Lutheran Community at Telford.

“Fire doors closest to resident room 233 could not completely close, with approximately a 1/4-inch gap between the doors that would allow smoke to enter the fire-safe area.”

“The main kitchen's side-by-side freezer contained unsealed, unlabeled, and undated bags of frozen breaded chicken and onion rings, as well as a pan of meatloaf patties.”

“Resident medical information was accessible to residents and visitors. Two medication carts with open laptops displaying resident medical information were positioned in the second-floor dining area entrance where they could be easily viewed.”

“The facility's camera system was recording in areas where resident privacy should be maintained, including resident common areas where medications are administered, hallways containing resident bedrooms, and second-floor resident common areas.”

“A glucometer from resident 1 was used to take a reading for resident 2. The reading of 210 appeared on resident 2's medication administration record but was not found on resident 2's glucometer. This is a repeat violation from 9/4/2024.”

“A resident was observed rubbing the groin area of another resident over their clothing while the resident was asleep. This incident was preceded by multiple documented behavioral concerns including inappropriate sexual comments, attempted touching, and verbal harassment directed at the same resident. The facility's safeguards were insufficient to protect the resident's right to be free from unwanted sexual harassment or sexual contact, despite prior incidents and awareness of monitoring needs.”

“A direct care staff person working in the Secure Dementia Care Unit received only 2.75 hours of dementia care training during the 2024 training year, falling short of the required 6 hours of annual dementia care training.”

“A resident with a history of sexually inappropriate behaviors toward other residents and impaired judgment was not supervised for approximately 20 minutes in a common area, during which time this resident engaged in inappropriate sexual contact with another sleeping resident in the facility's secured dementia care unit.”

“The facility's system to safeguard residents' money and property was inadequate. A resident reported missing cash and personal belongings, and of five residents interviewed, none expressed knowledge of the home's safeguarding system.”

“A resident's support plan was not updated to reflect a change in the resident's condition or behavior, specifically regarding the resident being found outside the secured dementia care unit unaccompanied.”

“Staff person A did not receive orientation on fire safety and emergency preparedness topics (evacuation procedures, staff duties, designated meeting places, smoking safety, fire extinguishers, smoke detectors/fire alarms, and emergency services notification) prior to or during their first work day.”

“Staff person B did not receive annual training in emergency preparedness procedures, recognition and response to crises and emergency situations, resident rights, and the Older Adult Protective Services Act during training year 2023.”

“Staff C used a resident's glucometer to check another resident's blood sugar level, violating sanitary conditions and creating a cross-contamination risk.”

“The first aid kit in the 2nd floor wellness office was missing antiseptic, a required component of a complete first aid kit.”

“An unlabeled, undated food item wrapped in aluminum foil was found in the freezer section of a stand-alone refrigerator in the Secured Dementia Care Unit, creating a risk of use of outdated food.”

“Resident 1 displayed multiple incidents of physical aggression toward other residents and staff members, including pushing another resident to the floor, grabbing and twisting a staff member's arm, slapping staff, and punching another resident in the face, resulting in serious injuries requiring hospitalization. The facility was dismissive of escalating aggressive behaviors, failed to implement adequate positive interventions and safe management techniques, and neglected resident safety by housing two residents in a shared suite despite known aggression triggers.”

“The facility failed to complete an updated assessment after Resident 1 displayed physical aggression toward another resident on 2/5/24, pushing them to the ground. The resident's initial assessment dated prior to this incident indicated only minimal aggression needs, but the assessment was not updated to reflect the significant change in the resident's condition despite incident documentation in the resident's digital chart.”

“A contracted CNA (Staff person A) stole a resident's debit card on their first day of work (11/11/2023) and made approximately 37 unauthorized purchases totaling an estimated amount between 11/11 and 11/20/2023. This constitutes financial abuse and mistreatment of the resident.”

“The facility provided an incomplete staff list to the Department that included only directly employed staff but lacked names and contact information for staffing agency employees, including Staff person A who worked through an agency.”

“Staff person A did not receive required fire safety and emergency preparedness orientation on their first work day (11/11/2023), including evacuation procedures, staff duties during emergencies, designated meeting places, smoking safety, fire extinguisher use, smoke detectors/fire alarms, and telephone/emergency notification procedures.”

“The home's emergency food supply lacked adequate protein sources. While the facility had enough total nonperishable food to serve 82 residents three meals per day for three days, the supply consisted primarily of fruits, vegetables, cereals, and jellies with no canned protein items such as tuna, chicken, or beans.”