Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Lehigh Llc during CMS and state inspections, most recent first.
Improper food storage and labeling were observed in the dietary department. Surveyors found ice accumulation in the walk-in freezer and six trays of pre-poured juices in a reach-in refrigerator with no label or date. An ADM confirmed the juices should have been labeled and dated.
Unsafe and Poorly Maintained Resident Environment: Surveyors observed multiple environmental deficiencies across TCU, 1A, 2B, and 2C, including food debris in a microwave, stained and damaged ceiling tiles, holes in walls, missing baseboard, broken dresser shelves taped together, marred and chipped bathroom walls, rust and peeling paint on toilet equipment, broken and missing air vents, debris in a wall unit HVAC, torn flooring, broken blinds, rusty shower ceiling tiles, and mechanical lifts with missing rubber strips and rust.
Failure to Provide Timely ADL Assistance and Hygiene Care: Several residents who needed staff help with bathing, grooming, personal hygiene, and incontinence care were observed with poor hygiene or delayed care. Residents with cognitive impairment, dementia, chronic illness, and mobility limitations were found with dirty or unkempt hair, facial hair, dirty nails, and soiled briefs, and records showed no documented bathing or grooming care for weeks in some cases. One resident’s incontinence care was delayed after a call light request, and the DON confirmed the lack of documented ADL assistance.
Failure to assess residents for self-administration of medications. Two residents were observed handling prescribed medications without the required Interdisciplinary Team assessment documented. One resident with paraplegia, Parkinson’s disease, and chronic pain syndrome had topical medications left unsecured at the bedside and stated he self-administered them as needed. Another resident with dementia, hallucinations, mild cognitive impairment, atrial fibrillation, and HTN was observed taking scheduled meds in his room without a nurse present, despite a physician order stating he may not administer his own medications. The DON confirmed neither resident had been assessed per policy.
A resident with intact cognition, generalized weakness, and COPD was found in bed on multiple observations with the call system device tucked inside the nightstand drawer and out of reach. The care plan directed staff to keep the call light within reach, and the DON confirmed it should have been placed within the resident’s reach.
Failure to provide and document restorative ROM exercises for three residents. Residents with muscle weakness, dementia, and a below-the-knee amputation had restorative nursing programs for active and passive ROM to maintain strength and mobility, but nursing records showed multiple days with no evidence the exercises were completed and no refusals were documented. The DON confirmed the exercises should have been completed.
Failure to Place Ordered Bilateral Fall Mats: A resident with CVA, left hemiplegia, generalized weakness, and HTN had a physician order and care plan directing padded fall mats on both sides of the bed while in bed. Although the resident was dependent for bed mobility and transfers and had a fall risk/history of falls, staff observed only one padded fall mat on the right side of the bed, and the DON confirmed bilateral mats were supposed to be in place.
Failure to use EBP and proper PPE was cited when a nurse aide provided care to a resident with an indwelling catheter, bowel incontinence, and dependence for catheter care and brief changes without wearing a gown. The aide changed soiled briefs and linens, then left the room without removing soiled gloves or performing hand hygiene before entering another resident’s room; the DON confirmed staff should have used appropriate PPE and removed used gloves before exiting the room.
A resident with dementia, DM, diabetic peripheral angiopathy, severe cognitive impairment, and hospice-level wound care had multiple right foot and heel wounds that were not treated as ordered. The wound consultant’s updated instructions for saline cleansing, crushed metronidazole, Betadine-moistened gauze, and a gauze roll were not accurately transcribed into the physician orders, an older toe order was left active, and several wound treatments and heel boot applications were not documented as completed. Staff later found worsening wound conditions, including odor, drainage, and maggots in the wound bed.
Food and drinks on the 1st floor TCU were not served at proper temperatures and were reported as unpalatable. Resident Council minutes and resident interviews described meals as late, cold, and often not palatable, and a test tray audit found hot items below the required temp and apple juice above the required cold temp standard. The ADM confirmed the food did not meet expected temperature standards.
