Lutheran Community At Telford
Inspection history, citations, penalties and survey trends for this long-term care facility in Telford, Pennsylvania.
- Location
- 12 Lutheran Home Drive, Telford, Pennsylvania 18969
- CMS Provider Number
- 395804
- Inspections on file
- 18
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Lutheran Community At Telford during CMS and state inspections, most recent first.
A resident with multiple medical conditions and memory impairment was administered another resident's medications by an agency RN who did not properly verify the resident's identity using the electronic medication administration record, contrary to facility procedures as confirmed by the DON.
Surveyors determined that the facility did not provide documentation showing fire dampers were exercised within the required four-year interval, as confirmed by the Maintenance Director during interview.
The facility did not perform required testing of electrical receptacles at resident bed locations, including both hospital-grade and non-hospital grade outlets, as mandated by regulations. Documentation and interviews confirmed that testing for physical integrity, polarity, and grounding blade retention force was not conducted throughout the facility.
Surveyors found that the facility did not maintain required documentation for emergency generator testing and maintenance, including monthly load tests, transfer switch operations, annual load bank tests, preventative maintenance, and the 3-year 4-hour load test, as confirmed by the Maintenance Director.
A resident with an indwelling urinary catheter was observed multiple times with the catheter bag containing urine placed on the floor, contrary to facility policy and standards of care. The DON confirmed that the catheter bag should not be in contact with the floor. The resident had neuromuscular dysfunction of the bladder and congestive heart failure, and had a physician's order for the catheter.
A resident who was alert, oriented, and able to independently use the bathroom was unnecessarily catheterized to obtain a urine specimen, despite being able to voluntarily void. This action was not in accordance with individualized care or facility policy, and resulted in the resident experiencing hematuria following the procedure.
A resident with hypotension and Parkinson's disease was prescribed midodrine hydrochloride, with instructions not to administer it if their systolic blood pressure (SBP) was 140 mm/Hg or higher. Despite this, the medication was given on multiple occasions when the resident's SBP exceeded the specified limit. The DON confirmed the medication was administered outside the established parameters.
Failure to Prevent Medication Error Due to Improper Resident Identification
Penalty
Summary
A resident with diagnoses of congestive heart failure, anxiety, and atrial fibrillation, and noted to have some memory impairment, was given another resident's evening medications by an agency RN. Clinical record review and staff interview revealed that the nurse failed to correctly identify the resident using the electronic medication administration record, as required by facility procedure. The Director of Nursing confirmed that the nurse did not follow the established protocol of verifying the resident's identity by checking the picture in the electronic record and comparing it to the resident receiving the medications.
Failure to Exercise Fire Dampers at Required Intervals
Penalty
Summary
The facility failed to ensure that fire dampers were exercised at the required four-year intervals, as mandated by NFPA 101 HVAC standards. During a document review, surveyors found that the facility could not provide documentation showing that the fire dampers had been exercised within the previous 48 months. An interview with the Maintenance Director confirmed that the necessary documentation was not available, affecting the entire facility.
Plan Of Correction
Fire damper exercise documentation not provided at the time of survey has been obtained. The fire dampers have been exercised. The fire dampers will be exercised again in June 2026 to remain within the 48-month testing regulation. Inspection will be entered in the electronic preventative maintenance program as a task to be completed as required. Monitored by the Director of Maintenance or designee.
Failure to Test Electrical Receptacles at Resident Bed Locations
Penalty
Summary
The facility failed to ensure that electrical receptacles at resident bed locations were tested according to required intervals. Specifically, document review revealed that non-hospital grade receptacles were not tested at intervals not exceeding 12 months, and hospital-grade receptacles were not tested based on documented performance data, with a minimum frequency of at least every 12 months. The required testing includes visual inspection of physical integrity, verification of correct polarity of hot and neutral connections, and measurement of the retention force of the grounding blade, except for locking-type receptacles. These requirements apply to all resident care rooms throughout the facility. During the survey, the Maintenance Director confirmed in an exit interview that testing of electrical receptacles at resident bed locations had not been performed. The deficiency affects the entire facility, as the lack of testing was not limited to a specific area or group of residents. No information was provided regarding specific residents or their medical conditions in relation to this deficiency.
