LUTHERAN HOME AT TOPTON, THE

ONE SOUTH HOME AVENUE, TOPTON, PA 19562 (610) 682-1400
Non profit - Corporation 194 Beds Independent Data: November 2025
Trust Grade
65/100
#198 of 653 in PA
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Last Inspection: October 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Lutheran Home at Topton has a Trust Grade of C+, indicating it is slightly above average but not among the best options available. It ranks #198 out of 653 facilities in Pennsylvania, placing it in the top half, and #8 of 15 in Berks County, meaning there are only a few local facilities ranked higher. The facility's trend is stable, with one reported issue each year from 2024 to 2025, but the staffing turnover rate is a significant concern at 97%, which is much higher than the state average of 46%. Although the home has no fines on record, several incidents were noted, such as a resident at risk for falls being assisted by a single staff member instead of the required two, and a failure to implement physician orders for medication administration. Overall, while there are strengths like good health inspections and no fines, families should be aware of the staffing challenges and specific care failures.

Trust Score
C+
65/100
In Pennsylvania
#198/653
Top 30%
Safety Record
Low Risk
No red flags
Inspections
Holding Steady
1 → 1 violations
Staff Stability
⚠ Watch
97% turnover. Very high, 49 points above average. Constant new faces learning your loved one's needs.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Pennsylvania facilities.
Skilled Nurses
✓ Good
Each resident gets 49 minutes of Registered Nurse (RN) attention daily — more than average for Pennsylvania. RNs are trained to catch health problems early.
Violations
⚠ Watch
15 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 1 issues
2025: 1 issues

The Good

  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in fire safety.

The Bad

Staff Turnover: 97%

51pts above Pennsylvania avg (47%)

Frequent staff changes - ask about care continuity

Staff turnover is very high (97%)

49 points above Pennsylvania average of 48%

The Ugly 15 deficiencies on record

Jun 2025 1 deficiency
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility fail...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to implement safety interventions for one of three sampled residents at risk for falls. (Resident 5) Findings include: Clinical record review revealed that Resident 5 had diagnoses that included neurocognitive disorder with Lewy body dementia (a progressive brain disorder that can cause cognitive decline, motor problems, sleep disturbances, and visual hallucinations) and seizures. The Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively impaired and dependent on staff for care. Review of the care plan revealed that the resident was at risk for falls, exhibited resistance to care, and required the assistance of two staff members for care. On June 6, 2025, a nurse noted that the resident was being changed by a single nurse aide (NA) and that the resident jerked her legs while on her side, causing her to roll out of bed. Review of the facility investigation revealed that only one staff member had been present during care and that the resident was not positioned properly in the bed. In an interview on June 27, 2025, at 12:40 p.m., NA 1 stated that the resident had required the assistance of two staff for care since early May 2025. In an interview on June 27, 2025, at 1:30 p.m., the Director of Nursing confirmed that the nurse aide did not follow the resident's care plan. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.
Oct 2024 1 deficiency
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 29 sampled residents. ...

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Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 29 sampled residents. (Resident 99) Findings include: Review of the policy entitled, Administering Medication, last reviewed January 25, 2024, revealed staff were to obtain vital signs if necessary and document physician indicated medication administration information. Clinical record review revealed that Resident 99 had diagnoses that included hypertension (high blood pressure) and cardiomyopathy (the heart muscle is no longer able to pump blood efficiently). On June 8, 2024, the physician ordered staff to administer a blood pressure medicine (losartan potassium) once a day. Staff were not to administer the medication if the resident's systolic blood pressure (the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 100 millimeters of mercury (mmHg). Review of Resident 99's September and October 2024 Medication Administration Records revealed that staff administered the medication 53 out of 53 times with no documentation that the blood pressure was assessed prior to medication administration per physician's order. In an interview on October 24, 2024, at 8:43 a.m., the Administrator confirmed there was no documented evidence that the blood pressure was taken prior to medication administration per physician's order, and it should have been. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Nov 2023 6 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**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 ...

