Pennsylvania Department of Health
 LUTHERAN COMMUNITY AT TELFORD
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LUTHERAN COMMUNITY AT TELFORD
Inspection Results For:

There are  32 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
LUTHERAN COMMUNITY AT TELFORD - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000
Based on an Emergency Preparedness Survey completed on June 22, 2026, at Lutheran Community at Telford, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.


 Plan of Correction:


Initial comments:Name: NEW HEALTH CENTER - Component: 04 - Tag: 0000
Facility ID# 124502

Component 04

New Health Center

Based on a Medicare/Medicaid Recertification Survey completed on June 22, 2026, it was determined that Lutheran Community at Telford was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy.  Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a four-story, Type II (222), fire resistive building, with two lower levels, that is fully sprinklered.


 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: NEW HEALTH CENTER - Component: 04 - Tag: 0291 Based on document review and interview, it was determined the facility failed to ensure battery back-up lighting was maintained in operable condition, affecting one of five levels. Findings include: 1. Observation on June 22, 2026, at 11:30 a.m., revealed the battery back-up light in the basement mechanical room failed to illuminate when tested. Exit interview with the Administrator and Maintenance Director on June 22, 2026, at 12:00 p.m., confirmed the battery back-up light deficiency.
 Plan of Correction - To be completed: 08/21/2026

Battery was replaced in the back-up light in the basement mechanical room and is operational.

Task was updated in the work order system to be checked monthly.

Monitored by Director of Maintenance or designee.
NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: NEW HEALTH CENTER - Component: 04 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of hazardous areas, in sprinklered locations, affecting one of five levels. Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of hazardous areas, in sprinklered locations, affecting one of five levels. Findings include: 1. Observation on June 22, 2026, at 10:00 a.m., revealed combustible boxes on the transformer and various items stored within the 4th floor electrical room. Exit interview with the Administrator and Maintenance Director on June 22, 2026, at 12:00 p.m., confirmed the hazardous room storage.
 Plan of Correction - To be completed: 08/21/2026

Maintenance removed the combustible boxes and other inappropriately stored items from the 4th floor electrical room.

"No Storage" signs will be placed in these areas.

A task will be placed in the work order system to monitor monthly and randomly.

Monitored by Director of Maintenance or designee.


NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: NEW HEALTH CENTER - Component: 04 - Tag: 0345 Based on document review and interview, it was determined the facility failed to maintain fire alarm system components, affecting one required test. Findings include: 1. Document review on June 22, 2026, at 9:30 a.m., revealed documentation of smoke detector sensitivity testing was unavailable at time of survey. Exit interview with the Administrator and Maintenance Director on June 22, 2026, at 12:00 p.m., confirmed smoke detector sensitivity testing was not available at time of survey.
 Plan of Correction - To be completed: 07/22/2026

Smoke detector sensitivity testing was completed on 6/11/2026.

Awaiting report.

Monitored by Director of Maintenance or designee.
NFPA 101 STANDARD HVAC:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: NEW HEALTH CENTER - Component: 04 - Tag: 0521 Based on document review and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting three of five levels. Findings include: 1. Document review on June 22, 2026, at 9:30 am, revealed the June 2026 fire damper inspection report listed 21- failed dampers. Documentation of subsequent repairs was not available at time of survey. Exit interview with the Administrator and Maintenance Director on June 22, 2026, at 12:00 p.m., confirmed the missing documentation.
 Plan of Correction - To be completed: 08/21/2026

All 21 failed dampers have been replaced as of 07/22/2026.

Monitored by Director of Maintenance or designee.
NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: NEW HEALTH CENTER - Component: 04 - Tag: 0541 Based on observation and interview, it was determined the facility failed to maintain the fire protection rating for trash chutes affecting one of five levels. Based on observation and interview, it was determined the facility failed to maintain the fire protection rating for trash chutes affecting one of five levels. Findings include: 1. Observation on June 22, 2026, at 12:15 p.m., revealed the 1st floor linen chute door failed to close and positively latch when tested. Exit interview with the Administrator and Maintenance Director on June 22, 2026, at 12:00 p.m., confirmed the chute door failed to close and latch when tested.
 Plan of Correction - To be completed: 08/21/2026

Hinge pin was replaced on the 1st floor linen chute and chute door closes and positively latches.

The monthly task to monitor linen chute closures will be reviewed with maintenance staff.

Monitored by Director of Maintenance or designee.
NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: NEW HEALTH CENTER - Component: 04 - Tag: 0761 Based on document review and interview, it was determined the facility failed to maintain fire doors, affecting four of five levels. Findings include: 1. Document review on June 22, 2026, at 9:30 a.m., revealed the June 2026 annual fire door inspection listed 7- doors deficient. Evidence of corrective action was not available at time of survey. Exit interview with the Administrator and Maintenance Director on June 22, 2026, at 12:00 p.m., confirmed the door deficiencies.
 Plan of Correction - To be completed: 08/21/2026

Doors listed as deficient on the annual fire door inspection will be repaired using the work order system for notification and documentation.

Security completes fire door checks during rounds.

Monitored by Director of Maintenance or designee.
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: NEW HEALTH CENTER - Component: 04 - Tag: 0923 Based on observation and interview, it was determined the facility failed to maintain oxygen cylinder storage on one of five levels. Based on observation and interview, it was determined the facility failed to maintain oxygen cylinder storage on one of five levels. Findings include: 1. Observations on June 22, 2026, at 10:15 a.m., revealed an unsecured oxygen cylinder, 4th floor Nurse Station. Exit interview with the Administrator and Maintenance Director on June 22, 2026, at 12:00 p.m., confirmed the freestanding oxygen cylinder.
 Plan of Correction - To be completed: 08/21/2026

Free standing cylinder was removed on 06/22/2026

Signs for "full" and "empty" will be tagged on the oxygen tanks.

Staff will be in serviced on proper storage of oxygen tanks.

Monitored by Director of Maintenance or designee.


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