Failure to provide timely dressing assistance and respect resident preferences: Two residents who required ADL help and had care plans for staff assistance remained in bed in night clothes after pressing call bells for help. One resident with Parkinson’s disease and dementia and another resident with hemiplegia after a stroke both stated they preferred to be up before 9 a.m., but staff did not promptly assist them with dressing; the DON confirmed the delay.
A resident with a history of fractured femur, CVA, and osteoarthritis had a physician order for diclofenac sodium gel to be applied to the lower extremities four times daily for pain, but multiple scheduled doses were not given because the medication was not available from the pharmacy. Documentation on the TAR indicated missed applications with references to nursing notes, which stated the gel was unavailable, and the DON confirmed that the ordered medication was not applied as prescribed due to pharmacy non-availability.
Two residents with intact cognitive abilities were found self-administering medications, including Fluticasone nasal spray, multivitamin gummies, Tylenol, and CBD gummies, without documented interdisciplinary assessment or secured storage, contrary to facility policy.
A resident with multiple sclerosis and diabetes was inaccurately coded as being on dialysis in the MDS assessment, despite no supporting documentation in the clinical record. The DON confirmed the error during staff interview.
A resident who was dependent on staff for all ADLs, including grooming and personal hygiene, was repeatedly observed lying in bed with dirty fingernails and not dressed, indicating that staff did not provide the necessary assistance as required by the care plan and clinical assessment.
A resident with hypertension and heart failure received Propranolol HCI on multiple occasions when their systolic blood pressure was below the physician-ordered threshold. The DON confirmed that staff administered the medication outside of the prescribed parameters.
A resident at risk for pressure ulcers and with a current heel wound was observed multiple times without prescribed Medix boots in place, despite physician orders and care plan interventions requiring their use at all times. The boots were found on the floor, and the resident's heels were directly on the bed, indicating staff did not follow necessary pressure ulcer prevention measures.
A resident with cognitive impairment and multiple diagnoses fell while returning to bed. Although x-rays were ordered following the incident, the responsible party was not informed until the next day, contrary to the facility's protocol requiring immediate notification.
The facility failed to maintain sanitary conditions in the kitchen, with the dish machine not achieving the correct sanitizer concentration and black substance on surrounding walls. A dietary employee did not check the sanitizer concentration, and the Director of Dietary confirmed this was against protocol.
The facility failed to maintain a clean and safe environment in two shower rooms. Observations revealed dirty and damaged shower chairs, a leaking shower head, and dirty lift wheels in both the first-floor and second-floor central baths.
A facility failed to accurately complete the MDS assessment for a resident receiving hospice services. Despite a physician's order for hospice care, the MDS did not reflect this status. The DON confirmed the oversight during an interview.
A resident with congestive heart failure had a physician's order for daily weight monitoring and provider notification for significant weight gain. The facility failed to obtain the resident's weight on multiple occasions and did not notify the physician of a 3.7-pound weight gain in 24 hours. The DON confirmed these deficiencies.
The facility failed to implement interventions for two residents to prevent decline in range of motion. A resident with muscle weakness did not receive a recommended daily restorative nursing program for arm movement. Another resident with dementia and hemiplegia was observed without a required carrot splint on her right hand, despite physician orders and care plan instructions.
Improper Food Storage and Labeling in Dietary Department
Penalty
Summary
The facility failed to store food in a sanitary manner in the dietary department. During a kitchen tour, surveyors observed an accumulation of ice on the floor on the left side of the walk-in freezer entryway and on the ceiling on the right side of the fan. In a reach-in refrigerator, six trays of pre-poured juices were found with no label or date. The Assistant Dietary Manager confirmed that the pre-poured juices should have been labeled and dated.
