8
Total Daily Staff: 86
Waking Staff: 65
Inspection Report — Oct 16, 2024
Complaint Investigation
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
Residents Served: 74
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 5
Resident Mobility Need: 43
Residents Age 60 or Older: 74
Inspection Report — Sep 5, 2024
Plan of Correction
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.
Citations (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
Residents Served: 74
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 5
Total Daily Staff: 117
Waking Staff: 88
Inspection Report — Jul 2, 2024
Complaint Investigation
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
Residents Served: 73
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 — Jun 11, 2024
Complaint Investigation
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.
Citations (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
Residents Served: 76
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 12
Total Daily Staff: 102
Waking Staff: 77
Inspection Report — May 16, 2024
Follow-Up
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.
Citations (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
Residents Served: 70
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 — Apr 9, 2024
Follow-Up
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.
Citations (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
Residents Served: 72
Residents Served in Dementia Unit: 12
Current Hospice Residents: 12
Residents with Mobility Need: 28
Total Daily Staff: 100
Waking Staff: 75
Inspection Report — Nov 28, 2023
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
Residents Served: 68
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 10
Residents with Mobility Need: 15
Residents 60 Years or Older: 68
Inspection Report — Aug 3, 2023
Follow-Up
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.
Citations (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
Residents Served: 68
Total Daily Staff: 95
Waking Staff: 71
Notice — Apr 12, 2023
Date: Apr 12, 2023
Visit Reason
This letter responds to a request from the facility to use the Safely You Falls Management Program to support fall detection and management for individuals with cognitive impairment.
Findings
The Department reviewed the submitted information and determined that the informed consent process meets regulatory requirements for resident rights and privacy. The letter does not endorse the program but confirms compliance with privacy regulations if procedures are maintained.
Inspection Report — Apr 4, 2023
Renewal
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.
Citations (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
Residents Served: 75
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 — Jul 15, 2022
Follow-Up
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.
Citations (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
Residents Served: 70
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 — Mar 8, 2022
Renewal
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.
Citations (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
Residents Served: 70
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 — Jan 3, 2022
Follow-Up
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.
Citations (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
Residents Served: 73
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 — Dec 1, 2021
Renewal
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 — Oct 21, 2021
Renewal
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 — Jun 4, 2021
Routine
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 — May 5, 2021
Renewal
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 — Apr 20, 2021
Routine
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 — Mar 19, 2021
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
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Inspection Report — Feb 18, 2021
Renewal
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.
Citations (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
Residents Served: 62
Residents in Secured Dementia Care Unit: 11
Current Hospice Residents: 6
Total Daily Staff: 90
Waking Staff: 68
Inspection Report — Feb 5, 2021
Routine
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 — Jan 20, 2021
Renewal
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.
Inspection Report — Dec 21, 2020
Follow-Up
Date: Dec 21, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction regarding the use of glucometers was found to be fully implemented. Proper protocols were followed, staff training was completed, and no residents suffered ill effects.
Citations (1)
85a Sanitary conditions shall be maintained. Staff Member A used the glucometer of Resident 1 to check the blood glucose levels of Resident 2 on 8/4/2020, which was a repeat violation. Proper cleaning and sanitizing protocols were followed and staff received education on glucometer use.
Report Facts
Residents Served: 63
Residents Served in Secured Dementia Unit: 14
Hospice Current Residents: 6
Resident Support Staff: 0
Total Daily Staff: 95
Waking Staff: 71
Residents Age 60 or Older: 63
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 32
Inspection Report — Nov 23, 2020
Follow-Up
Date: Nov 23, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction related to a resident care refusal incident was found to be fully implemented. The facility demonstrated compliance with safe storage procedures and proper care following the incident.
Citations (1)
185a - The home failed to follow its policy regarding resident refusals when a resident refused ostomy bag care on 11/15/20. The assigned staff did not communicate the refusals to their supervisor during the shift.
Report Facts
Residents Served: 72
Secured Dementia Care Unit Residents Served: 13
Staff Total Daily: 95
Staff Waking: 71
Inspection Report — Nov 5, 2020
Follow-Up
Date: Nov 5, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to a resident abuse incident involving delayed reporting. Abuse education and incident reportable training were completed, and medical evaluation documentation deficiencies were corrected.
Citations (4)
15a - Resident Abuse Report: The home failed to immediately report suspected sexual abuse of a resident, delaying notification to the local area agency on aging until four days after the incident.
16c - Written Incident Report: The home did not report the incident to the Department within 24 hours, reporting it two days late.
