Lutheran Community At Telford
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 REDACTED], 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. 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 Resident 4 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.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
LUTHERAN COMMUNITY AT TELFORD in TELFORD, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TELFORD, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LUTHERAN COMMUNITY AT TELFORD or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.