Unsafe and Poorly Maintained Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment on four of four nursing units, including TCU, 1A, 2B, and 2C. During observations on July 26, 2026, the inside of the microwave in the TCU nourishment room had food debris throughout. In room [ROOM NUMBER]-B, there was a brown stain on the ceiling tile near the window. In room [ROOM NUMBER], there were six holes in the wall and a three-foot area of baseboard missing in front of bed A, and the dresser for bed A had three broken shelves held together with tape. In the bathroom, the wall on the right side was marred and paint was chipped away. Additional observations showed a quarter-sized hole in the wall in room [ROOM NUMBER] in front of bed A, along with a stained ceiling tile above the toilet, a marred wall, and chipped paint in the bathroom. In room [ROOM NUMBER], there was substantial rust and peeling paint on the front of the raised toilet seat bar. In room [ROOM NUMBER], there were multiple broken and missing air vents and debris inside the wall unit air conditioner/heater. In room [ROOM NUMBER], the wood flooring was torn between bed A and the wall. On July 27, 2026, room [ROOM NUMBER] B had broken window blinds and three ceiling tiles with brown stains, room [ROOM NUMBER] A had brown marks on the wall behind the bed and a brown stain on the ceiling tile to the left of the bed, and the TCU shower room had rusty metal ceiling tiles in the first shower stall to the left of the doorway. A mechanical lift was observed with a missing rubber strip on one footrest and rust on the other footrest, and another mechanical lift was missing a rubber strip on the right side of the footrest.
Failure to Provide Timely ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to ensure appropriate assistance with bathing and personal hygiene for four residents who required staff help with activities of daily living. Resident 7 had diagnoses including bladder cancer, muscle weakness, and polyneuropathy, and the MDS indicated severe cognitive impairment with a need for staff assistance with hygiene and self-care. The care plan directed staff to assist with ADLs due to immobility and bladder cancer, yet the resident was repeatedly observed with dirty nails, messy and unclean hair, white flakes on clothing, and long facial hair. The clinical record showed no evidence of a shower or bath, hair, nail, foot care, or facial hair grooming since June 30, 2026, and there were no documented refusals. Resident 13 had anxiety, depression, and dementia, with the MDS showing moderate cognitive impairment and substantial assistance needed for bathing and grooming. The care plan identified ADL deficits related to confusion and impaired balance and directed staff to assist with bathing, but the resident was repeatedly observed with facial hair on the upper lip and disheveled hair. Resident 13 stated a preference for showers, yet the record showed no evidence of a shower or bath, hair care, or facial hair grooming since June 30, 2026, and no refusals were documented. Resident 114 had anxiety, depression, and chronic respiratory failure, with mild cognitive impairment and substantial assistance needed for bathing and personal hygiene; she was observed with dirty, unkempt hair and stated she had gone weeks without a shower, while the record showed no shower, bath, or hair care since June 30, 2026. Resident 121 had a rotator cuff tear, diabetes, obesity, and generalized muscle weakness, and was dependent on staff for toileting, personal hygiene, and bed mobility. During the survey, the resident reported a wet and soiled brief, activated the call bell, and incontinence care was not provided until 35 minutes later. The DON confirmed there was no documented evidence that staff assisted the residents with ADLs to maintain proper grooming and hygiene, and that incontinence care should be performed timely.
Failure to assess residents for self-administration of medications
Penalty
Summary
The facility failed to assess whether two residents were clinically appropriate to self-administer medications. The facility policy required the Interdisciplinary Team to determine which medications could be safely self-administered and to assess the resident’s physical capacity, cognitive status, and ability to store medications securely, with the results documented in a Self Administration of Medication Assessment. For one resident, the clinical record showed diagnoses including paraplegia, Parkinson’s disease, and chronic pain syndrome, and the MDS indicated intact cognition but dependence on staff for activities of daily living. During observation, a tube of ketoconazole cream and a bottle of Derma-Smoothe/fluocinolone scalp oil were found unsecured on the bedside table, and the resident stated he self-administered both medications as needed; the DON confirmed the resident had not been assessed for self-administration as required by policy. For the second resident, the clinical record showed diagnoses including dementia, hallucinations, mild cognitive impairment, atrial fibrillation, and hypertension. Although the MDS recorded intact cognition, the resident was observed taking five scheduled morning medications in his room without a nurse present, and the resident stated he was taking his medications. A physician order stated the resident may not administer his own medications, and there was no evidence that the Interdisciplinary Team had assessed him for self-administration. The LPN confirmed she left the medications at the bedside and left the room, the nurse unit manager confirmed there was no order allowing self-administration, and the DON confirmed the resident had not been assessed per facility policy.
