Health inspection·July 7, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **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 the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for one of 17 sampled residents. (Resident 15) Residents Affected - Few Findings include: Clinical record review revealed that Resident 15 was readmitted to the facility on [DATE], and had diagnoses that included anemia, peripheral vascular disease, diabetes mellitus, arthritis, and dementia. Review of a nursing admission assessment dated [DATE], revealed no documentation that Resident 15 had a pressure ulcer. On May 17, 2023, a nurse noted that staff identified a suspected deep tissue injury to the right heel. Review of section M (assessment that determined the condition of the resident's skin) of the MDS assessment dated [DATE], indicated that the resident had an unhealed pressure ulcer that was present upon admission to the facility. In an interview on July 7, 2023, at 9:40 a.m., Registered Nurse 1 confirmed that Resident 15 had a pressure ulcer to the right heel and that the ulcer developed after the resident was readmitted to the facility. Page 1 of 2 395804 395804 07/07/2023 Lutheran Community at Telford 12 Lutheran Home Drive Telford, PA 18969

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and staff interview, it was determined that the facility failed to maintain a medication error rate of less than five percent on one of two nursing units observed during medication administration. (Second floor nursing unit) Residents Affected - Few Findings include: Clinical record review revealed that Resident 7 had a physician's order dated June 7, 2023, that staff was to administer divalproex (an anticonvulsant medication) every morning. The order indicated that the medication was to be given whole and was not to be crushed. Clinical record review revealed that Resident 47 had a physician's order dated June 28, 2022, that staff was to administer aspirin every morning. The order indicated that the medication was to be given whole and was not to be crushed. During observation of medication administration on July 6, 2023, at 8:49 a.m., Licensed Practical Nurse (LPN1) crushed both medications which resulted in a medication error rate of 5.41%. In an interview on July 7, 2023, at 1:29 p.m., Registered Nurse 1 confirmed that the medications were not to be crushed. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395804 Page 2 of 2