42b - Abuse: A resident sexually abused another resident, and the facility failed to prevent this abuse. Immediate 15-minute checks were implemented to monitor safety.
141a 1-10 Medical Evaluation Information: Resident #2's medical evaluation form lacked documentation of height, weight, pulse rate, blood pressure, and temperature.
Report Facts
Residents Served: 70
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 12
Residents Age 60 or Older: 69
Residents with Mobility Need: 28
Inspection Report — May 29, 2020
Follow-Up
Date: May 29, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction regarding the improper use of a glucometer was fully implemented. The facility demonstrated compliance with sanitary conditions and no residents suffered ill effects from the incident.
Citations (1)
85a Sanitary Conditions: Staff member A used the glucometer of resident 1 to check blood glucose levels of residents 2 and 3 on 5/16/2020, violating sanitization protocol.
Report Facts
Residents Served: 73
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 9
Inspection Report — Jan 9, 2020
Annual Inspection
Date: Jan 9, 2020
Visit Reason
The visit was the Pennsylvania Department of Human Services, Bureau of Human Services Licensing annual licensing inspection of the facility.
Findings
The facility was found to be in compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Notice — Dec 10, 2019
Date: Dec 10, 2019
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home 'Lehigh Commons' pursuant to Title 55, PA Code, Chapter 2600. It informs the facility that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal and notification letter with an enclosed certificate of compliance.
Report Facts
Inspection Report — May 1, 2019
Complaint Investigation
Date: May 1, 2019
Visit Reason
The inspection was conducted as a complaint investigation and incident review at Lehigh Commons on May 1, 2019.
Complaint Details
The inspection was triggered by a complaint and incident as stated under the inspection reason. No substantiation status is provided.
Findings
The inspection found violations related to the resident support plan not being updated to reflect assistance needs. A plan of correction was submitted to update the Resident Assessment and Support Plan (RASP) for the affected resident.
Citations (1)
55 Pa. Code Ch. 2600, 227d: The Resident Assessment and Support Plan dated 7/14/2018 for resident #1 was not updated to reflect the resident's need for assistance with showering and toileting.
Report Facts
Residents Served: 73
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas J. Howanitz | Executive Director | Named as administrator and signed plan of correction |
Notice — Nov 27, 2018
Date: Nov 27, 2018
Visit Reason
Notification of license renewal application approval for the Personal Care Home Lehigh Commons and information about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and outlines the Department's obligation to conduct an annual inspection.
Report Facts
Inspection Report — Dec 7, 2017
Renewal
Date: Dec 7, 2017
Visit Reason
The inspection was conducted as a renewal licensing inspection of Lehigh Commons Personal Care Home, including visits on December 7, 2017 and March 9, 2018.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found, including issues with carbon monoxide detector batteries, fire drill procedures, staff qualifications and training, medication administration, and safety equipment. Plans of correction were submitted with ongoing compliance monitoring.
Citations (14)
55 Pa.Code §2600.18 - The batteries in the carbon monoxide detector near the furnace were not dated as required by the Care Facility Carbon Monoxide Alarm Standards Act.
55 Pa.Code §2600.29a(b)(1) - The home conducted a fire drill while a hospice resident was actively dying and did not evacuate that resident to a fire safe area.
55 Pa.Code §2600.29a(b)(2) - The home did not obtain written authorization indicating that Resident #1 was not to evacuate during monthly fire drills.
55 Pa.Code §2600.29a(b)(4) - Staff did not simulate evacuation properly during the fire drill; the simulation was incomplete.
55 Pa.Code §2600.29a(b)(10) - The resident's assessment and support plan was not updated to reflect evacuation needs during a fire drill.
55 Pa.Code §2600.54(a) - Direct care staff person A was retained beyond the 30-day provisional period pending approval of a high school diploma from Poland.
55 Pa.Code §2600.65(d) - Personnel files for direct care staff did not document completion of required Department-approved training.
55 Pa.Code §2600.65(f) - Direct care staff person A was missing mandatory elements of the 2016 annual training, including medication self-administration and care for residents with mental illness or intellectual disability.
55 Pa.Code §2600.65(g) - Direct care staff person A did not receive required fire safety training during 2016.
55 Pa.Code §2600.81(b) - An enabler bar attached to a resident's bed was uncovered and posed a risk of injury.
55 Pa.Code §2600.132(h) - Resident #1 was not evacuated during a fire drill; only 61 of 62 residents were evacuated.
55 Pa.Code §2600.187(a) - Resident #2's medication administration record was not initialed after administration of Atorvastatin on 12/6/17.
55 Pa.Code §2600.187(b) - Resident #3's medication administration record had an incorrect date written for medication administration on 11/29/17.