Call Light Not Kept Within Resident’s Reach
Penalty
Summary
The facility failed to ensure that a call system was accessible for one resident who had diagnoses including high blood pressure, prostate cancer, generalized muscle weakness, and COPD. The resident’s MDS assessment dated May 11, 2026, showed intact cognition and dependence on staff for activities of daily living, including toileting, dressing, and personal hygiene. The care plan identified the resident as at risk for falls and directed staff to keep the call light within reach for assistance as needed. However, on multiple observations, the resident was found in bed with the call system device tucked inside the top drawer of the nightstand, out of reach. The DON confirmed that the call system device should have been placed within the resident’s reach.
Failure to Document and Provide Restorative ROM Exercises
Penalty
Summary
The facility failed to implement restorative nursing interventions to maintain and/or improve range of motion for three residents with limited ROM. Facility policy required staff to document restorative treatment daily or as described in the care plan, including the number of minutes performed and whether the treatment was refused or withheld. Resident 4 had diagnoses including muscle weakness, epilepsy, and depression, and the MDS showed moderate cognitive impairment, impaired ROM of both upper extremities, dependence for personal hygiene and dressing, and a restorative nursing program for active and passive ROM exercises. The care plan called for active and passive ROM to the upper and lower extremities, and nursing documentation on June 11, 2026, stated the resident was to continue ROM exercises to prevent contractures and was tolerating them well. Review of records showed no documentation that Resident 4 received the ROM exercises for 9 of 30 days, with no documented refusals. Resident 13 had diagnoses including anxiety, depression, and dementia, with moderate cognitive impairment, assistance needed for most ADLs, substantial assistance with bathing, and a restorative program for active ROM exercises. Her care plan called for active ROM to all extremities, but there was no evidence the exercises were performed for 10 of 30 days and no refusals were documented. Resident 84 had diagnoses including a below-the-knee amputation, diabetes, and depression, with no cognitive impairment, impaired lower extremity function, substantial assistance needed for most ADLs, and a restorative program for active ROM exercises. Her care plan called for cues, reminders, and physical assistance as needed, but there was no evidence the exercises were performed for 10 of 29 days and no refusals were documented. The DON confirmed the restorative nursing exercises were not documented on the listed dates and should have been completed.
Failure to Place Ordered Bilateral Fall Mats
Penalty
Summary
The facility failed to implement safety interventions for one resident who was admitted with cerebral infarction, left-sided hemiplegia, generalized muscle weakness, and high blood pressure. The resident’s physician ordered padded fall mats on both sides of the bed while the resident was in bed, and the care plan identified the resident as at risk for falls with a history of falls and directed staff to place mats on both sides of the bed. The MDS assessment indicated the resident was dependent and required two staff for bed mobility and transfers. During multiple observations, the resident was in bed with only one padded fall mat on the right side of the bed, and the DON confirmed that bilateral padded fall mats were to have been in place.
