ROSE CITY NURSING AND REHAB AT LANCASTER
For profit - Corporation
124 Beds
LME FAMILY HOLDINGS
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
11/100
#486 of 653 in PA
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Rose City Nursing and Rehab at Lancaster has received a Trust Grade of F, which indicates significant concerns about the quality of care provided. With a state rank of #486 out of 653 and a county rank of #26 out of 31, the facility is in the bottom half of nursing homes in Pennsylvania, suggesting limited options for improvement compared to local peers. The facility's trend is worsening, as it has increased from 11 issues in 2024 to 15 in 2025, highlighting ongoing challenges. Staffing is a mixed bag with a 3/5 average rating, but concerningly high turnover at 58%, which is above the state average, indicating potential instability among caregivers. Additionally, the facility has incurred $85,790 in fines, which is higher than 89% of Pennsylvania facilities, raising questions about compliance with regulations. Specific incidents include a critical failure to implement care plans for residents with known aggressive behaviors, leading to one resident choking on a sandwich and another requiring psychiatric hospitalization. Furthermore, the facility did not conduct required performance reviews for several staff members, which could impact the quality of care. While there are some strengths, such as a 5/5 rating in quality measures, these significant weaknesses suggest families should proceed with caution when considering this facility for their loved ones.
- Trust Score
- F
- In Pennsylvania
- #486/653
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 58% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $85,790 in fines. Lower than most Pennsylvania facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 36 minutes of Registered Nurse (RN) attention daily — about average for Pennsylvania. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 38 deficiencies on record. Higher than average. Multiple issues found across inspections.
11/100
Bottom 26%
Review needed
11 → 15 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 15 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Pennsylvania average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 58%
12pts above Pennsylvania avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $85,790
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: LME FAMILY HOLDINGS
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (58%)
10 points above Pennsylvania average of 48%
The Ugly 38 deficiencies on record
2 life-threatening
Aug 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
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents and staff interview, it was determined that the facility failed refund to the resident or ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents and staff interview, it was determined that the facility failed refund to the resident or resident representative any and all refunds due to the resident within 30 days from the resident's date of discharge from the facility for one of three residents (Resident R1). Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE] and ceased to breathe while in the facility on 5/28/25. Review of the record of Resident R1's payer source revealed that Resident R1 had privately paid for care. During an interview on 8/6/25, at 9:55 a.m., the Business Office Manager (BOM) confirmed that she had submitted a request for a refund of payment to Resident R1's Representative. The BOM provided evidence of a communication with the financial office, dated 6/11/25. The BOM was able to provide a request for an update Resident R1's Representative refund, dated 8/5/25. The BOM was able to provide evidence that the refund request was processed and provided to the Resident Representative on 8/6/25. During an interview on 8/6/25, at approximately 12:45 p.m., the Director of Nursing confirmed that the facility failed to refund the Resident or Resident Representative the refunds due to the Resident within 30 days from the Resident's date of discharge from the facility. 28 Pa. Code 201.24 (b) admission Policy.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(2) Management.28 Pa. Code 201.29(a) Resident Rights.
Apr 2025
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based upon review of clinical records, it was determined the facility failed to notify the physician of a significant weight loss for one of 21 residents reviewed (Resident 34).
Findings include:
Revi...
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Based upon review of clinical records, it was determined the facility failed to notify the physician of a significant weight loss for one of 21 residents reviewed (Resident 34).
Findings include:
Review of Resident 34's Weight Summary revealed Resident 34 weighed 192.3 pounds on August 2, 2024.
Further review of Resident 34's Weight Summary revealed that on October 8, 2024, the next available weight, Resident 34 weighed 178.0 pounds indicating a 7.4 percent weight loss.
Review of Resident 34's clinical record failed to reveal evidence that Resident 34's physician was notified of Resident 34's significant weight loss.
Interview with the Nursing Home Administrator and Director of Nursing on April 25, 2025, at 10:08 a.m. confirmed that Resident 34's physician was not notified of Resident 34's weight loss.
28 Pa. Code 211.12(c)(d)(3) Nursing Services
Previously cited 8/12/2024
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy and procedure review, clinical record review, and staff interview, it was determined that...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy and procedure review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free from the use of restraints for one of the eight residents reviewed. (Residents 74).
Findings include:
A review of the facility's policy titled Use of Restraints, revised in July 2023, revealed, that restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vests, wheelchair safety bars, Geri-chairs, and lap cushions and trays that the resident cannot remove. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. Orders for restraints will not be enforced for longer than 12 hours unless the resident's condition requires continued treatment.
Clinical records review revealed Resident 74 was admitted to the facility on [DATE], with a diagnosis of Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and Alcoholic cirrhosis of the liver (is a severe condition resulting from prolonged excessive alcohol consumption, leading to the replacement of healthy liver tissue with scar tissue).
An observation was conducted on April 22, 2025, at 10:02 a.m., and 1:52 p.m. Both observations revealed Resident 74 was lying in bed, with their eyes closed. Observations also revealed Resident 74 was wearing a blue hand mitt on both hands. The resident was calm and quiet during the observation.
An observation conducted on April 23, 2025, at 9:18 a.m., revealed that the resident was lying in bed, with hand mitts on both hands. The resident was calm with eyes closed.
An interview with non-licensed Employee 4 was conducted on April 22, 2025, at 1:55 p.m. Employee E4 reported that the resident was admitted to the facility with the hand mitts. Employee E4 reported that the hand mitts were used because the resident had restless behaviors of hitting self and grabbing especially when being fed.
A review of the hospital records dated February 21, 2025, revealed: Pt (patient) appears to be sleeping comfortably. No PRN (as needed) needed. Mitts on, pt does not appear to be striking chest anymore as he was yesterday.
A review of the clinical records failed to reveal an assessment was completed for the use of the hand mitts. Further review failed to reveal a physician's order for the use of the hand mitts and that the responsible party was notified.
An interview with the Director of Nursing conducted on April 24, 2025, at 11:52 a.m., confirmed that Resident 74 was not assessed for the use of hand mitts on both hands. The DON also confirmed that there was no physician order and that the responsible party was not notified of the use of the hand mitts.
The facility failed to ensure Resident 74 was free from the use of restraints.
28 Pa. Code 211.5(f) Clinical Records
Previously cited 3/15/24, 8/12/24.
28 Pa. Code 211.8(a)(c)(d)(e) Use of Restraints
28 Pa. Code 211.12(d)(1)(5) Nursing
Previously cited 3/15/24, 8/12/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on review of facility policy, review of clinical record, review of facility documentation and staff interview, it was determined that the facility failed to conduct a comprehensive investigation...