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**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 status for one of 36 sampled residents. (Resident 157) Findings include: Clinical record review revealed that Resident 157's MDS assessment dated [DATE], Section C (Brief Interview for Mental Status) was incomplete and Section H (Appliances) inaccurately indicated that the resident had an indwelling catheter. There was no documented evidence or physician's order to reflect that the resident had an indwelling catheter. In an interview on November 15, 2023, at 9:45 a.m., the Registered Nurse Assessment Coordinator (RNAC) confirmed that the MDS sections were not completed accurately during the assessment period to reflect the resident's current status.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of incident reports and staff interview, it was determined that the facility failed to p...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of incident reports and staff interview, it was determined that the facility failed to provide adequate supervison and interventions in order to prevent falls for one of six sampled residents who were at risk for falls. (Resident 131) Findings include: Clinical record review revealed that Resident 131 had diagnoses that included dementia, anxiety, insomnia and a lack of coordination. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and experienced behaviors that occurred daily including pacing and rummaging. The assessment also indicated that the resident required supervision to walk in the corridor and on the unit and required limited assistance for transfers and that the resident had experienced two or more falls during the assessment period. A review of the care plan revealed that the resident was at risk for falling related to frequent falls, cognitive loss, a desire to ambulate frequently, wandering, a recent history of falls, attempts to self transfer and non-compliance with her transfer status. There was an intervention that she required an assist of one with the rolling walker for transfers. Review of incident reports revealed that on March 4, at 11:46 a.m, the resident had fallen and was found on the floor. On March 12, 2023, at 11:05 a.m., the resident was walking in the hallway without her rolling walker and she fell forward onto the floor. On March 17, 2023, at 8:03 p.m., the resident had fallen and was found on the floor. On April 15, 2023, at 12:00 p.m., the resident was found on the floor in the hallway without her walker and had a laceration to her upper eye. On the same day, the resident fell again at 6:55 p.m On May 26, 2023, at 6:30 p.m., the resident had fallen and had hit her head. On the same night at 8:44 p.m., the resident fell and again hit her head. On May 30, 2023, at 11:32 a.m., the resident was found on the floor in her room holding her head. On June 2, 2023, at 6:00 p.m., the resident was found on the floor in the hallway. The resident stated that I was running and I tripped and fell. On June 9, 2023, at 3:38 p.m., the resident was found on the floor in another resident's room. On July 5, 2023, at 4:00 p.m., the resident was observed running in the hallway without her walker and she fell. On July 26, 2023, at 2:36 p.m., the resident was found on the floor near the nursing station and appeared to have attempted to stand independently and fell. On July 31, 2023, at 12:00 p.m., the resident was again found on the floor near the nursing station. Review of incident reports from March 4, 2023, through July 31, 2023, revealed that the resident had experienced six falls on the day shift between 11:00 a.m., through 2:45 p.m., and eight falls on the evening shift between 3:00 p.m., through 8:44 p.m., for a total of 13 falls in five months. There was a lack of documentation to support that the facility provided adequate supervision to prevent multiple falls in the early afternoon into the early evening hours. In an interview on November 5, 2023, at 11:10 a.m., the Administrator stated that there was no documented evidence that the facility implemented adequate interventions and/or supervision in order to prevent multiple falls. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the pharmacist's recommendations were acknowledged by the physician for one of 36 sampled...

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Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the pharmacist's recommendations were acknowledged by the physician for one of 36 sampled residents. (Resident 20) Findings include: Clinical record review for Resident 20 revealed multiple recommendations from the consultant pharmacist on July 27, August 18, and September 28, 2023. These included recommendations regarding seizure medications and bowel stimulants. There was no documented evidence that Resident 20's physician acknowledged or acted upon the pharmacist's recommendations. In an interview on November 14, 2023, at 3 p.m., the Assistant Director of Nursing confirmed that there was no documented evidence that the physician acknowledged Resident 20's recommendations from the pharmacist. 28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

