Inspection Reports for Lutheran Community at Telford

The inspection was an unannounced full renewal inspection conducted on 07/16/2025 and 07/17/2025 to assess compliance with licensing regulations and facility standards.

The inspection identified multiple deficiencies including breaches in resident record confidentiality, privacy violations due to camera placement, sanitary condition issues such as improper glucometer use and blood glucose strip contamination, fire safety concerns including limited use of alternate exit routes and evacuation procedures, outdated food storage, combustible storage near heat sources, medication administration errors, and labeling and documentation deficiencies related to medications. Plans of correction were accepted and implemented with follow-up dates scheduled.

The inspection was conducted as a complaint and incident investigation to review concerns related to resident interactions and staff training in the secured dementia care unit.

The investigation found incidents of inappropriate sexual behavior and verbal abuse between residents in the secured dementia care unit, occurring during times of insufficient supervision. Additionally, a direct care staff person had not completed the required dementia care training hours for 2024.

The visit was complaint-related and incident-driven, investigating allegations of resident-to-resident sexual harassment and abuse. The complaint was substantiated based on observations and staff interviews confirming incidents occurred during times of inadequate supervision.

The inspection was conducted as a complaint and incident investigation at Lutheran Community at Telford, focusing on resident safety and compliance with care standards.

The inspection identified deficiencies related to resident abuse, safeguarding of resident property, and support plan revisions. The facility was found to have incidents of inappropriate resident interactions, lack of supervision, missing resident belongings, and outdated support plans reflecting resident behaviors.

The visit was complaint-related and incident-driven, focusing on allegations of resident abuse and safety concerns. The complaint was substantiated with findings of inappropriate resident interactions and supervision failures.

The inspection was conducted as a renewal inspection of the Lutheran Community at Telford facility on 09/04/2024 and 09/05/2024 to review compliance with licensing requirements.

The inspection identified multiple deficiencies including failure to provide timely fire safety orientation to new staff, incomplete annual training for a staff member, improper use of resident glucometers, missing antiseptic in a first aid kit, presence of unlabeled food in the secured dementia care unit refrigerator, incomplete resident medical evaluations, and incorrect calibration of a resident glucometer. Plans of correction were accepted or directed with proposed completion dates and implementation noted.

The inspection was a partial, unannounced complaint and incident investigation conducted on 05/22/2024 to review concerns related to resident abuse and behavioral management at Lutheran Community at Telford.

The investigation found multiple incidents of physical and verbal abuse by Resident 1 towards staff and other residents, including serious injury to Resident 2. The facility was found to have neglected proper interventions and safety measures, such as room assignments and behavioral assessments, to manage Resident 1's aggression.

The visit was complaint-related and substantiated, revealing neglect in managing Resident 1's aggressive behaviors and failure to protect Resident 2 from injury.

The inspection was a partial, unannounced follow-up visit conducted on 12/21/2023 to review the implementation of a previously submitted plan of correction related to an incident.

The facility was found to have fully implemented the plan of correction addressing an incident involving financial abuse by an agency-contracted CNA who stole a resident's debit card and made unauthorized purchases. Additional deficiencies related to incomplete staff contact lists and lack of fire safety orientation for agency staff were also addressed with directed plans of correction.

The inspection was conducted as a renewal review of the Lutheran Community at Telford facility on 07/24/2023 to assess compliance with licensing requirements.

The facility was found to have an inadequate emergency food supply lacking protein sources, though it had enough nonperishable food to serve three meals a day for three days to all residents. A plan of correction was implemented and fully accepted by 09/07/2023.

The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to assess regulatory compliance at Lutheran Community at Telford.

No regulatory citations or deficiencies were identified during this unannounced partial inspection conducted on 08/25/2022.

The inspection was conducted as a complaint and incident investigation at Lutheran Community at Telford on 06/16/2022.

The inspection found deficiencies related to medication administration records, specifically failure to document medication administration times and staff initials. A plan of correction was submitted and accepted, including staff education and implementation of medication administration audit reports.

The visit was complaint-related and incident-related. The submitted plan of correction was fully implemented as of 06/16/2022.

The inspection was conducted as a renewal inspection of the Lutheran Community at Telford facility to review compliance with licensing regulations.

The inspection identified several deficiencies including an expired boiler inspection certificate, missing signatures on a resident contract, lack of signage for video monitoring cameras, unsecured poisonous materials accessible to residents, missing emergency telephone number tags on telephones, and a burned-out light bulb at a resident's bedside. All deficiencies had plans of correction submitted and were implemented by the dates noted.

The inspection was a partial, unannounced visit conducted due to an incident at the facility, with a follow-up type of Plan of Correction (POC) submission.

The facility was cited for failing to report an incident involving a resident's unwitnessed fall and subsequent rib fracture to the Department within the required 24-hour timeframe. The plan of correction was accepted, and corrective actions including staff communication protocols were implemented.

The inspection was conducted as a follow-up to verify the implementation of a submitted plan of correction related to a prior incident involving combustible storage and fire safety.

The submitted plan of correction was determined to be fully implemented, including the purchase and installation of a new stove with safety features and staff training on stove safety. Continued compliance must be maintained.

The inspection was conducted as a renewal review of the Lutheran Community at Telford facility on 03/30/2021 and 03/31/2021 by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.

The inspection identified multiple deficiencies including uncovered trash outside the home, outdated food in the kitchen, failure to post weekly menus and activity calendars in conspicuous places, unlocked medications in a resident's room, and medication administration errors. Plans of correction were accepted and documented as implemented.

The document is a renewal license issued in response to the facility's April 20, 2021 renewal application to operate a Personal Care Home. The Department advises that an annual onsite inspection will be conducted within the next twelve months.

The document does not report any inspection findings but confirms issuance of a regular license and states that enforcement action will be taken if noncompliance is found during the upcoming inspection.