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Based on review of facility policy, review of clinical record, review of facility documentation and staff interview, it was determined that the facility failed to conduct a comprehensive investigation for an injury of unknown origin for one of 19 residents reviewed (Resident 47).
Findings include:
Review of facility policy, Abuse Policy, undated, indicated that all reports of resident abuse, neglect,, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be thoroughly investigated by the administrator or designee.
Review of Resident 47's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated December 6, 2024, indicated that the resident had severe cognitive impairment and had a diagnosis of dementia (irreversible, progressive degenerative disease of the brain, resulting in a loss of reality contact and functioning ability).
Review of Resident 47's nursing progress note of December 31, 2024, revealed an assessment of the resident showed a 5 x 6 (no further unit of measurement) hematoma with a 3 x 3 purple bruise in the center.
Assessment indicated that most likely cause was hitting right forehead at the brow against the wall or headboard when transferring into bed at some point last night.
Interview with the Director of Nursing (DON) on April 25, 2025, at 12:04 p.m. revealed that protocol is to interview staff on the shift the injury was identified and the prior shift to determine the cause of the injury. The DON confirmed that a thorough investigation had not been completed to determine the cause of the injury.
28 Pa. Code 201.18(b)(1) Management
Previously cited 3/15/24
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29(a)(c) Resident rights
28 Pa. Code 211.12(d)(1)(5) Nursing services
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 clinical records review, and resident and staff interview, it was determined that the facility failed to follow the physician's order for a diabetic wound order for one of three residents rev...
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Based on clinical records review, and resident and staff interview, it was determined that the facility failed to follow the physician's order for a diabetic wound order for one of three residents reviewed (Resident 37).
Findings include:
A review of Resident 37's diagnoses list includes End Stage Renal Disease (ESRD- Where kidney function has declined to the point that the kidneys can no longer function on their own), and Diabetes (A group of metabolic disorders characterized by a high blood sugar level over a prolonged period of time).
Clinical records review revealed Resident 39 goes out for Hemodialysis (A process of purifying the blood of a person whose kidneys are not working normally) three times a week.
An interview with Resident 37 was conducted on April 22, 2025. At 9:50 a.m., confirmed going to dialysis three times a week every Tuesday, Thursday, and Saturday. The resident reported leaving the facility at approximately 10:15 a.m. and returning to the facility at around 5:00 p.m.
Clinical records review revealed Resident 39 had a Diabetic wound (Open sores or wounds that commonly occur on the feet, especially to the bottom of the foot, in people with diabetes) to the left lateral (side) foot upon admission.
A review of the physician order dated March 14, 2025, revealed an order to cleanse the left lateral foot wound with normal saline solution, apply Collagen (A wound care that contributes to the formation of a strong, flexible matrix that supports tissue regeneration and repair), cover with dry dressing daily and as needed.
A review of the April 2025, Treatment Administration Record revealed that from April 1, 2025, until April 11, 2025, Resident 37's diabetic wound was not treated on the following dates: April 3, 6, 10, 11, and 12. April 3 and April 12, 2025, documentation revealed treatment was not done due to Leave of Absence. There was no documentation/reason as to why wound treatment was not done on April 6, 10, and 11, 2025.
An interview with the Director of Nursing was conducted on April 25, 2025, at 1:00 p.m. The DON confirmed that the diabetic wound care was not done during dialysis days on April 3, 10, and 12, but was unable to provide documented evidence as to why it was not done on April 6, and 11 which was a non-dialysis day.
The facility failed to follow the physician's order for Resident 37's left lateral foot diabetic wound.
28 Pa. Code 211.5(f) Clinical Record
Previously cited 3/15/24, 8/12/24
28 Pa. Code 211.12(d)(1)(5) Nursing
Previously cited 3/15/24, 8/12/24
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 upon review of clinical records and interview, it was determined the facility failed to ensure that a current smoking assessment for one of one resident reviewed (Resident 24).
Findings include:...
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Based upon review of clinical records and interview, it was determined the facility failed to ensure that a current smoking assessment for one of one resident reviewed (Resident 24).
Findings include:
Review of Resident 24's diagnosis list revealed diagnoses including Multiple Sclerosis (slow progressive disease of the central nervous system), major depressive disorder and unspecified dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).
Interview with Resident 24 on April 23, 2025, at 12:00 p.m. revealed Resident 24 to be alert and oriented. Resident 24 stated that resident periodically leaves the premises to smoke and follows the rules of the smoking agreement with the facility.
Review of the facility Smoking Agreement revealed the resident must leave the property to smoke and never to smoke on the premises or in the building.
Further review of the Smoking Agreement revealed the resident will never share nor give, nor hand out any smoking materials to any other resident.
Further review of the Smoking Agreement revealed resident will sign in and out for LOA (leave of absence) as per policy and procedure.
Review of Resident 24's clinical record revealed Resident 24 is currently a smoking resident due to a grandfather clause in the facility's policy.
Review of Resident 24's clinical record revealed a Smoking Safety Evaluation dated July 29, 2023.
Further review of Resident 24's clinical record failed to reveal evidence that a current Smoking Safety Evaluation was completed since July 2023.
Interview with the Nursing Home Administrator and Director of Nursing on Aril 25, 2025 at 9:56 a.m. revealed that no Smoking Safety Evaluation was completed for Resident 24 since July 2023.
28 Pa. Code 201.18(c)(4) Management
Previously cited 3/15/2024
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based upon review of facility policy and procedure and review of clinical records, it was determined the facility failed to ensure weight loss and weight gain was adequately monitored for two of 23 re...
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Based upon review of facility policy and procedure and review of clinical records, it was determined the facility failed to ensure weight loss and weight gain was adequately monitored for two of 23 residents reviewed (Resident 34 and Resident 79).
Findings include:
Review of facility policy and procedure titled Weight Assessment and Intervention, revised March 2022, revealed Any weight change of five percent or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing.
Review of Resident 34's diagnosis list revealed diagnoses including dysphagia (inability/difficulty swallowing), Diabetes Mellitus (DM - failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).
Review of Resident 34's physician orders dated September 2022 revealed an order for monthly weights.
Review of Resident 34's Weight Summary revealed on August 2, 2024, Resident 34 weighed 192.3 pounds.
Further review of Resident 34's Weight Summary revealed the next weight obtained was on October 8, 2024.
Resident 34 weighed 178.0 pounds on October 8, 2024. This indicated a 7.44% weight loss between August 2024 and October 2024.
Review of Resident 34's clinical record failed to reveal a weight for September 2024.
Further review of Resident 34's clinical record failed to reveal evidence of a reweight after the October 8, 2024, was obtained.
