Lutheran Community At Telford

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.

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