Failure to Use Enhanced Barrier Precautions and PPE
Penalty
Summary
Provide and implement an infection prevention and control program was cited after staff failed to use enhanced barrier precautions and proper PPE during care for a resident with an indwelling catheter. The resident had diagnoses including neuromuscular dysfunction of the bladder with urinary retention, chronic kidney disease, urinary tract infection, and diarrhea. The resident was always incontinent of bowel and dependent on staff for catheter care and changing briefs. During observation, the resident reported that her brief was soiled and needed to be changed. A nurse aide then changed the resident’s brief and soiled bed linens without wearing a gown, left the room without changing the soiled gloves or performing hand hygiene, and entered another resident’s room. The DON later confirmed that staff should have used appropriate PPE during the resident’s care and removed used gloves before exiting the room.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to provide prescribed wound treatments for a resident with multiple right foot and heel wounds, including arterial wounds and end-of-life skin failure wounds, in accordance with wound care recommendations and physician orders. The resident had dementia, diabetes mellitus, diabetic peripheral angiopathy, severe cognitive impairment, and was dependent on staff for care. He was also receiving hospice care for metastatic bladder cancer and palliative wound care for his wounds. A wound care consultation on June 2, 2026 changed the treatment for the right fifth toe and right heel wounds to cleansing with normal saline, application of crushed metronidazole powder, and coverage with Betadine-moistened gauze secured with a large surgical pad and rolled gauze wrap. Subsequent wound care notes continued those recommendations. However, the physician orders entered into the treatment record did not include the rolled gauze wrap, and the prior order for the fifth toe to be treated twice daily and left open to air was not discontinued in the treatment administration record even though the wound care recommendation had changed. The record also showed discrepancies between the consultant’s recommendations and the orders entered for the resident’s wound care. The treatment administration record showed no documented evidence that evening wound care was provided on June 12, 26, and 27 for multiple right foot wounds, and there was no documented evidence that bilateral heel boots were applied on the evening shift of June 26. Staff interviews confirmed the transcription discrepancy and the lack of documentation for the missed treatments. Later, hospice and nursing staff found worsening wound conditions, including increased eschar, strong odor, drainage, and maggots in the wound bed. The wound care nurse practitioner confirmed that the gauze roll dressing was intended to secure the Betadine-soaked gauze on the wounds, and the attending PA confirmed the order should have included the rolled gauze and that the prior fifth toe order should have been discontinued.
Food Served at Improper Temperatures
Penalty
Summary
Food and drink were not provided at a palatable and appetizing temperature on the 1st floor TCU. Resident Council minutes from January through May 2026 documented resident complaints that food was served cold and was not palatable. During interviews on June 4, 2026, Residents 1 through 10 stated that meals were often late, usually the wrong temperature, and often unpalatable. Facility documentation for test tray meal evaluation required hot entree, starch, and vegetable items to be at least 135 F and cold drinks to be 41 F or below at point of service, but a test tray audit found the chicken thigh with onion gravy at 127 F, potato wedges at 103 F, mixed vegetables at 109 F, and apple juice at 54 F. The meal was not palatable to taste, and the Administrator confirmed the food did not meet the expected temperature standards.
Failure to Provide Timely Dressing Assistance and Respect Resident Preferences
Penalty
Summary
The facility failed to provide timely assistance with dressing and morning care to two residents, both of whom required help with activities of daily living and had care plans directing staff to assist with transfers, movement, and dressing. Resident 1 had diagnoses including Parkinson’s disease, muscle weakness, and dementia, and the MDS indicated moderate cognitive impairment. On June 4, 2026, Resident 1 was observed in bed in night clothes at 10:15 a.m., with the call bell activated at 10:30 a.m. and again at 10:44 a.m. By 11:00 a.m. and 11:28 a.m., he remained in bed in his night clothes. He stated that he had asked the nurse who responded to his call bell both times to assist him with dressing for the day, but the nurse left without providing or offering assistance. He also stated that he preferred to get out of bed before 9:00 a.m. Resident 10 had diagnoses including hemiplegia and hemiparesis due to a stroke and a seizure disorder, and the MDS indicated she required assistance with activities of daily living and did not have cognitive impairment. Her care plan also directed staff to assist with transfers, movement, and dressing. On June 4, 2026, her call bell was observed activated at 10:41 a.m. At 10:44 a.m., she stated that she was waiting for an aide to assist her with dressing, that she preferred to be out of bed before 9:00 a.m., and that she had pressed the call bell twice since 8 a.m. but staff turned it off without offering assistance. At 11:25 a.m., she was still in bed in her night clothes, and later stated that she was not assisted to dress until 12:28 p.m. The DON confirmed that Residents 1 and 10 had not been provided timely assistance to maintain their dignity and respect their preferences.