Further review of Resident 34's clinical record failed to reveal evidence that the facility dietitian was notified of Resident 34's weight loss.
Interview with the Nursing Home Administrator and Director of Nursing on April 25, 2025, at 10:08 a.m. confirmed that no reweight was obtained and further confirmed that the dietitian was not notified of Resident 34's weight loss.
A review of Resident 79's weights and vitals revealed that on March 14, 2025, the resident's weight was 406 pounds and on April 2, 2025, the weight was 434 pounds, a 28 pounds (6.90%) significant weight gain in 19 days period.
A review of the Dietitian's progress notes dated April 4, 2025, at 11:07 a.m., revealed resident with significant weight gain, their previous weight was 406 pounds likely inaccurate. The resident receives outside food and continues to eat snacks despite frequent counseling from staff.
Clinical records review failed to reveal that Resident 79 was reweighed to confirm the significant weight change identified on April 2, 2025.
An interview with the Director of Nursing on April 25, 2025, at 1:00 p.m., confirmed that Resident 79's weight was not re-checked after a significant weight change was identified on April 2, 2025.
28 Pa. Code 211.10(c) Resident Care Policies
28 Pa. Code 211.12(c)(d)(3) Nursing Services
Previously cited 8/12/2024
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**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 resident assessme...
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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 resident assessments accurately reflect the residents' status for three of 23 residents reviewed (Residents 32, Resident 52 and Resident 67).
Findings include:
Review of Resident 32's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated February 8, 2025, revealed under section N0415 - High Risk Drug Classes, that the resident was not marked for receiving opioid.
Further review of Resident 32's physician orders dated November 1, 2024, revealed evidence that the resident was ordered Oxycodone HCl oral Tablet 5 mg every 6 hours as needed for pain.
Review of the February 2025 and April 2025 Medication Administration Record (MAR) revealed that the resident did receive a daily dose of Oxycodone HCl 5 mg daily except for April 19, and April 23 2025.
Interview with Licensed Employee E3 on April 25, 2025, at 12:33 p.m. confirmed that the assessment was coded inaccurately for Residents 32.
Review of Resident 52's Quarterly MDS dated [DATE] revealed Resident 52 had an active diagnosis including MDRO (multi-drug resistant organism).
Review of Resident 52's active diagnosis list failed to reveal evidence of an MDRO.
Interview with Licensed Employee E3, Nursing Home Administrator and Director of Nursing on April 25, 2025 at 10:10 a.m. confirmed Resident 52 did not have a current diagnosis of MDRO and further confirmed the Quarterly MDS dated [DATE] was inaccurate.
Review of Resident 67's Quarterly MDS dated [DATE] revealed Resident 67 had an active diagnosis including MDRO.
Review of Resident 67's active diagnosis list failed to reveal evidence of an MDRO.
Interview with Licensed Employee D3, Nursing Home Administrator and Director of Nursing on April 25, 2025 at 10:10 a.m. confirmed Resident 67 did not have a current diagnosis of MDRO and further confirmed the Quarterly MDS dated [DATE] was inaccurate.
28 Pa. Code 211.5(f) Clinical Records
Previously cited 8/12/2024
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on observation, review of the clinical record, and interview with resident and staff, it was determined that the facility failed to develop a comprehensive care plan for three of 24 residents re...
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Based on observation, review of the clinical record, and interview with resident and staff, it was determined that the facility failed to develop a comprehensive care plan for three of 24 residents reviewed (Residents 32, 37, and 91).
Findings include:
Observation on April 22, 2025, at 10:25 a.m. revealed Resident 32 was receiving oxygen at 4 liters per minute through a nasal cannula (device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help).
Review of Resident 32's physician's orders included an order on June 20, 2024 for oxygen at 4 Liter/minute via nasal cannula every shift for shortness of breath.
Review of the Resident 32's current active care plan failed to reveal a care plan or interventions for oxygen therapy.
Interview with the Nursing Home Administrator on April 25, 2025, at 12:20 p.m. confirmed that Resident 32 did not have a care plan for oxygen therapy.
A review of Resident 37's diagnosis list includes End Stage Renal Failure (ESRD- Where kidney function has declined to the point that the kidneys can no longer function on their own).
Clinical records review revealed Resident 37 has Hemodialysis (A process of purifying the blood of a person whose kidneys are not working normally) three times weekly.
An observation conducted on April 22, 2025, at 9:45 a.m., revealed resident was sitted in the wheelchair. Further observations revealed bumps on the resident's left upper arm skin.
An interview with Resident 37 conducted on April 22, 2025. At 9:50 a.m., confirmed going to dialysis three time a week every Tuesdays, Thursdays, and Saturdays. The resident also confirmed presence of dialysis shunt (A connection between a vein and artery that helps your body create the flow of blood it needs for dialysis to work) to the left upper arm.
A review of Resident 37's care plan failed to reveal that a comprehensive care plan for Dialysis and presence of dialysis shunt to the left upper arm was developed.
An interview with the Director of Nursing (DON) on April 25, 2025, at 1:00 p.m., confirmed that a comprehensive care plan for Resident 37's Dialysis was not developed.
Review of Resident 91's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) of March 18, 2025, section K0300, Weight Loss, revealed that the resident had a loss of 5% or more in the last month or loss of 10% or more in the last six months and was not on a physician prescribed weight loss regimen.
Review of Resident 91's clinical record revealed a weight change note of April 11, 2025, that indicated resident had continued weight loss. Further review of the clinical record revealed no evidence that a comprehensive care plan was developed to address the resident's weight loss.
Interview with the DON on April 25, 2025, at 10:14 a.m. confirmed that there was no care plan to address Resident 91's nutritional status.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on observations, a review of the facility's policy and clinical records, and interview with resident and staff, it was determined that the facility failed to ensure medications and fluid restric...
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Based on observations, a review of the facility's policy and clinical records, and interview with resident and staff, it was determined that the facility failed to ensure medications and fluid restriction orders for dialysis residents were followed for two of three residents reviewed (Residents 37 and 56).
Findings include:
A review of the facility's policy titled Encouraging and Restricting Fluids, undated, revealed the following guidelines for restricting fluids: Remove the resident's water pitcher and cup from the room. Store in designated area. If the resident refuses to have the water pitcher removed, notify the supervisor and in turn the physician; Record the amount of fluid consumed on the intake and output record. Record fluid intake in ml's; and Remove fluid container. Documentation includes the amount (in ml's) of fluids consumed by the resident during the shift.
A review of Resident 37's diagnosis list includes End Stage Renal Failure (ESRD- Where kidney function has declined to the point that the kidneys can no longer function on their own), and dependence on renal Hemodialysis (A process of purifying the blood of a person whose kidneys are not working normally).
