Cycle 1
Health 2025-07-03 · Fire 2025-07-03
3 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Telford, PA
Lutheran Community At Telford
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
12 Lutheran Home Drive, Telford, PA
(215) 723-9819
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
75
Certified beds
Average residents
67
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.88
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.03
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.63
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.18
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.93
CMS adjusted RN staffing hours
Adjusted total hours
4.91
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
861
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.85
Composite VBP score used to determine payment impact.
Payment multiplier
1.0177
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.36
Baseline 19.45% · Performance 18.02% · Measure score 7.36 · Achievement 7.36 · Improvement 5.39
Healthcare-associated infections
5.61
Baseline 7.08% · Performance 6.16% · Measure score 5.61 · Achievement 5.61 · Improvement 3.93
Total nurse turnover
8.21
Baseline 19.12% · Performance 30.12% · Measure score 8.21 · Achievement 8.21 · Improvement 0
Adjusted total nurse staffing
3.96
Baseline 4.28 hours · Performance 4.20 hours · Measure score 3.96 · Achievement 3.96 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.38% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 4.71% · Lower 95% interval 6.49% |
| Discharge to community | 54.01% |
50.57%
3.4 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 51.25% · Lower 95% interval 42.65% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.18% |
95.27%
2.9 pts better
|
Numerator 54 · Denominator 55 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 55 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 28 · Denominator 42 |
| Discharge mobility score | 57.14% |
50.94%
6.2 pts better
|
Numerator 24 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 1.82% |
2.29%
0.5 pts better
|
Numerator 1 · Denominator 55 · Adjusted rate 2.39% |
| Healthcare-associated infections requiring hospitalization | 6.16% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 2.08% · Lower 95% interval 3.35% |
| Staff COVID-19 vaccination coverage | 17.86% |
8.2%
9.7 pts better
|
Numerator 20 · Denominator 112 |
| Staff flu vaccination coverage | 47.48% |
42%
5.5 pts better
|
Numerator 66 · Denominator 139 |
| Discharge function score | 83.33% |
56.45%
26.9 pts better
|
Numerator 35 · Denominator 42 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 34.29% |
25.2%
9.1 pts better
|
Numerator 12 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.2
0.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.9%
13.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
3.2%
2.7 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 7.0% · Q3 5.3% · Q4 3.4% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
6.5%
4.4 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.6% |
19.9%
12.7 pts worse
|
19.6%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 34.0% · Q3 38.3% · Q4 29.8% · 4Q avg 32.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.9% |
18.7%
1.2 pts worse
|
16.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 22.2% · Q3 20.0% · Q4 18.8% · 4Q avg 19.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.3% |
19.6%
10.7 pts worse
|
16.3%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 25.1% · Q3 35.8% · Q4 33.3% · 4Q avg 30.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.5% |
18.3%
5.2 pts worse
|
14.9%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 21.7% · Q3 23.9% · Q4 24.4% · 4Q avg 23.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
1.7%
2.1 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 5.4% · Q3 5.3% · Q4 1.7% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.6% |
26.4%
9.2 pts worse
|
19.8%
15.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.5% · Q2 40.5% · Q3 32.9% · Q4 35.8% · 4Q avg 35.6% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
5.3%
3.8 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.2% · Q3 1.1% · Q4 1.3% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
68.9%
28.9 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 98.4% · Q3 97.1% · Q4 98.3% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
9.8%
3.2 pts worse
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 12.1% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
68.7%
31.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
23.1%
0.6 pts better
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 20.7% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-13 · Fire 2024-06-13
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-07-07 · Fire 2023-07-07
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-07-03
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-07-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-08
E · Potential for more than minimal harm
2024-06-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-06-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-06-13
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-06-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-01
F · Potential for more than minimal harm
2023-07-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-07-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-07-07
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2023-08-31
C · Minimal harm
2023-07-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-07-03
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-05-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-02
D · Potential for more than minimal harm
2024-06-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-30
D · Potential for more than minimal harm
2023-07-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-15
Penalties and ownership
What sits behind the stars
Ownership
Grace Inspired Ministries
5% Or Greater Direct Ownership Interest · Organization
Cressman, William
Corporate Director · Individual
First Savings Bank Of Perkasie
5% Or Greater Mortgage Interest · Organization
Floyd, Randall
Corporate Director · Individual
Friends Services For The Aging
Operational/Managerial Control · Organization
Godshall, Jeffrey
Corporate Director · Individual
Gotwals, Beth
Corporate Director · Individual
Grace Inspired Ministries
Operational/Managerial Control · Organization
Harbaugh, David
Corporate Officer · Individual
Hertzler, Ronald
Corporate Director · Individual
Jaworski, Dorothy
Corporate Director · Individual
Kraynak, Michele
Corporate Officer · Individual
Mckee, Daniel
Operational/Managerial Control · Individual
Mckee, Daniel
Corporate Director · Individual
Mckee, Daniel
Corporate Officer · Individual
Rose, Kelly
Corporate Director · Individual
Rutter, Thomas
Corporate Director · Individual
Schea, Fred
Corporate Officer · Individual
Shrager, Ellen
Operational/Managerial Control · Individual
Shrager, Ellen
Corporate Director · Individual
Shrager, Ellen
Corporate Officer · Individual
Smolinsky, Patti
Corporate Director · Individual
Truist Bank
5% Or Greater Mortgage Interest · Organization
Williams, Judith
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Souderton Mennonite Homes
Souderton, PA
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Community At Rockhill, The
Sellersville, PA
5-star overall rating with 5-star inspections with 1 recent health deficiencies
#3
Peter Becker Community
Harleysville, PA
5-star overall rating with 4-star inspections with $3,174 in total fines with 2 recent health deficiencies
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