Failure to Obtain and Administer Ordered Pain Medication
Penalty
Summary
The facility failed to ensure that a physician-ordered medication was available and administered as prescribed for one resident. The resident had diagnoses including a fractured femur, a stroke, and osteoarthritis, and on February 7, 2026, a physician ordered diclofenac sodium external gel to be applied to the resident’s lower extremities four times daily for pain related to osteoarthritis. Review of the February 2026 Treatment Administration Record showed that on February 8, 2026, all four scheduled applications, and on the morning of February 9, 2026, were marked as “other see notes.” Nursing notes for those dates documented that the diclofenac sodium gel was not applied because it was not available from the pharmacy. In an interview on February 11, 2026, the Director of Nursing confirmed that the medication had not been applied as ordered due to its unavailability from the pharmacy on the identified dates. This deficiency reflects a failure to provide pharmaceutical services to meet the resident’s needs and to ensure that ordered medications were obtained and available for use as prescribed.
Failure to Assess and Document Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess two residents for their ability to self-administer medications, as required by facility policy. For one resident with diagnoses including heart failure, diabetes, depression, and mild cognitive impairment, observations revealed multiple medications, including a bottle of Fluticasone nasal spray and multivitamin gummies, left unsecured on the bedside table. The resident reported self-administering these medications, but there was no documentation of an interdisciplinary team assessment or approval for self-administration, nor was there evidence of secured storage to prevent access by others. Another resident, diagnosed with high blood pressure and high cholesterol, was found to have a bottle of Tylenol and CBD gummies unsecured in a dresser drawer. This resident also reported self-administering Tylenol daily, with no documentation of an assessment for self-administration or secured storage of the medications. Interviews with staff and the administrator confirmed that neither resident had been assessed for self-administration of medications as required by facility policy.
Inaccurate MDS Assessment Coding for Resident
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident. Clinical record review showed that the resident had diagnoses of multiple sclerosis and diabetes. However, the MDS assessment incorrectly indicated that the resident was on dialysis, despite there being no documentation in the clinical record to support this. During an interview, the Director of Nursing confirmed that the MDS assessment was inaccurately coded and that the resident was not on dialysis at the time.
Failure to Provide Required ADL Assistance for Dependent Resident
Penalty
Summary
A resident with diagnoses including acute respiratory failure, chronic obstructive pulmonary disease, and a disorder of the brain was found to be dependent on staff for activities of daily living (ADLs) and had an ADL self-care deficit as documented in the clinical record and care plan. Observations conducted over two consecutive days revealed that the resident remained in bed with dirty fingernails, was not dressed, and had not received necessary assistance with grooming and personal hygiene from staff. Staff interviews confirmed that the resident was dependent on staff for all ADL care, yet appropriate assistance was not provided during the observed periods. These findings were based on clinical record review, direct observation, and staff interview, demonstrating a failure by the facility to ensure that required assistance with grooming and personal hygiene was provided to a resident who was unable to perform these tasks independently.
Failure to Follow Medication Administration Parameters
Penalty
Summary
Staff failed to follow physician's orders for a resident diagnosed with hypertension and heart failure. The physician had ordered Propranolol HCI to be administered twice daily, with specific parameters not to give the medication if the resident's systolic blood pressure was below 110 mm/Hg or if the heart rate was less than 55. Clinical record review showed that the medication was administered on three occasions in July and three occasions in August when the resident's systolic blood pressure was under 110 mm/Hg. The Director of Nursing confirmed that the medication was given outside of the established parameters.
Failure to Apply Pressure-Relieving Devices as Ordered
Penalty
Summary
A resident with diagnoses including acute respiratory failure, COPD, and a brain disorder was identified as being at risk for pressure sores and was dependent on staff for activities of daily living. The care plan included interventions to prevent skin impairment due to incontinence, such as elevating both heels off the bed with pillows and the application of Medix boots (pressure-relieving boots) at all times, as ordered by the physician. Clinical documentation indicated the presence of a pressure sore on the resident's right heel, with recommendations to float the heels using the prescribed boots. Despite these interventions and orders, multiple observations over two consecutive days revealed that the resident was lying in bed without the Medix boots in place, with both heels resting directly on the bed. The boots were seen on the floor in the resident's room during all observed periods. The DON confirmed that the boots were to be applied at all times as a pressure-relieving device. This failure to implement prescribed interventions resulted in the facility not providing necessary treatment and services to promote healing and prevent new pressure sores for the resident.