An observation conducted on April 22, 2025, at 9:50 a.m., revealed Resident 37 was in the room sitting in a wheelchair. Further observation revealed a big white Styrofoam cup on the resident's tray table (approximately 16 oz size) half filled with water.
An observation conducted on April 23, 2025, at 9:30 a.m., revealed a big white cup on the resident's tray table, almost empty.
An interview with Resident 37 was conducted on April 23, 2025, at 9:32 a.m. The resident reported that staff usually refill her cup with fresh water every shift but sometimes they do, sometimes they don't. The resident denied being educated by staff on how much fluids she/he can consume every shift/daily.
A review of the physician's order dated March 3, 2025, revealed an order for Fluid restriction:1500ml total per 24 hours as follows: Dietary: 1080 ml on meal trays, Breakfast 360 ml, Lunch 360 ml, Dinner 360 ml. Nursing: 420 ml, Day shift 180 ml, Evening shift 150 ml, Night shift 90 ml.
Clinical records review failed to reveal that Resident 37's fluid intake was monitored and that the order for a 1500 cc fluid restriction in 24 hours was being followed.
A clinical records review revealed Resident 37 goes to dialysis every Tuesday, Thursday, and Saturday.
Interview with Resident 37 on April 22, 2025, at 9:50 a.m., confirmed going to dialysis every Tuesday, Thursday, and Saturday. Resident 37 reported that the pickup time was usually 10:30 a.m., and the return time was usually 5:00 p.m.
A review of Resident 37's physician's order dated January 2, 2025, revealed an order for Gabapentin (A medication used to treat nerve pain) 100mg 1 capsule three times a day for pain, and Calcium Acetate (A phosphate binder medication used to treat excess phosphate in the blood) 667 give two tablets three times a day. Both medications were scheduled at 8:00 a.m., 12:00 noon, and 4:00 p.m.
A review of the April 2025 Medication Administration Record (MAR) revealed that from April 1, 2025, until April 22, 2025, medications Gabapentin and Calcium Acetate's 12:00 noon scheduled medications were not administered ten times. MAR review revealed that the ordered medications were missed during dialysis days.
The above was conveyed to the Nursing Home Administrator and Director of Nursing on April 24, 2025, at 1:30 p.m.
Review of Resident 56's clinical record revealed diagnoses including but not limited to end stage renal disease (ESRD- failure of kidney function to remove toxins from blood) and diabetes.
Review of Resident physician's orders revealed an order for daily fluid restriction of 2L (liters) daily as follows: 7-3 shift 1000cc (cubic centimeters which equal milliliters); 3-11 shift 750 cc; 11-7 shift 250cc.
Review of Resident 56's Medical Administration Record (MAR) failed to reveal evidence of the amount of fluid Resident 56 was receiving each shift.
Interview with Nursing Home Administrator on April 25, 2025, at approximately 12:25pm confirmed the above findings.
The facility failed to ensure Resident 37 and Resident 56's medications and fluid restrictions ordered by the physician were followed.
28 Pa. Code 211.5(f) Clinical Record
Previously cited 3/15/24, 8/12/24
28 Pa. Code 211.12(d)(1)(5) Nursing
Previously cited 3/15/24, 8/12/24
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure residents receiving psychotropic medications (any medication that ...
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Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure residents receiving psychotropic medications (any medication that affects brain activity associated with mental processed and behavior) were monitored for their side effects for three of five residents reviewed (Residents 37, 43, and 59).
Findings include:
Review of facility policy Psychotropic Medication Use, revised February 2025, revealed that residents are monitored for adverse consequences associated with psychotropic medications.
A review of Resident 37's diagnosis list includes major depressive disorder, recurrent, with severe psychotic symptoms.
A review of Resident 37's physician order dated January 23, 2025, revealed an order for Aripiprazole (An anti-psychotic medication) 2 mg (milligram) given one tablet by mouth one time daily.
Clinical records review failed to reveal that Resident 37 was monitored for a side effect of the medication from January 23, 2025, until April 23, 2025.
A review of Resident 43's diagnosis list includes anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and Major Depressive Disorder (Characterized by a low mood or loss of interest in activities that last for a long time that can interfere with normal functioning).
A review of Resident 43's physician order dated April 3, 2025, revealed an order for Risperidone (An anti-psychotic medication) 0.5 mg one tablet at bedtime.
Clinical records review failed to reveal that Resident 43 was monitored for a side effect of the medication from April 3, 2025, until April 23, 2025.
A review of Resident 59's diagnosis list included diagnoses of but not limited to anxiety disorder, schizophrenia, and depression.
Review of Resident 59's physician's orders included orders for olanzapine 20 mg (anti-psychotic) at bedtime for schizophrenia, rexulti 2 mg (anti-psychotic) at bedtime for schizophrenia, remeron 15 mg (anti-depressant) one tablet in the evening for depression, sertraline HCL 25 mg (anti-anxiety) at bedtime for anxiety, clonazepam 0.5 mg (anti-anxiety) one tablet three times a day for anxiety disorder.
Further review of Resident 59's clinical record revealed no evidence that the resident was monitored for side effects of psychotropic medications.
An interview with the Director of Nursing on April 25, 2025, at 1:00 p.m., confirmed that Residents 39, 47, and 59 were not monitored for side effects from the use of antipsychotic medications.
28 Pa. Code 211.5(f) Clinical Records
Previously cited 3/15/24, 8/12/24.
28 Pa. Code 211.12(d)(1)(5) Nursing
Previously cited 3/15/24, 8/12/24.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observations, a review of the medication manufacturer's guidelines, and staff interviews, it was determined that the facility failed to ensure that medications were properly stored and labele...
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Based on observations, a review of the medication manufacturer's guidelines, and staff interviews, it was determined that the facility failed to ensure that medications were properly stored and labeled on one of two medication carts (Fourth Floor Medication cart) and one of two Medication Rooms (Second Floor Medication Room).
Findings Include:
A review of the manufacturer's storage guidelines for Novolog Insulin (fast-acting insulin), revealed that the medication must be stored at room temperature and discarded within 28 days after opening.
A review of manufacturers' storage guidelines for Lantus Insulin Pen (long-acting insulin) revealed that the medication may be stored at room temperature and discarded within 28 days after opening.
A review of the manufacturer's guidelines for Basaglar Insulin Kwikpen (a long-acting insulin) revealed that the medicine should be discarded 28 days after opening or removal from refrigeration.
