Lutheran Community at Telford

In the surveyor’s words

From the most serious findings on record at Lutheran Community at Telford, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF658Jun 17, 2026

  Based on policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that a registered nurse (RN) maintained professional standards of quality in carrying out nursing care to promote and maintain the well-being of individuals as set forth in the Pennsylvania Code Title 49 Professional and Vocational standards for one of eleven sampled residents. (Resident 22)Findings include: Review of Pennsylvania Code Title 49, Chapter 21, State Board of Nursing, Subchapter A, Registered Nurses, revealed guidelines which included that an RN shall carry out actions which promote, maintain, and restore the well-being of individuals and follow appropriate standards of practice and professional codes of behavior to assure safe and effective… […]

• No harm, potential for more than minimal, isolatedF686Jun 17, 2026

  Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident with pressure ulcers received necessary treatment and services for one of two sampled residents with wounds. (Resident 22)Findings include: Review of the facility policy entitled, Wound Care, last reviewed May 20, 2026, revealed that staff were to utilize preventative measures to avoid the development of pressure injuries unless the development was clinically unavoidable and necessary treatments and services were to be provided to promote healing and prevent infection and new injuries from developing. Clinical record review revealed that Resident 22 had diagnoses that included Alzheimer's disease, malnutrition, and diabetes. […]

• No harm, potential for more than minimal, isolatedF689Jun 17, 2026

  Based on facility policy review, review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to implement safety precautions and develop interventions to prevent further falls for one of two sampled residents at risk for falls. (Resident 9) Findings include: Review of the facility policy entitled, Accidents and Incidents, last reviewed May 20, 2026, revealed that after a fall, vital signs were to be taken and recorded initially and every shift for 24 hours, the interdisciplinary team was to determine final interventions, and the care plan was to be updated. […]

• No harm, potential for more than minimal, isolatedF689Nov 21, 2025

  Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident was free from safety hazards due to receiving the wrong medications for one of five sampled residents. (Resident 4)Findings include:Clinical record review revealed that Resident 4 had diagnoses of congestive heart failure, anxiety and atrial fibrillation. The Minimum Data Set assessment dated [DATE], indicated that the resident had some memory impairment. Review of an incident report dated November 13, 2025, at 5:20 p.m., revealed that an agency nurse RN1 gave Resident 4 another resident's (Resident 5) evening medications. […]

• No harm, potential for more than minimal, isolatedF690Jul 3, 2025

  Based on facility policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure that adequate catheter care was provided for one of two sampled residents with an indwelling urinary catheter. (Resident 15) Findings included: Review of the facility policy entitled, Foley Catheter, Maintenance, last reviewed June 2, 2025, revealed that catheter maintenance was completed with current standards of care which included not to place the catheter bag on the floor. Clinical record review revealed that Resident 15 had diagnoses that included neuromuscular dysfunction of the bladder and congestive heart failure. On April 12, 2025, the physician ordered for the resident to have an indwelling catheter every shift. […]