Failure to Notify Responsible Party of Resident's Fall
Penalty
Summary
The facility failed to notify the responsible party of a change in condition for one of the residents. The resident, who had diagnoses including diabetes, polyneuropathy, and muscle weakness, experienced a fall on October 10, 2024, at 7:25 a.m. while returning to bed after using the toilet. Following the fall, a nurse's note at 11:05 a.m. indicated new physician orders for x-rays of the right hip, pelvis, and thoracic and lumbar spine. However, the responsible party was not informed of the fall and the subsequent x-rays until the next day at 3:15 p.m. The Director of Nursing confirmed that staff are required to notify the responsible party immediately after such incidents.
Sanitation Deficiency in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. The dish machine did not achieve the appropriate concentration of sanitizer solution, which should be between 50-100 parts per million, for three full cycles. Additionally, there was a black substance on the walls surrounding the dish machine, indicating a lack of cleanliness. A backflow of water was observed from a drain on the dish room floor, and debris was found on a windowsill in the food preparation area. During an interview, a dietary employee admitted to not checking the concentration of the sanitizer solution during the morning operation. The Director of Dietary confirmed that staff are required to check and accurately record the concentration of the sanitizer solution while the dish machine is operating, as per the facility's protocol.
Facility Fails to Maintain Clean and Safe Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in two shower rooms, specifically the first-floor and second-floor central baths. Observations in the first-floor central bath revealed a shower chair with a black substance at the base, another chair with brown smudges on the seat and a black substance at the base, and a bariatric shower chair with hair on the seat and base. Additionally, the wheels on two lifts were dirty. In the second-floor central bath, a shower chair had a cracked seat, a leaking shower head was observed in the left shower stall, the wheels on three lifts were dirty, and a shower chair had a black substance under the seat.
Inaccurate MDS Assessment for Hospice Services
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the current status of a resident. Specifically, for one of the 24 sampled residents, the MDS assessment did not indicate that the resident was receiving hospice services, despite a physician's order for hospice care being in place since March 11, 2024. This discrepancy was confirmed during an interview with the Director of Nursing on July 12, 2024, who acknowledged that the MDS assessment did not accurately identify the resident's hospice status.
Failure to Implement Physician's Orders for Resident with CHF
Penalty
Summary
The facility failed to implement physician's orders for a resident diagnosed with congestive heart failure. The physician's order required staff to obtain a daily weight for the resident and notify the provider if there was a weight gain of two pounds or more in one day. However, there was no evidence that the resident's weight was obtained or that the resident refused to be weighed on several specified dates. Additionally, on one occasion, the resident experienced a 3.7-pound weight gain in 24 hours, but the staff did not notify the physician of this significant change. The Director of Nursing confirmed the lack of evidence regarding the weighing of the resident and the notification of the physician about the weight change.
Failure to Implement Range of Motion Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent further decline and improve range of motion for two residents. Resident 35, diagnosed with muscle weakness, was recommended a daily restorative nursing program (RNP) for active range of motion to both arms following an occupational therapy discharge assessment. However, there was no evidence that this program was implemented, as confirmed by the Director of Rehabilitation Services. Resident 54, who had diagnoses including dementia, hemiplegia, and a right hand contracture, was ordered by a physician to have a carrot splint applied to her right hand at all times. Despite this, multiple observations revealed that the splint was not in place while the resident was in her chair, indicating a failure to follow the care plan designed to prevent limitation in movement.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Macungie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mosser Nursing Home | 2.2 mi | ★★★★★ | 1 | 0 |
| Lehigh Valley Hospital Tsu | 2.3 mi | ★★★★★ | 1 | 0 |
| Cedarbrook Senior Care And Rehabilitation | 2.5 mi | ★★★★★ | 8 | 0 |
| Cedar Crest Post Acute | 3 mi | ★★★★★ | 13 | 0 |
| Luther Crest Nursing Facility | 3.3 mi | ★★★★★ | 5 | 0 |
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