A review of the manufacturer's storage guidelines for Aplisol-Purified Protein Derivative (PPD) (a combination of proteins that are used in the diagnosis of tuberculosis), revealed vials in use for more than 30 days should be discarded due to possible oxidation (a reaction in which the element and degradation combine with oxygen) and degradation
A review of the manufacturer's guidelines for Acetylcysteine vials (A medication used to clear mucus) revealed that an open vial must be used right away. The opened container should be discarded after four days.
An observation was conducted on the fourth-floor medication cart in the presence of licensed nurse Employee E10 on April 23, 2025, at 9:20 a.m. The observation revealed the following: One Novolog Insulin pen opened and undated; One Lantus Insulin pen opened and undated; and One Basaglar Insulin pen, opened and undated.
An interview with Employee E10 was conducted on April 23, 2025, at 9:20 a.m. Employee E4 confirmed that the above insulin pens should have been dated when opened.
An observation was conducted on the second-floor medication room refrigerator on April 23, 2025, at 9:26 a.m., in the presence of licensed nurse Employee E11. The observation revealed one PPD vial, opened and undated, and one vial of Acetylcysteine, opened and undated.
An interview conducted with Employee E11 on April 23, 2025, at 9:30 a.m., confirmed that the above medications should have been dated when opened.
The above was conveyed to the Nursing Home Administrator on April 25, 2025, at 12:45 p.m.
The facility failed to ensure medications were properly stored and labeled on the fourth-floor medication cart and second-floor medication room.
28 Pa. Code 211.12(d)(1)(5) Nursing
Previously cited 3/15/24, 8/12/24
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based upon review of staffing records and performance reviews it was determined the facility failed to ensure performance reviews were completed for five of five staffing records reviewed, ( Employee ...
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Based upon review of staffing records and performance reviews it was determined the facility failed to ensure performance reviews were completed for five of five staffing records reviewed, ( Employee E5,Employee E6,Employee E7,Employee E8 and Employee E9).
Findings include:
Review of staffing records and performance reviews revealed five staff members, E5, E6, E7, E8 and E9, did not have annual performance reviews performed within the last year.
Interview with the Nursing Home Administrator on April 25, 2025, at 12:30 p.m. confirmed staff performance reviews were not completed.
28 Pa. Code 201.20(a)(c) Staff Development
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected most or all residents
Based upon review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure medication regimen reviews were acted upon by a physician for fi...
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Based upon review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure medication regimen reviews were acted upon by a physician for five of five residents reviewed (Residents 37, 43, 59, 75, and 84).
Findings include:
Review of undated facility policy titled, Pharmacy Medication Regimen Review, indicated that the clinical pharmacist reviews condition concerns and reviews resident's medication regimen to identify any potential causes/concerns. The clinical pharmacist then faxes recommendations back to the facility. The clinical nurse then reviews recommendations and contacts physician for further orders. The physician signs Medication Regimen Review when reviewed.
Review of Resident 37's clinical record revealed that medication regimen reviews were completed on January 15, 2025, February 12, 2025, March 13, 2025, and recommendations were made. Further review of Resident 37's clinical record revealed no evidence of the reviews, recommendations, or evidence that the recommendations were addressed by the physician.
Review of Resident 43's clinical record revealed that medication regimen reviews were completed on January 15, 2025, March 13, 2025, and recommendations were made. Further review of Resident 37's clinical record revealed no evidence of the reviews, recommendations, or evidence that the recommendations were addressed by the physician.
Review of Resident 59's clinical record revealed that medication regimen reviews were completed on July 16, 2024, August 14, 2024, and December 10, 2024, and recommendations were made. Further review of Resident 59's clinical record revealed no evidence of the reviews, recommendations, or evidence that the recommendations were addressed by the physician.
Review of Resident 75's clinical record revealed that medication regimen reviews were completed on June 24, 2024, January 1, 2025, and February 25, 2025, and recommendations were made. Further review of Resident 75's clinical record revealed no evidence of the reviews, recommendations, or evidence that the recommendations were addressed by the physician.
Review of Resident 84's clinical record revealed that medication regimen reviews were completed on July 16, 2024, and August 14, 2024, and recommendations were made. Further review of Resident 84's clinical record revealed no evidence of the reviews, recommendations, or evidence that the recommendations were addressed by the physician.
Interview with the Nursing Home Administrator on April 25, 2025, at 12:00 p.m. confirmed that there was no evidence that the pharmacy recommendations were addressed by the physician.
28 Pa. Code 211.5(f) Clinical records Previously cited 8/12/24, 3/15/24
28 Pa. Code 211.10(c) Resident care policies
Previously cited 3/15/24
28 Pa. Code 211.12(d)(3)(5) Nursing services
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based on review of staff documentation, it was determined the facility failed to ensure the required 12 hours of annual training was completed by five of five staff members reviewed (Employee E5, Empl...
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Based on review of staff documentation, it was determined the facility failed to ensure the required 12 hours of annual training was completed by five of five staff members reviewed (Employee E5, Employee E6, Employee E7, Employee E8 and Employee E9.
Findings include:
Review of Employees E5, E6, E7, E8, E9 training documentation regarding 12-hour annual training failed to reveal evidence that Employees E5, E6, E7, E8 andE9 completed the annual 12-hour training as required.
Interview with the Nursing Home Administrator April 25, 2025, at 12:30 p.m. confirmed Employees E5, E6, E7, E8 and E9 did not complete the required 12-hour annual training.
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
Aug 2024
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based upon clinical record review and staff interview, it was determined the facility failed to comprehensively assess a resident who developed a pressure ulcer for one of four residents reviewed (Res...
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Based upon clinical record review and staff interview, it was determined the facility failed to comprehensively assess a resident who developed a pressure ulcer for one of four residents reviewed (Resident 4).
Findings include:
Review of Resident 4's clinical record included diagnoses of but not limited to Paraplegia (paralysis of the legs and lower body caused by a problem with the spinal cord or nerves, type 2 Diabetes (condition resulting from insufficient production of insulin, resulting in high blood sugar), and Peripheral Vascular Disease (condition that affects blood flow to the limbs and organs outside of the heart and brain).
Review of physician's orders included an order for weekly skin assessment, progress note, and vital signs. Document skin assessment under Forms tab Weekly Skin Review every day shift every Thursday.
Review of Resident R4's nursing progress note of July 9, 2024, revealed resident observed with a 3 centimeter (cm) by 2 cm open area to the right buttock. Area was cleansed and treatment applied. Treatment order received July 9, 2024, for the right buttock to cleanse, barrier cream, and foam border. D/C (discontinue) when healed.