**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 document the rationale for th...

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**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 document the rationale for the continued use of as needed (PRN) anti-anxiety medications for three of five sampled residents. (Residents 128, 134, 168) Findings include: Clinical record review revealed that Resident 128 had diagnoses that included Alzheimer's disease, dementia, psychosis, anxiety and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory impairment and had taken an anti-anxiety medication three days of the assessment period. A review of the care plan revealed that the resident had increased behaviors. There was an intervention for the primary care physician to monitor drug use. On September 8, 2023, a physician ordered for staff to administer an anti-anxiety medication (Ativan) every four hours PRN for anxiety and/or behaviors. Review of the Medication Administration Records (MAR's) for September, October, and November 2023, revealed that staff had administered the PRN anti-anxiety medication 15 times in September, 13 times in October and two times in November and the physician's order was still current for the PRN medication. There was no documentation in the resident's clinical record to extend the PRN Ativan beyond the 14 days from the original order on September 8, 2023. Clinical record review revealed that Resident 134 had diagnoses that included anxiety disorder. Review of the MDS assessment dated [DATE], indicated that the resident had no memory impairment and had taken an anti-anxiety medication. A review of the care plan revealed that the resident had anxiety. There was an intervention for the primary care physician to monitor drug use. On October 14, 2023, a physician's order directed staff to administer an anti-anxiety medication (lorazepam) every 12 hours as needed for anxiety. Review of the MAR for October and November 2023, revealed that staff had administered the PRN anti-anxiety medication four times in October and three times in November and the physician's order was still current for the PRN medication. There was no documentation in the resident's clinical record to extend the PRN lorazepam beyond the 14 days from the original order on October 14, 2023. Clinical record review revealed that Resident 168 had diagnoses that included Alzheimer's disease, bi-polar disease, anxiety and schizoaffective disorder. The MDS assessment dated [DATE], indicated that the resident had some memory impairment and had taken an anti-anxiety medication during the assessment period. A review of the care plan revealed that the resident was at risk for a mood problem related to anxiety and bi-polar disease. There was an intervention for the primary care physician to monitor drug use. On October 31, 2023, a physician ordered for staff to administer an anti-anxiety medication (clonazepam) every 12 hours PRN for anxiety. Review of the MAR for October and November 2023, revealed that staff had administered the PRN anti-anxiety medication nine times and the physician's order was still current for the PRN medication. There was no documentation in the resident's clinical record to extend the PRN clonazepam beyond the 14 days from the original order on October 31, 2023. In an interview on November 15, 2023, at 10:00 a.m., the Assistant Director of Nursing confirmed there was no documented evidence that the aformentioned residents were reassessed after the 14 day period to determine the need to continue the medications. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0810 (Tag F0810)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that ada...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that adaptive equipment was provided to one of three sampled residents who utilized adaptive equipment for meals. (Resident 131) Findings include: Clinical record review revealed that Resident 131 had diagnoses that included dementia, anxiety and a lack of coordination. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and required extensive assistance from staff for eating. A review of the care plan revealed that the resident had a nutrition problem related to dementia and significance weight loss. There was an intervention for staff to provide adaptive equipment including Kennedy cups (spill proof drinking cups that included a lid and a straw), for all drinks. Review of an occupational therapy Discharge summary dated [DATE], revealed that upon discharge from therapy services, the resident was able to consistently drink by herself after staff placed the Kennedy cup into her hand. The recommendation was for the resident to maintain self hydration and the prognosis for that was good with consistent staff follow through. In addition, on November 14, 2023, a dietician noted that the resident continued to benefit from the use of adaptive equipment, including the use of Kennedy cups with lids and straws. On November 13, 2023, at 1:05 p.m., Resident 131 was observed seated in the dining room and she received her lunch: however, she was served her coffee in a regular mug without a lid or a straw. On November 14, 2023, at 9:33 a.m., she was again seated in the dining room, received her breakfast, and was served her coffee in a regular mug without a lid or a straw. On November 14, 2023, at 12:24 p.m., the resident was seated in the dining room and she had juice that was in a regular juice cup without a lid or a straw. In an interview on November 15, 2023, at 11:15 a.m., the Director of Nursing stated that the resident was to have her drinks served to her in a Kennedy cup as recommended by occupational therapy and the dietician. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.
MINOR (B)