55 Pa.Code §2600.233(c) - Directions for use of the home's magnetic lock door system were not posted near the device.
Report Facts
Number of Residents Served: 69
Number of Residents Served in Secured Dementia Care Unit: 13
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 10
Number of Residents Age 60 or Older: 68
Number of Residents with Mental Illness: 1
Number of Residents with Mobility Need: 19
Number of Residents Not Evacuated: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Howanitz | Executive Director | Named as administrator and legal entity representative on multiple pages |
Inspection Report — Aug 25, 2017
Complaint Investigation
Date: Aug 25, 2017
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident and fine related to alleged abuse at the facility.
Complaint Details
The complaint investigation substantiated abuse by a staff member who was suspended immediately and terminated after findings by Adult Protective Services. The facility notified the resident's family, physician, and relevant authorities and will provide additional training and ongoing monitoring.
Findings
A violation of 55 Pa.Code §2600.42(c) was found where a staff person was rough with a resident, pulling the resident's arm and yelling at the resident during AM care. The alleged perpetrator was suspended and later terminated following the investigation.
Citations (1)
55 Pa.Code §2600.42(c) - A resident was not treated with dignity and respect when a staff person was rough, pulled the resident's arm, and yelled at the resident during AM care on 8/18/17.
Report Facts
Number of Residents Served: 69
Number of Residents Served in Secured Dementia Care Unit: 13
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 9
Number of Residents Age 60 or Older: 69
Number of Residents with Mental Illness: 1
Number of Residents with Mobility Need: 19
Number of Residents with Physical Disability: 1
Inspection Report — Mar 28, 2017
Complaint Investigation
Date: Mar 28, 2017
Visit Reason
The inspection was conducted as a complaint investigation at Lehigh Commons Personal Care Home.
Complaint Details
The inspection was triggered by a complaint. The violation regarding the missing Influenza poster was substantiated.
Findings
The facility was found to be noncompliant with 55 Pa.Code Chapter 2600 due to the absence of the Department of Health's Influenza poster as required by the Influenza Awareness Act. A plan of correction was submitted to post the required poster by May 3, 2017.
Citations (1)
55 Pa.Code §2600.18 requires a home to comply with applicable laws and regulations. The facility did not have the Department of Health's Influenza poster posted as required by the Influenza Awareness Act.
Report Facts
Number of Residents Served: 59
Number of Residents Served in Secured Dementia Care Unit: 13
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 10
Number of Residents 60 Years of Age or Older: 66
Number of Residents with Mental Illness: 1
Number of Residents with Mobility Need: 21
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marc Heil | Administrator | Named in facility header information |
| Ryan Novak | Inspector | Conducted the inspection on 03/28/2017 |
| Thomas J. Howanitz | Executive Director | Signed plan of correction |
Notice — Mar 1, 2017
Date: Mar 1, 2017
Visit Reason
Notification of renewal application receipt and explanation of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it serves as a license renewal confirmation and informational notice.
Report Facts
Inspection Report — Feb 10, 2017
Complaint Investigation
Date: Feb 10, 2017
Visit Reason
The inspection was conducted as a complaint investigation at Lehigh Commons Personal Care Home on February 10, 2017.
Complaint Details
The inspection was triggered by a complaint. Specific substantiation status is not stated.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found related to staffing hours, evacuation procedures, sanitary practices, medication storage, and medication administration. Plans of correction were submitted to address these issues with ongoing monitoring by the Resident Care Director or designee.
Citations (7)
55 Pa.Code §2600.57(c) - Direct care staff were not available to provide the required 2 hours per day of personal care services to residents with mobility needs on 2/5/17 and 2/6/17.
55 Pa.Code §2600.57(d) - The facility failed to provide at least 75% of personal care service hours during waking hours on 2/5/17 and 2/6/17.
55 Pa.Code §2600.60(a) - Staffing was insufficient to safely evacuate residents requiring assistance during emergencies; only 3 staff were present from 11pm to 7am on 2/6/17.
55 Pa.Code §2600.132(h) - Staff failed to fully evacuate residents during fire drills and did not have adequate space in stair towers for wheelchairs.
55 Pa.Code §2600.163(b) - Staff did not follow proper sanitary practices and glove usage in the kitchen, contributing to a gastrointestinal virus outbreak.
55 Pa.Code §2600.183(d) - Insulin medications were not properly labeled or discarded according to manufacturer instructions, risking resident safety.
55 Pa.Code §2600.187(d) - The facility failed to follow prescriber directions for medication administration times, with some medications given outside prescribed time frames.
