Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Telford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Souderton Mennonite Homes | 1.3 mi | ★★★★★ | 6 | 0 |
| Community At Rockhill, The | 1.5 mi | ★★★★★ | 1 | 0 |
| Peter Becker Community | 5 mi | ★★★★★ | 3 | 0 |
| Dock Terrace | 5.1 mi | ★★★★★ | 4 | 0 |
| Elm Terrace Gardens | 6.4 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.