Minor Issue - procedural, no safety impact

Transfer Notice (Tag F0623)

Minor procedural issue · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to noti...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer and the reasons for transfer in writing for 12 of 14 sampled residents who were transferred to the hospital. (Residents 8, 20, 22, 49, 55, 70, 115, 117, 125, 128, 134, 171) Findings include: Review of the facility policy entitled, Discharge and Transfer, last reviewed January 25, 2023, revealed that the facility must notify the resident and resident representative in writing prior to a transfer or discharge in a language and manner they understand. Clinical record review revealed that Resident 8 was transferred and admitted to the hospital on [DATE], and October 10, 2023, after changes in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 20 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 22 was transferred and admitted to the hospital on [DATE], and October 5, 2023, after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 49 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 55 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 70 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 115 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 117 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 125 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 128 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 134 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 171 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with written information regarding the resident's transfer to the hospital. In an interview on November 14, 2023, at 12:15 p.m., the Administrator confirmed that written transfer information, including the reasons for the move, was not provided to the residents and the residents' representatives.
Aug 2023 2 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**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 implement physician's orders ...

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**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 implement physician's orders to obtain therapy services for one of three sampled residents who were referred to therapy. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included depression, pain, dementia, osteoarthritis, lack of coordination, and difficulty walking. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident required extensive assistance from staff for activities of daily living. On April 14, 2023, staff documented that the resident had decreased strength and endurance and that the resident's family had requested physical therapy for ambulation. A physician's order dated April 14, 2023, referred the resident for therapy services per the resident's family's request. There was no evidence that the resident was evaluated for therapy services, per the physician's order. In an interview on August 21, 2023, at 1:41 p.m., the Assistant Director of Nursing confirmed there was no evidence that the resident was evaluated for therapy services, per the physician's order. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Based on clinical record review and staff interview, it was determined that the facility failed to provide treatment for pressure ulcers for one of three sampled residents with pressure ulcers. (Resid...

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Based on clinical record review and staff interview, it was determined that the facility failed to provide treatment for pressure ulcers for one of three sampled residents with pressure ulcers. (Resident 3) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included anemia and weakness. Review of a wound evaluation dated August 15, 2023, revealed that Resident 3 had a stage three pressure ulcer to the left upper back. The treatment plan recommendation was for staff to apply hydrogel and gauze island once daily for 30 days. There was no evidence that staff entered the recommended treatment into the resident's clinical record or provided treatment to the pressure ulcer until August 21, 2023, six days after the evaluation. In an interview on August 21, 2023, at 3:42 p.m., the Assistant Director of Nursing confirmed staff should have entered the treatment into the resident's clinical record and there was no evidence that any wound treatment was provided to the resident's pressure ulcer prior to August 21, 2023. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Apr 2023 1 deficiency
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, and resident and staff interview, it was determined that the facility failed to ensure that res...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, and resident and staff interview, it was determined that the facility failed to ensure that residents were being provided bathing as per their preferred schedules for two of six sampled residents. (Residents 2 and 4) Findings include: Clinical record review revealed that Resident 2 had diagnoses that included chronic respiratory failure and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was totally dependent on staff for bathing and that choosing between a bath, shower or bed bath was a very important aspect of her routine. In an interview on April 21, 2023, at 10:00 a.m., Resident 2 stated that she was never sure when staff was going to offer her a shower. She further stated that she prefers to get a shower twice a week as per her schedule which is part of her routine. Review of the shower/bathing documentation for the last 30 days revealed that she preferred to receive assistance with showers on Tuesday and Friday evenings. On Tuesday April 4 and 11, 2023, and on Friday March 31 and April 7, 2023, staff noted that the task of assisting her with her shower as not applicable. There was no consistent documented evidence that staff were offering and providing assistance for the resident to receive her showers twice weekly as per her preferred schedule. Clinical record review revealed that Resident 4 had diagnoses of Alzheimer's and heart disease. The MDS assessment dated [DATE], revealed that the resident was totally dependent on staff for bathing and that choosing between a bath, shower or bed bath was a very important aspect of her routine. A review of the care plan revealed that the resident was at risk for a self care deficit related to decreased mobility and dementia. There was an intervention for the resident to receive baths twice weekly as per her schedule. In an interview on April 21, 2023, at 10:40 a.m., Resident 4 stated that the staff does not offer her a shower on a consistent basis twice weekly as per her preferred schedule. She further stated that she only recalls receiving assistance to get a shower one time in the recent weeks. The resident was already dressed and seated in her wheelchair at this time and she stated that staff did not offer to giver her a shower as scheduled today. Review of the shower/bathing documentation for the last 30 days revealed that she preferred to receive assistance with showers on Tuesday and Fridays. There was only one documented shower in the last 30 days. The other days were listed as either bed baths or not applicable. In an interview on April 21, 2023, at 11:25 a.m., the Assistant Director of Nursing, confirmed that there was no reason why residents were not getting their showers as preferred and scheduled. In a second interview on April 21, 2023, at 12:16 p.m., the Administrator confirmed that there was no documented evidence that showers were being offered to residents on a consistent basis as per their preferred schedule. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Dec 2022 4 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Based on clinical record review and staff interview, it was determined that the facility failed to provide adequate interventions and supervision to prevent elopement (leaving an area without permissi...