Report Facts
Number of Residents Served: 62
Number of Residents in Secured Dementia Care Unit: 13
Number of Current Hospice Residents: 4
Number of Residents Age 60 or Older: 61
Number of Residents with Mobility Need: 24
Number of Residents with Mental Illness: 1
Number of Residents with Intellectual Disability: 0
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas J. Howanitz | Executive Director | Signed plans of correction and named in report cover letter. |
| Marc Heil | Administrator | Named as facility administrator in violation report header. |
Inspection Report — Dec 13, 2016
Complaint Investigation
Date: Dec 13, 2016
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Complaint Details
The inspection was triggered by a complaint. Specific substantiation status is not stated.
Findings
Multiple violations related to staffing, medical evaluations, resident assessments, support plans, and documentation were identified. Plans of correction were partially implemented with ongoing monitoring by the administrator.
Citations (5)
55 Pa.Code §2600.60(a) - Staffing did not meet resident needs during overnight shifts, with insufficient direct care staff for residents requiring two-person assist evacuations.
55 Pa.Code §2600.141(a)(1) - A resident's initial medical evaluation was completed more than 60 days prior to admission, exceeding the required timeframe.
55 Pa.Code §2600.225(a) - Resident assessments were incomplete for several residents as of the inspection date, missing required documentation within 15 days of admission.
55 Pa.Code §2600.227(d) - A resident's support plan did not reflect fall risk status despite multiple unwitnessed falls in two months.
55 Pa.Code §2600.227(g) - A resident and their designee did not sign and date the Resident Assessment and Support Plan as required.
Report Facts
Number of Residents Served: 61
Number of Residents Served in Secured Dementia Care Unit: 12
Number of Current Hospice Residents: 4
Number of Hospice Residents in Past Year: 10
Residents Age 60 or Older: 60
Residents with Mental Illness: 1
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marc Heil | Administrator | Named as responsible for monitoring and ongoing compliance in plans of correction |
| Cindy Yellenic | Department representative on-site during inspection |
Inspection Report — Nov 1, 2016
Complaint Investigation
Date: Nov 1, 2016
Visit Reason
The inspection was conducted as a partial, unannounced investigation triggered by an incident.
Complaint Details
The inspection was incident-driven and unannounced. The violation involved the fire alarm system becoming inoperative and delayed repair.
Findings
The facility was found to have violations related to fire safety, specifically a fire alarm system that became inoperative due to water damage and was not repaired within the required 48 hours. A plan of correction was submitted detailing evacuation procedures and repair timelines.
Citations (1)
55 Pa.Code §2600.130(g) requires repair of inoperative smoke detectors or fire alarms within 48 hours. The fire alarm system became inoperative on 8/31/2016 and was not repaired until 9/9/2016.
Report Facts
Number of Residents Served: 69
Total Daily Staff: 89
Waking Staff: 67
Number of Current Hospice Residents: 2
Number of Hospice Residents in past year: 10
Number of Residents 60 Years or Older: 69
Number of Residents with Mobility Need: 20
Number of Residents with Physical Disability: 1
Inspection Report — Oct 28, 2016
Complaint Investigation
Date: Oct 28, 2016
Visit Reason
The inspection was conducted as a complaint investigation regarding alleged violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes.
Complaint Details
The complaint investigation substantiated violations related to resident abuse, neglect, and failure to comply with reporting and care requirements.
Findings
Multiple violations were found including failure to report suspected abuse, leaving a resident unattended in the bathroom for approximately 2 hours, inadequate assistance with activities of daily living, lack of dignity and respect in resident care, incomplete resident assessments, and failure to update resident support plans.
Citations (6)
55 Pa.Code 2600.15(a) - The home failed to immediately report suspected abuse of a resident as required by law.
55 Pa.Code 2600.16(c) - The home did not submit an incident report regarding alleged abuse when a resident was left unattended in the bathroom for approximately 2 hours.
55 Pa.Code 2600.23(a) - A resident requiring assistance with showers and ADLs was left unattended in the bathroom for 2 hours and did not receive required assistance.
55 Pa.Code 2600.42(c) - A resident was left unattended in the bathroom for approximately 2 hours and was not treated with dignity and respect by staff.
55 Pa.Code 2600.225(c) - Resident assessments were incomplete; one resident's most recent assessment was from 2015 and not updated timely.
55 Pa.Code 2600.227(d) - Resident support plans were not updated to reflect current care needs, including assistance with meals.