Review of the clinical record revealed a weekly skin review was completed on July 11, 2024. Further review of the clinical record failed to reveal susquent weekly skin reviews were completed. There was also no other documentation of the wound including the stage, description, infection, or pain, from July 11, 2024, until August 2, 2024, when the resident was admitted to the hospital.
Interview with the Nursing Home Administrator on August 12, 2024, at 12:55 p.m. confirmed that there was no documentation for the continued assessment of Resident 4's pressure ulcer.
28 Pa. Code: 211.5(f) Clinical records
Previously cited 3/15/24
28 Pa. Code: 211.12(d)(1)(5) Nursing services
Previously cited 3/15/24
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
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, it was determined that the facility failed to maintain a safe environment for one of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, it was determined that the facility failed to maintain a safe environment for one of four resident bathrooms on the second floor.
Findings include:
Observation of the bathroom in room [ROOM NUMBER] on August 12, 2024, at 11:00 a.m. revealed a missing ceiling tile, exposing pipes in the ceiling.
An additional observation revealed that the plastic grab bar for the toilet was cracked.
Interview with the Nursing Home Administrator on August 12, 2024, at 1:00 p.m. confirmed the above observations.
28 Pa. Code 207.2 (a) Administrator's responsibility
Mar 2024
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based upon clinical record review and review of facility documentation, it was determined the facility failed to protect a resident from abuse for one of 24 residents reviewed (Resident 91).
Findings ...
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Based upon clinical record review and review of facility documentation, it was determined the facility failed to protect a resident from abuse for one of 24 residents reviewed (Resident 91).
Findings include:
Review of Resident 91's diagnosis list revealed diagnoses including Dysphagia (inability/difficulty swallowing) and protein calorie malnutrition. Resident 91 expired on December 18, 2023, on hospice services.
Review of Resident 91's clinical record revealed multiple occasions between November 2023 and December 2023, when a family member was observed forcefully feeding Resident 91 and causing the resident to cough and choke.
Further review of the clinical record revealed staff members attempting to educate the family member, but the family member continued to provide the resident foods that were not on the resident's appropriate diet per physician's order.
Further review of the clinical record revealed an incident that occurred on December 11, 2023, which prompted the facility to halt visitation by the family member.
Review of Resident 91's progress notes dated December 11, 2023, and December 12, 2023, revealed the family member was continually force feeding the resident inappropriate food items and ultimately had to be physically removed from the premises by the local police department.
Interview with the Nursing Home Administrator and Director of Nursing on March 15, 2024, revealed that between November 2023 and December 11, 2023, no attempts were made to stop Resident 91's family member from feeding Resident 91 inappropriate food items. Multiple incidents occurred and were only met with re-education. The family member was continually permitted to visit Resident 91 and attempt to feed Resident 91 inappropriate items which was witnessed by multiple staff members.
The facility failed to protect Resident 91 from abuse by a family member.
28 Pa. Code 201.18(a)(b)(1)(2) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview it was determined the facility failed to review and revise the resident care plan quarterly for one of 24 residents reviewed. (Resident 53)
Findings...
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Based on clinical record review and staff interview it was determined the facility failed to review and revise the resident care plan quarterly for one of 24 residents reviewed. (Resident 53)
Findings Include:
Review of Resident 53's care plan revealed a target date of December 29, 2023.
Review of Resident 53's clinical record revealed no documented evidence of a care plan conference in the past year.
Interview with Social Worker E3 on December 15, 2024 at 11:30 a.m. confirmed Resident 53 has not had a care plan conference in the past year and the care plan was out of date.
28 Pa. Code 211.5(f) Clinical Records
28 Pa. Code 211.11(d) Resident Care Plan
28 Pa. Code 211.12(d)(1)(5) Nursing Services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on review of the Pennsylvania Professional Nursing Practice Act, facility policy and procedure review, observations and staff interview it was determined the facility failed to ensure staff met ...
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Based on review of the Pennsylvania Professional Nursing Practice Act, facility policy and procedure review, observations and staff interview it was determined the facility failed to ensure staff met the professional standards for a Registered nurse during medications administration for one of three residents reviewed. (Resident 69)
Findings Include:
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and on going data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals.
Review of facility policy and procedure titled Medication Administration- General Guidelines, undated, revealed medications are administered at the time they are prepared. Medications are not pre-poured.
Observations of medication administration on March 15, 2024 at 8:45 a.m. revealed Registered Nursing Employee E4 administering medications to a resident. This surveyor asked employee E4 if they were administering medications and would like to observe. Employee E4 stated they were going to administer medications to Resident 69 but had already prepared the medications because they needed to dissolve, Employee E4 then pulled a medications cup half filled with an orange liquid and dissolved medications inside that was unlabeled and uncovered. The surveyor stated that they needed to see medications administration from the beginning of preparation. Employee E4 then placed the medications cup back into the medications cart and proceeded to administer medications to two other residents before administering the pre-poured medications to Resident 69.
Interview with the Director of Nursing and the Nursing Home Administer on March 15, 2023 at 11:45 a.m. confirmed Licensed Nursing Employee E4 had no followed professional standards by not administering medications at the time it was prepared.
28 Pa. 211.10(c) Resident care policies
28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observations, staff interview, clinical record review and facility policy and procedure review it was determined the facility failed to administer medications accurately to one of three resid...
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Based on observations, staff interview, clinical record review and facility policy and procedure review it was determined the facility failed to administer medications accurately to one of three residents reviewed resulting in a medications administration error rate of 25%. (Resident 70)
Findings Include:
Review of Facility policy and procedure titled Enteral Tube Medications Administration undated, revealed crushed medications are not mixed together. The powder from each medication is mixed with water, or other suitable dilutant if water is unacceptable, before administration. Each medication is administered separately to avoid interaction and clumping.
Review of Resident 70's diagnosis list revealed a diagnosis of Gastrostomy (gastrostomy is the creation of an artificial external opening into the stomach for nutritional support).
Review of resident 70's physician orders revealed an order dated January 5, 2023 stating may crush meds and administer per PEG (feeding tube).
Observations of medications administration on March 15, 2024 at 8:45 a.m. revealed Registered Nursing Employee E4 preparing the following medications for Resident 70: midodrine 10mg (milligram) (increased blood pressure), Eliquis 5mg (blood thinner), glycopyrrolate 1mg (decreases drooling), Multivitamin, Senna plus 8.6-50mg (stool softener), Iron Sulfate 325mg (supplement), and Phos-Nak Packet (supplement). All the medications were crushed together and placed in a medication cup except for the Phos-Nak Packet which was poured into the same medication cup. The medication was then dissolved in approximately 15 milliliters of water in the medication cup. A piston syringe was attached to the residents PEG tube and flushed with 30 milliliters of water followed by the liquid containing all the medications then another 30 milliliters of water flushed through the tube.