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Based on clinical record review and staff interview, it was determined that the facility failed to provide adequate interventions and supervision to prevent elopement (leaving an area without permission or supervision) for one of 32 sampled residents. (Resident 37) Findings include: Clinical record review revealed that Resident 37 had diagnoses that included dementia. The Minimum Data Set assessment, dated September 7, 2022, indicated that the resident had memory problems and impaired decision-making ability. A physician's order dated April 16, 2021, directed that the resident wear a bracelet device for a wander management system used to prevent elopement and that staff check placement every shift. Review of facility documentation revealed that Resident 37 had a history of exit-seeking behavior and a nurse supervisor was called on November 2, 2022, at 4:19 p.m., because the resident was attempting to escape the secured third floor nursing unit. At 4:55 p.m, the resident was identified as missing and could not be located by staff. Resident 37 was found outside the facility in the parking lot area at 5:00 p.m. During an interview on December 21, 2022, at 11:20 a.m., the Administrator and Director of Nursing confirmed that the wander management system was not activated and that Resident 37 had entered the third floor elevator and exited the building from the first floor on November 2, 2022. CFR 483.25(d) Accidents Previously cited 12/30/2021 28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, observation, and staff interview, it was determined that the facility failed to ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, observation, and staff interview, it was determined that the facility failed to assess a newly admitted resident for the continued use of an indwelling urinary catheter for one of 32 sampled residents. (Resident 118) Findings include: Review of the facility policy entitled, Urinary Incontinence and Incontinence - Assessment and Management, last reviewed November 2022, revealed that when a resident was admitted from the hospital with an indwelling urinary catheter, the attending physician and staff was to evaluate the catheter for continued need and for the potential of removal. Clinical record review revealed that Resident 118 was admitted to the facility on [DATE]. According to the Minimum Data Set assessment, dated October 18, 2022, the resident had an indwelling urinary catheter in place since admission. On December 19 and 20, 2022, the resident was observed in bed with a catheter in place. There was no documentation in the clinical record that the facility assessed the resident for the clinical reason for her catheter use. In an interview on December 21, 2022, ADON 1 confirmed that the facility did not assess the resident's catheter use when she was admitted to the facility. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to store medications in accordance with facility policy on one of four nursing units. (Uni...

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Based on facility policy review, observation, and staff interview, it was determined that the facility failed to store medications in accordance with facility policy on one of four nursing units. (Unit D2) Findings include: Review of the facility policy entitled, Storage of Medications, last reviewed in November 2022, revealed that the nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Observation of a medication cart used for resident rooms 219-233 revealed an open bottle of nasal spray that was not labeled with an open date. In an interview Registered Nurse 1 stated that the nasal spray should have been labeled with the open date. Observation of a medication cart used for resident rooms 206-218 revealed three pens of Lantus insulin that were in use and were not labeled with an open date and one pen of insulin lispro that was in use and was not labeled with an open date. In an interview Licensed Practical Nurse 1 stated that the insulin pens should have been labeled with an open date. In an interview on December 20, 2022, at 1:38 p.m., the Director of Nursing confirmed that staff were to label the medications with an open date once they were in use. 28 Pa. Code 211.9(h)(i) Pharmacy services. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

Based on facility policy review and observation, it was determined that the facility failed to store food under sanitary conditions on two of four nursing units. (A Wing and Unit D2) Findings include:...