Report Facts
Number of Residents Served: 67
Total Daily Staff: 87
Waking Staff: 65
Number of Current Hospice Residents: 4
Number of Hospice Residents in past year: 10
Residents Age 60 or Older: 66
Residents with Mobility Need: 20
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marc Heil | Administrator | Named as facility administrator and legal entity representative signing violation reports |
Inspection Report — Oct 4, 2016
Complaint Investigation
Date: Oct 4, 2016
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
The inspection was triggered by a complaint. Specific violations related to staffing and fire department notification were substantiated.
Findings
The facility was found to have staffing deficiencies related to meeting residents' physical assistance needs, especially in the Secured Dementia Care Unit. Additionally, the facility failed to notify the local fire department correctly regarding resident mobility needs and evacuation assistance.
Citations (2)
55 Pa.Code 2600.60(a) - Staffing was insufficient to meet the needs of residents requiring physical assistance, particularly during night shifts and in the Secured Dementia Care Unit.
55 Pa.Code 2600.124 - The facility's notification to the fire department did not include total capacity or a clear description of residents' mobility needs and evacuation assistance required.
Report Facts
Number of Residents Served: 69
Number of Residents in Secured Dementia Care Unit: 14
Residents 60 Years or Older: 68
Residents with Mobility Need: 32
Residents with Physical Disability: 2
Number of Hospice Residents in Past Year: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marc Heil | Administrator | Named as the facility administrator and signed the plan of correction. |
| Jesse Hummel | Department representative on-site during inspection. |
Inspection Report — Sep 15, 2016
Complaint Investigation
Date: Sep 15, 2016
Visit Reason
The inspection was conducted as a complaint investigation at Lehigh Commons on September 15, 2016.
Complaint Details
The inspection was complaint-driven as stated on page 2 under Reason(s) for Inspection(s).
Findings
The inspection identified violations related to notification to the fire department, medication administration records, prescriber directions, and resident support plans. Plans of correction were partially implemented with ongoing monitoring.
Citations (4)
55 Pa.Code §2600.124 - The home failed to notify the local fire department in writing of the address, bedroom locations, and residents with mobility issues. Two residents requiring assistance to evacuate were not listed as immobile.
55 Pa.Code §2600.187(a) - Resident #1's medication administration record was missing initials on several days, and blood glucose readings were inconsistently recorded.
55 Pa.Code §2600.187(d) - The home did not follow the prescriber's directions when a medication order for Furosemide was changed but not administered as ordered for several days.
55 Pa.Code §2600.227(d) - Resident #1's support plan did not reflect the correct diet; the resident was on a no concentrated sweet, low sodium, and low cholesterol diet but documentation was inconsistent.
Report Facts
Number of Residents Served: 71
Number of Current Hospice Residents: 5
Number of Hospice Residents in past year: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marc Heil | Administrator | Named as Administrator on page 2 and signed plan of correction pages. |
| Cindy Yellenic | Department representative on-site during inspection on 09/15/2016. |
Inspection Report — Apr 27, 2016
Renewal
Date: Apr 27, 2016
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services on April 27, 2016, to assess compliance with 55 Pa. Code Chapter 2600 for the Personal Care Home Lehigh Commons.
Findings
The inspection identified violations related to refund processing, staffing for resident evacuation, and medication administration training. Plans of correction were submitted addressing delayed refunds, increased staffing for evacuation needs, and annual medication training documentation.
Citations (3)
55 Pa.Code §2600.28(b)(2) - Refunds must be made within 30 days of the resident's discharge. A refund of $5,906.00 was delayed due to miscommunication between the facility and corporate accounts payable.
55 Pa.Code §2600.60(a) - Staffing must meet residents' needs as specified in assessments and support plans. On 04/27/15, 69 residents were present with 12 in secured dementia and 67 in personal care; staffing was insufficient for evacuation needs.
55 Pa.Code §2600.182(b) - Prescription medication must be administered by qualified personnel. The annual medication administration training did not include a Student Examination Data Summary sheet for medication technicians A, B, C, D, E, F, and G.
Report Facts
Number of Residents Served: 59
Refund Amount: 5906
Number of Residents 60 Years or Older: 69
Number of Residents in Secured Dementia Unit: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James C O'Brien | Executive Director | Named in plan of correction and signature on violation reports |
Notice — Apr 14, 2016
Date: Apr 14, 2016
Visit Reason
This document serves as a renewal notice and license issuance for the Personal Care Home facility Lehigh Commons, confirming the facility's authorized capacity and informing about the requirement for annual inspections.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
Document — April 19, 2017
Date: April 19, 2017
Visit Reason
The document does not contain any information regarding an inspection or regulatory visit.
Findings
No findings or content are available due to lack of readable text.
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