Plan Of Correction
Electrical receptacle testing documentation not provided at survey was obtained. Electrical receptacle testing of hospital and non-hospital grade receptacles was completed in November 2024. Hospital and non-hospital grade receptacles testing will occur again in November 2025 so as not to exceed the 12-month requirement. Inspection will be entered in the electronic preventative maintenance program as a task to be completed as required. Monitored by Director of Maintenance or designee.
Failure to Maintain and Document Emergency Generator Testing
Penalty
Summary
The facility failed to maintain and inspect its emergency generator system as required by NFPA standards. During a document review, surveyors found that the facility could not provide documentation for several critical tests and inspections, including the monthly 30-minute load test, monthly operation of transfer switches, annual 90-minute load bank test (if the generator could not meet 30% of its nameplate rating), generator preventative maintenance records indicating no evidence of wet stacking, and the required 3-year 4-hour load test. An exit interview with the Maintenance Director confirmed the absence of these records. The lack of documentation affected the entire facility, as it could not be demonstrated that the emergency power system was being properly maintained and tested according to regulatory requirements.
Plan Of Correction
Documentation verifying maintenance and inspection of emergency generator not provided at survey has been obtained. a. Monthly 30-minute load tests have been completed and will continue on July 22, 2025. b. Monthly operation of transfer switch occurs during monthly load tests. A column will be added to the log to confirm completion. c. Annual 90-minute load bank had been completed. It will be completed next in April 2026. d. Preventative maintenance had been completed in March 2025 by a contractor with no signs of wet stacking. e. The 3-year 4-hour load test was completed. It will be completed next in March 2028. Inspection will be entered in the electronic preventative maintenance program as a task to be completed as required. Monitored by Director of Maintenance or designee.
Failure to Maintain Proper Catheter Bag Placement
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was not provided adequate catheter care according to facility policy and current standards of care. The facility's policy, last reviewed on June 2, 2025, specifically stated that catheter bags should not be placed on the floor. Despite this, observations on multiple occasions showed the resident's catheter bag containing urine resting on the floor, and at one point, the overbed tray table wheels were on top of the bag. The resident involved had diagnoses including neuromuscular dysfunction of the bladder and congestive heart failure, and had a physician's order for an indwelling catheter. The improper placement of the catheter bag was confirmed by the Director of Nursing, who acknowledged that the bag should not be in contact with the floor. These findings were based on policy review, clinical record review, direct observation, and staff interview.
Plan Of Correction
As part of catheter care, resident 15 was provided a catheter bag holder to ensure the catheter is positioned properly. Each resident with a Foley will be monitored by the resident care coordinator and/or infection control nurse. Monitoring will be done weekly for one month and then monthly. Staff is being in-serviced currently on proper catheter care and it will be included with their annual competency training. Audits will be reviewed at QAPI. Monitored by Director of Nursing.
Unnecessary Catheterization for Urine Specimen Collection
Penalty
Summary
A resident with diagnoses including heart failure, anemia, malignant neoplasm of the prostate, and acute kidney failure was admitted to the facility and assessed as alert, oriented, and continent of bladder. The care plan indicated the resident was at risk for incontinence due to impaired mobility but was able to independently ambulate to and from the bathroom. An intervention was in place to assist the resident to the toilet as needed and to ensure an unobstructed path to the bathroom. Following the onset of a fever of unknown origin, a physician ordered a urine specimen to rule out a UTI. Despite the resident's ability to voluntarily void and independently use the bathroom, nursing staff obtained the urine specimen via straight catheterization. Documentation noted the resident had hematuria following the procedure. The Director of Nursing confirmed that the resident was catheterized for the urine specimen even though he was capable of providing a voided sample, which was not in accordance with individualized care and the facility's policy to avoid unnecessary catheterization.
Failure to Adhere to Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that physician's orders were properly implemented for one of the residents in their care. Resident 19, who had diagnoses including hypotension and Parkinson's disease, was prescribed midodrine hydrochloride to be administered three times a day for orthostatic hypotension. The physician's order specified that the medication should not be given if the resident's systolic blood pressure (SBP) was 140 mm/Hg or higher. However, a review of the Medication Administration Record showed that the medication was administered on four occasions in May 2024 and once in June 2024 when the resident's SBP was above the specified threshold. The Director of Nursing confirmed during an interview that the medication was administered outside the established parameters for Resident 19, indicating a failure to adhere to the physician's orders.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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