The Birches of Lehigh Valley

A resident's blood glucose reading was not noted on the medication administration record, and some readings in the glucometer were not found in the records.

The medication administration record did not include the initials of the staff person who administered a PRN medication.

Prescribed twice-daily blood sugar checks for a resident were not completed.

The first aid kit in the resident transportation vehicle was missing a thermometer.

Criminal history checks and hiring policies were not in accordance with the Older Adult Protective Services Act.

The written notification to the local fire department lacked current bedroom locations, evacuation assistance needs, and resident mobility census.

Discrepancies were noted between the resident's controlled substance record and the Narcotic Destruction Log regarding the number of pills remaining and destroyed.

A resident's medication administration record was initialed to indicate medication was taken before the resident actually received it, as the resident subsequently refused the dose.

The resident-home contract for Resident #1 was not signed by the resident or payor.

The resident-home contract for Resident #7 was not signed by the resident or payor.

The facility failed to properly document a resident's needs on the preadmission screening form, resulting in inadequate supervision that allowed a resident to wander from the facility.