Interview with the Director of Nursing and the Nursing Home Administrator on March 15, 2024 at 11:45 a.m. confirmed the medications were administered incorrectly per policy.
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review, it was determined the facility failed to ensure a Speech Therapy Evaluation was completed as ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review, it was determined the facility failed to ensure a Speech Therapy Evaluation was completed as ordered for one of 24 residents reviewed (Resident 91).
Findings include:
Review of Resident 91's diagnosis list revealed diagnoses including Dysphagia (inability/difficulty swallowing) and protein calorie malnutrition.
Review of Resident 91's physician's orders dated [DATE] revealed an order for a speech evaluation and treatment.
Review of Resident 91's clinical record revealed Resident 91 expired on [DATE].
Review of Resident 91's clinical record failed to reveal evidence that a Speech Evaluation was completed.
Interview with the Nursing Home Administrator and Director of Nursing on [DATE] at 11:00 a.m. confirmed a speech evaluation was never completed for Resident 91 as per physician's order.
28 Pa. Code: 201.18(e)(4) Management
28 Pa. Code: 211.12(d)(3) Nursing Services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on a review of the minutes from Residents' Council meetings and grievances lodged with the facility and staff and resident interviews it was determined that the facility failed to demonstrate ef...
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Based on a review of the minutes from Residents' Council meetings and grievances lodged with the facility and staff and resident interviews it was determined that the facility failed to demonstrate efforts to respond and resolve resident complaints raised at resident group meetings including those voiced by four Residents (Residents 20, 65, 57, and Resident 24).
Findings include:
Review of resident concern/Grievance log revealed there were no grievances recorded for the months of August 2023, September 2023, October 2023, November 2023, or December 2023.
During resident council meeting on March 13, 2024, 10:00 a.m. four residents (Residents 20, 65, 57, and Resident 24) all reported filing grievances during the months listed above.
Interview conducted with the facility's social worker (SW) on March 14, 2024, at 11:28 a.m. revealed social worker started working in the facility near the end of December 2023. SW reported the previous SW did not keep any copies or list of grievances for the months of August 2023, September 2023, October 2023, November 2023, or December 2023. The social worker stated he/she was unable to provide any evidence that grievances were investigated or resolved during the months noted above.
During an Interview with the Nursing Home Administrator (NHA) on March 15, 10:14 a.m. The NHA revealed the facility has gone through three social workers since May 2023. The NHA also reported that since the turnover rate in the social work department has been high that the investigations into resident grievances have fallen through the cracks. The above information was discussed with the Administrator who confirmed the facility administration is unable to provide evidence the facility investigated resident grievances during the months noted above.
28 Pa. Code: 201.18(e)(4) Management
28 Pa. Code: 201.29(i) Resident Rights
28 Pa. Code: 211.12(d)(3) Nursing Services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy and procedure review, and staff interview it was determined the facility failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy and procedure review, and staff interview it was determined the facility failed to monitor the nutritional status for three of nine residents reviewed. (Residents 53, 69, and Resident 87)
Findings Include:
Review of facility policy and procedure titled Weight Assessment and Intervention, revised March 2019, revealed the nursing staff will measure the resident weight on admission then weekly for four weeks. If no weight concerns are noted at this point, weights will be monitored monthly thereafter or as per Dietitian or MD. Weights will be recorded in each individual's medical record. Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Physician and Dietitian. The threshold for significant unplanned and undesired weight loss will be based on the following criteria. 1 month - 5% weight loss is significant, 3 months- 7.5% is significant, 6 months 10% is significant.
Review of Resident 53's weights revealed weights on February 4, 2024 of 244.8 pounds and a weight on March 4, 2024 of 213.3 pounds after returning to the facility after a hospital stay. This was a significant weight loss of 13.1% loss over one month.
Further review of Resident 53's weights revealed there was no weight to determine the accuracy of the readmission weight on March 4, 2024.
Review of the progress notes revealed a Dietary entry on March 11, 2024 at 3:56 p.m. revealed the resident triggered for a significant weight loss and requested a re-weight to verify the weight loss and would follow-up pending the new weight.
Review of Resident clinical record revealed Resident 53 was sent out tot the hospital again on March 11, 2024 and the facility was unable to obtain the re-weight.
Review of Resident 69's weights revealed a weight on December 2, 2023 of 132 pounds and a weight on January 2, 2024 of 125.2 pounds, a significant weight loss of 5.15%.
Further review of Resident 69's weights revealed there was no re-weight to determine accuracy and the next weight was obtained on January 24, 2024 of 122.6 pounds.
Review of Resident 69's progress notes revealed a Dietary entry dated January 6, 2024 stating weight 130 pounds within normal limits. Monthly weight is stable.
Further review of Resident 69's progress notes revealed a Dietary entry dated January 25, 2024 stating weight loss with a weight on January 12, 2024 of 97.8 pounds and the resident tube feeding rate was increased for added calories.
Review of Resident 69's weights revealed there was no weight obtained by the facility on January 12, 2024 and the most current weight was January 24, 2024 which was not addressed by the dietitian on January 25, 2024.
Review of Resident 87's clinical record revealed they were admitted to the facility on [DATE] with a weight 128 pounds.
Further review of Resident 87's weights revealed the next weight obtained was December 2, 2023 of 118.6 pounds a significant weight loss of 7.34%.
Further review of Resident 87's weights revealed the next weight obtained was on February 1, 2024 after the resident had signed on to hospice services.
Review of Resident 87's admission Nutritional Risk Assessment completed November 17, 2023 noted the weight admission 128 pounds.
Further review of Resident 87's clinical record revealed there was no further documentation by the dietitian until January 3, 2024 which did not address the significant weight loss since admission and had no recommendations due to a hospice eval which the resident was not admitted to until January 11, 2024.
Interview with the Nursing Home Administrator and the Director of Nursing on March 15, 2024 at 11:45 a.m. confirmed the facility failed to obtain re-weights and admission weight per policy and there was a delay in interventions being developed by the clinical dietitian to maintain residents' weights.
28 Pa. Code 211.5(f) Clinical Records
28 Pa. Code 211.12(d)(1)(5) Nursing Services
28 Pa Code: 211.10(c) Resident care policies
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on review of facility policy, observations and interview with staff, it was determined that the facility failed to maintain appropriate temperatures during dishwashing.
Findings include:
Review ...
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Based on review of facility policy, observations and interview with staff, it was determined that the facility failed to maintain appropriate temperatures during dishwashing.
