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. 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 Page 1 of 2 Event ID: 395804 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Community at Telford 12 Lutheran Home Drive Telford, PA 18969 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)