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Based on facility policy review and observation, it was determined that the facility failed to store food under sanitary conditions on two of four nursing units. (A Wing and Unit D2) Findings include: Review of facility policy entitled, Resident Food Services, last reviewed November 2022, revealed that food prepared outside of the Dining Services Department that was not immediately served to the resident was to be clearly labeled with the resident's name, the date the food was brought to the facility, and the use-by date. Observation of the refrigerator on unit D2 on December 20, 2022, at 12:51 p.m., revealed a box of strawberry smoothies with an expiration date of November 30, 2022, two containers of blueberry oatmeal with an expiration date of October 13, 2022, and two containers of vanilla bean oatmeal with an expiration date of October 31, 2022. There were two containers of food items that were not labeled or dated. Observation of the refrigerator on A Wing on December 20, 2022, at 1:16 p.m., revealed seven containers of food items that were not dated. There was a frozen dinner that was not labeled with the date it had been removed from the freezer. 28 PA. Code 201.18(b)(3) Management.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Why is there high staff turnover? How do you retain staff?"
  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most Pennsylvania facilities.
Concerns
  • • 15 deficiencies on record. Higher than average. Multiple issues found across inspections.
  • • 97% turnover. Very high, 49 points above average. Constant new faces learning your loved one's needs.
Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.

About This Facility

What is Lutheran Home At Topton, The's CMS Rating?

CMS assigns LUTHERAN HOME AT TOPTON, THE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Pennsylvania, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Lutheran Home At Topton, The Staffed?

CMS rates LUTHERAN HOME AT TOPTON, THE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 97%, which is 51 percentage points above the Pennsylvania average of 47%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 100%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Lutheran Home At Topton, The?

State health inspectors documented 15 deficiencies at LUTHERAN HOME AT TOPTON, THE during 2022 to 2025. These included: 14 with potential for harm and 1 minor or isolated issues.

Who Owns and Operates Lutheran Home At Topton, The?

LUTHERAN HOME AT TOPTON, THE is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 194 certified beds and approximately 114 residents (about 59% occupancy), it is a mid-sized facility located in TOPTON, Pennsylvania.

How Does Lutheran Home At Topton, The Compare to Other Pennsylvania Nursing Homes?

Compared to the 100 nursing homes in Pennsylvania, LUTHERAN HOME AT TOPTON, THE's overall rating (4 stars) is above the state average of 3.0, staff turnover (97%) is significantly higher than the state average of 47%, and health inspection rating (4 stars) is above the national benchmark.

What Should Families Ask When Visiting Lutheran Home At Topton, The?

Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.

Is Lutheran Home At Topton, The Safe?

Based on CMS inspection data, LUTHERAN HOME AT TOPTON, THE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Lutheran Home At Topton, The Stick Around?

Staff turnover at LUTHERAN HOME AT TOPTON, THE is high. At 97%, the facility is 51 percentage points above the Pennsylvania average of 47%. Registered Nurse turnover is particularly concerning at 100%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Lutheran Home At Topton, The Ever Fined?

LUTHERAN HOME AT TOPTON, THE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Lutheran Home At Topton, The on Any Federal Watch List?

LUTHERAN HOME AT TOPTON, THE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

LUTHERAN HOME AT TOPTON, THE

ONE SOUTH HOME AVENUE, TOPTON, PA 19562 | (610) 682-1400

C+
Trust Grade (65/100)
4.0
CMS Rating
15
Deficiencies

Strengths

  • Licensed facility

Concerns

  • Review findings

Ask about: Staff Retention, Rn Coverage

nursinghomedata.org | Data: CMS November 2025