Inspection Reports for The Birches of Lehigh Valley

PA, 18045

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Deficiencies per Year

8 6 4 2 0
2024
2025
Unclassified

Census Over Time

0 40 80 120 160 May '24 Aug '24 Mar '25 Apr '25 May '25 Jun '25 Sep '25
Census Capacity
Inspection Report Follow-Up Census: 88 Capacity: 130 Deficiencies: 1 Sep 11, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident and settlement review at the facility.
Findings
The facility failed to provide required supervision for a resident who wandered off and was missing for approximately one hour, posing potential harm. The submitted plan of correction was accepted and fully implemented, with ongoing quality assurance actions planned.
Deficiencies (1)
Description
Failure to provide required supervision for a resident who exited the building and wandered off, resulting in potential resident harm.
Report Facts
License Capacity: 130 Residents Served: 88 Secured Dementia Care Unit Capacity: 57 Secured Dementia Care Unit Residents Served: 36 Hospice Current Residents: 11 Residents Age 60 or Older: 88 Residents with Mobility Need: 9
Inspection Report Follow-Up Census: 90 Capacity: 130 Deficiencies: 1 Jun 10, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, to review the submitted plan of correction for the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction related to resident personal equipment, specifically addressing a wheelchair that was in disrepair prior to an incident. Continued compliance is required.
Deficiencies (1)
Description
Resident's wheelchair was 'wobbly' prior to the incident, indicating equipment was not in good repair as required.
Report Facts
License Capacity: 130 Residents Served: 90 Secured Dementia Care Unit Capacity: 57 Secured Dementia Care Unit Residents Served: 43 Hospice Current Residents: 4 Resident Support Staff: 54 Total Daily Staff: 198 Waking Staff: 149 Residents Age 60 or Older: 90 Residents with Mobility Need: 54
Inspection Report Census: 101 Capacity: 130 Deficiencies: 0 Jun 5, 2025
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 101 License Capacity: 130 Secured Dementia Care Unit Capacity: 50 Secured Dementia Care Unit Residents Served: 45 Hospice Current Residents: 6 Residents Age 60 or Older: 100 Residents with Mobility Need: 50
Inspection Report Complaint Investigation Census: 90 Capacity: 130 Deficiencies: 0 May 6, 2025
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on multiple dates in May 2025.
Findings
No regulatory citations or deficiencies were identified as a result of the inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 130 Residents Served: 90 Secured Dementia Care Unit Capacity: 57 Secured Dementia Care Unit Residents Served: 43 Current Hospice Residents: 4 Residents Age 60 or Older: 90 Residents with Mobility Need: 48
Inspection Report Enforcement Census: 90 Capacity: 130 Deficiencies: 2 Apr 17, 2025
Visit Reason
The inspection was conducted due to complaints and incidents reported at The Birches of Lehigh Valley, leading to multiple licensing inspections between February 12, 2025, and April 17, 2025.
Findings
The facility was found to have serious violations including staff impairment due to drug use during shifts and failure to adequately supervise residents, resulting in resident elopement and neglect. These violations led to the revocation of the facility's license.
Complaint Details
The inspection was complaint-related, triggered by incidents including staff impairment and resident elopement. The report details investigations and corrective actions taken in response to these complaints.
Deficiencies (2)
Description
Direct care staff persons were found to be under the influence of THC during their shift, impairing their ability to provide necessary personal care services safely.
Failure to respond to exit door alarms resulted in a resident eloping and being found outside in unsafe conditions, constituting neglect and abuse.
Report Facts
License Capacity: 130 Residents Served: 90 Secured Dementia Care Unit Capacity: 57 Residents Served in Secured Dementia Care Unit: 43 Total Daily Staff: 144 Waking Staff: 108 Plan of Correction Directed Completion Date: 2025
Inspection Report Complaint Investigation Census: 90 Capacity: 130 Deficiencies: 1 Apr 17, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation following a report of staff misconduct involving drug use during a shift.
Findings
The investigation found that a staff member was unresponsive due to consuming THC-laced gummies during their shift, which impaired their ability to provide care. Immediate actions included calling 911, terminating involved staff, and re-educating all staff on the zero-tolerance drug and alcohol policy.
Complaint Details
The visit was complaint-related due to an incident where staff person A was found unresponsive after consuming THC-laced gummies during their shift. The complaint was substantiated with immediate corrective actions taken including police involvement and staff terminations.
Deficiencies (1)
Description
Direct care staff persons shall be free from a medical condition, including drug or alcohol addiction, that would limit their ability to provide necessary personal care services with reasonable skill and safety.
Report Facts
License Capacity: 130 Residents Served: 90 Secured Dementia Care Unit Capacity: 57 Secured Dementia Care Unit Residents Served: 43 Hospice Current Residents: 4 Residents Age 60 or Older: 90 Residents with Mobility Need: 54
Inspection Report Complaint Investigation Census: 99 Capacity: 130 Deficiencies: 0 Apr 10, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at THE BIRCHES OF LEHIGH VALLEY facility on 04/10/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 130 Residents Served: 99 Secured Dementia Care Unit Capacity: 57 Secured Dementia Care Unit Residents Served: 45 Current Residents in Hospice: 3 Residents Age 60 or Older: 99 Residents with Mobility Need: 55 Total Daily Staff: 154 Waking Staff: 116
Inspection Report Complaint Investigation Census: 99 Capacity: 130 Deficiencies: 1 Mar 12, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance at THE BIRCHES OF LEHIGH VALLEY facility on 03/12/2025.
Findings
