Pennsylvania Department of Health
LUTHERAN COMMUNITY AT TELFORD
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LUTHERAN COMMUNITY AT TELFORD - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated survey in response to a complaint completed on November 21, 2025, it was determined that Lutheran Community at Telford was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Clinical record review revealed that Resident 4 had diagnoses of congestive heart failure, anxiety and atrial fibrillation. The Minimum Data Set assessment dated September 17, 2025, 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 R4 another resident's (R5)'s evening doses of medication. The medications that were given in error were a muscle relaxer Baclofen, an anti-coagulant Eliquis, a pain medication Gabapentin, and a medication for acid indigestion Sodium B-carb. Review of nursing documentation dated November 14, 2025, at 9:30 p.m., revealed that the resident stated "I feel off all day today". The note further indicated that the resident stated that "she was not hungry but again complained she feels off".

In an interview on November 21, 2025, at 10:14 a.m., the Director of Nursing stated that the procedure for staff to identify a resident during medication pass was to check the picture in the electronic medication administration record and compare it to the resident being given the medications. At this time, the Director of Nursing confirmed that RN1 did not correctly identify R4 through the electronic medication administration record to ensure that she was giving medications to the correct resident.

28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Plan of Correction - To be completed: 12/16/2025

On call physician was notified and new orders received and implemented.
Resident was assessed and labs done as ordered.
Labs were within normal parameters for this resident.

RN1 reported the error to the supervisor. The agency was notified.

Name alert has been added in red to the EMAR in addition to the photos already in place to ensure proper identification of resident.

Residents will have photos updated as needed.

Medication errors are already part of QA and will continue to be monitored.

Monitored by Director of Nursing or designee.

51.3 (g)(1-14) LICENSURE NOTIFICATION:

51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Plan of Correction - To be completed: 12/26/2025

Reportable incidents will be reviewed.

Facility will report deaths or serious injuries due to a medication error.

Monitored by DON or designee

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