The facility was found to have a deficiency related to the Resident Assessment and Support Plan not being updated to reflect current resident needs including mobility, incontinence, and hospice services. The submitted plan of correction was accepted and fully implemented.
Complaint Details
The visit was complaint-related. The submitted plan of correction was accepted and determined to be fully implemented as of 03/12/2025.
Deficiencies (1)
Description
Resident Assessment and Support Plan dated 7-8-24 was not updated to reflect the residents’ current mobility needs, incontinence needs, or that the resident receives hospice services.
Report Facts
License Capacity: 130 Residents Served: 99 Secured Dementia Care Unit Capacity: 57 Secured Dementia Care Unit Residents Served: 44 Current Hospice Residents: 5 Residents Age 60 or Older: 99 Residents with Mobility Need: 56
Inspection Report Complaint Investigation Census: 100 Capacity: 130 Deficiencies: 5 Jan 7, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and incident involving resident abuse in the memory care neighborhood.
Findings
The inspection found multiple violations related to resident abuse, failure to report incidents timely, failure to follow prescriber's orders, and failure to update support plans. Corrective actions were accepted and implemented, including staff education, updated resident care plans, and ongoing quality assurance measures.
Complaint Details
The visit was complaint-related, triggered by an incident involving two residents engaging in inappropriate sexual acts that were not reported properly. The complaint was substantiated with findings of abuse and reporting violations.
Deficiencies (5)
Description
Failure to immediately report suspected abuse of residents in accordance with the Older Adult Protective Services Act.
Failure to report the incident to the Department within 24 hours as required.
Resident abuse involving inappropriate sexual acts between residents in the secured dementia care unit.
Failure to follow prescriber's orders due to missed medication administrations because medications were not available.
Failure to revise the support plan timely after an incident and discontinuation of 1-hour checks.
Report Facts
License Capacity: 130 Residents Served: 100 Secured Dementia Care Unit Capacity: 57 Secured Dementia Care Unit Residents Served: 43 Hospice Current Residents: 5 Residents with Mobility Need: 52 Residents Age 60 or Older: 100 Residents with Physical Disability: 1
Inspection Report Complaint Investigation Census: 85 Capacity: 130 Deficiencies: 3 Aug 29, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
The inspection found multiple violations including failure to report an incident to the Department, resident abuse incidents, and incomplete documentation in resident support plans. Corrective actions and plans of correction were accepted and implemented.
Complaint Details
The visit was complaint-related and involved substantiated incidents of resident abuse and failure to report incidents as required.
Deficiencies (3)
Description
Failure to report an incident involving a resident throwing hot soup at another resident to the Department’s Personal Care Home Regional Office.
Resident abuse incidents including physical altercations and inappropriate touching in the Secured Dementia Care Unit.
Resident support plan did not document 1:1 monitoring intervention for a resident with aggressive behaviors.
Report Facts
License Capacity: 130 Residents Served: 85 Residents in Secured Dementia Care Unit: 32 Hospice Residents: 3 Resident Support Staff: 128 Waking Staff: 96 Plan of Correction Follow-Up Date: 2024
Inspection Report Renewal Census: 75 Capacity: 130 Deficiencies: 6 Aug 6, 2024
Visit Reason
The inspection was conducted as a renewal inspection with an incident review at THE BIRCHES OF LEHIGH VALLEY facility on 08/06/2024.
Findings
The inspection found multiple deficiencies including unlocked electronic medication records, improperly stored poisonous materials, lint accumulation in dryers, combustible materials near heat sources, expired and undated medications, and missing posted codes for magnetic locks. All deficiencies had accepted plans of correction and were implemented by 09/19/2024.
Deficiencies (6)
Description
Electronic Medication Administration Record was unlocked and accessible on top of the medication cart near Room #115.
A tube of A&D ointment labeled as poisonous was found in Room #24's bathroom, accessible to a resident not assessed to handle poisons safely.
Lint was found in the lint trap of the far-right dryer in the laundry 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, posing a possible fire hazard.
Expired Lantus Solostar pen and undated medications were found in the medication cart for Residents #1 and #2.
Codes to operate magnetic locks near Room #24 were not posted.
Report Facts
License Capacity: 130 Residents Served: 75 Memory Care Capacity: 57 Memory Care Residents Served: 30 Current Hospice Residents: 3 Residents 60 Years or Older: 75 Residents with Mobility Need: 41 Total Daily Staff: 116 Waking Staff: 87
Inspection Report Follow-Up Census: 3 Capacity: 57 Deficiencies: 4 May 8, 2024
Visit Reason
The inspection was a partial announced follow-up visit conducted on 05/08/2024 to review the submitted plan of correction for the facility.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies related to trash receptacles, emergency telephone numbers, unobstructed egress, and combustible storage were corrected with ongoing audits planned to maintain compliance.
Deficiencies (4)
Description
The community restroom, outside the Director of Wellness’ office does not have a covered garbage can.
The telephone located in the entrance of the home does not have the emergency numbers posted on or near the phone.
The exit doors to the porch off the first-floor dining room exit to an enclosed porch/patio area. The doors do not note this is not an exit. Exit #3 had cardboard on the ground causing a tripping hazard and slowing egress.
PVC Primer container, a combustible material, was located next to the natural gas hot water heater, posing a fire hazard.
Report Facts
License Capacity: 57 Residents Served: 3 Staffing Hours: 3 Staffing Hours: 2

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