Findings include:
Review of facility policy, Dish Machine Temperatures (High Temperature Machines), revised July 2023, indicated a minimum wash temperature of 150 degrees Fahrenheit and a minimum rinse temperature of 180 degrees Fahrenheit. Additionally, the policy revealed that if the temperature does not reach the required minimum, DO NOT run any dishes through a wash/rinse cycle. If minimum temperatures are not reached, the Culinary & Nutrition Services Manager and/or the Administrator should be notified.
Observation on March 14, 2024, at 9:15 a.m. with the Food Service Director (FSD), revealed staff using the dishmachine, but the gauges were not working on the dishmachine. The FSD indicated that the gauges had stopped working the day before and staff had used the three compartment sink to wash dishes. The FSD was not sure if the dishmachine was a high temperature machine (uses heated water for sanitation) or low temperature machine (uses chemicals for sanitizing). The FSD indicated that staff put a thermometer through the machine to obtain a temperature and had switched to using chemicals, but had no way to measure the concentration of the sanitizer.
Review of the Dish Machine Temperature Log for March 2024 revealed that the wash temperature did not reach 150 degrees Fahrenheit on 16 of 36 occasions.
Additional interview with the FSD on March 15, 2024, 9:30 a.m. confirmed that the minimum wash temperatures had not been reached. The FSD indicated that earlier in the month maintenance adjusted the water temperature when the temperatures were noted to be below the minimum. The repair company was called on March 13, 2024, and had been in to make repairs on March 14, 2024. The repair company was observed working on the machine at the time of the interview.
Interview with the Nursing Home Administrator on March 15, 2024, at 11:30 a.m. confirmed that the minimum dishmachine temperatures had not been met.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
Previously cited 12/1/23
28 Pa Code 201.18(b)(3) Management
Jan 2024
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 F0801
(Tag F0801)
Could have caused harm · This affected 1 resident
Based on staff interview it was determined that the facility failed to ensure that the facility had a full-time qualified dietary services manager for the month of December 2023.
Findings include:
Obs...
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Based on staff interview it was determined that the facility failed to ensure that the facility had a full-time qualified dietary services manager for the month of December 2023.
Findings include:
Observation conducted during survey of January 3, 2023 revealed a newly hired certified dietary manager began managing the dietary department effective January 2, 2024.
Interview with the Nursing Home Administrator (NHA) revealed for during the month of December 2023, the facility did not have a qualified dietary manager. Further interview with Nursing Home Administrator revealed the maintenance director, Employee E3 assumed the position of the dietary manager.
Additional information received during the interview with the Nursing Home Administrator confirmed that Employee E3 did not have nor receive education/training regarding dietary/kitchen management. The NHA stated the facility utilitzed a remote dietitian but confirmed that she/he did not visit the facility during the month of December 2023.
The facility failed to ensure that a full-time qualified dietary services manager was available during the month of December 2023.
28 Pa. Code 211.6(c) Dietary services
28 Pa Code 201.18(e)(1)(6) Management
Dec 2023
5 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Comprehensive Care Plan
(Tag F0656)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record, facility documentation, and staff interviews, it was determined that the facility failed to ensure and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record, facility documentation, and staff interviews, it was determined that the facility failed to ensure and implement a comprehensive care plan for residents CL1 and R4 with history of seeking and aggressive behaviors which resulted in Resident CL1 ingesting a sandwich subsequently choking and expiring. Resident R4 exhibited physical aggressive behaviors which resulted in an involuntary psychiatric hospitalization. This failure placed residents in Immediate Jeopardy for two of two residents identified as being at risk.
Findings include:
Review of the clinical record revealed Resident CL1 had diagnoses including but not limited to Dysphagia (inability/difficulty swallowing), Schizophrenia (mental illness characterized by loss of reality contact, delusions, hallucinations and/or feelings of persecution), Bipolar Disorder (mental illness characterized by extreme mood swings), Anxiety (intense, persistent, and excessive worry and fear about everyday situations), and Depression (loss of pleasure or interest in activities for long periods of time).
Review of Resident CL1's quarterly comprehensive Minimum Data Set (MDS- assessment tool used to facilitate the management of resident care) dated August 23, 2023, revealed a BIMS of 09, indicating moderate cognitive impairment.
Further review of Resident CL1's clinical record revealed in March of 2023, resident was noted to have seeking behaviors to include entering other resident rooms, taking personal items from tables, closets, bins.
Additional review of Resident CL1's clinical record revealed a progress note dated April 26, 2023, when Resident CL1 was noted to make repeated requests for non-compliant food and was taking items (spoons, cups, etc) from nursing carts. The progress note continued that the behaviors are considered normal for resident.
Interview conducted with non-licensed Employee E3, on November 15, 2023, at 7:24 p.m. revealed Resident CL1 was hungry all the time. [Resident] would tell us he/she was hungry right after he/she ate. [Resident] would regularly take items off the food cart, and we would take the food away from [resident].
Review of facility provided documentation including witness statements revealed, on October 25, 2023, approximately 1:22 p.m. Resident CL1 self- propelled to the end of the hallway where a nurse aide had placed discarded meal items. Resident CL1 was observed by another resident with a (peanut butter and jelly) sandwich and reminded Resident CL1 to not eat the sandwich then went to inform staff of concern.
Further review of facility documentation revealed Resident CL1 was discovered by a nurse aide at 1:30 p.m. slumped over in wheelchair unresponsive. Nurse aide attempted to arouse Resident CL1 but was unsuccessful. Licensed nursing staff arrived and performed Heimlich maneuver. Emergency services (911) were contacted. No other interventions were noted to be used. Resident was pronounced dead at 1:41 p.m. with EMS present.
Review of Resident CL1's behavior care plan revealed a history of rejecting care, and noncompliance related to Depression, Schizophrenia, Anxiety, ineffective coping skills, and poor impulse control.
Review of Resident CL1's clinical record including care plans failed to reveal a care plan to address resident's inappropriate seeking behaviors.
Review of Resident R4's clinical record revealed a Physician Order Sheet (POS) with diagnoses listed including but not limited to Post Traumatic Seizures and history of traumatic brain injury.
Review of Resident R4's MDS assessments revealed admission/Medicare 5 day assessment dated [DATE] which indicated a BIMS (Brief Interview of Mental Score) score of 10 out of 15 (moderate cognitive impairment).
Review of Resident R4's clinical record revealed progress note dated November 30, 2023 (1:15 a.m) Called to the unit by one of the CNA of the unit. Resident is noted to be screaming at staff stating I want to get out of here attempted to open the balcony door. 911 notified. Police officers arrived on scene stating they cannot take resident out of unit unless he was 302. On call doctor notified order obtained to send resident to [local hospital] ER for evaluation for combative and psychotic behavior.
Further review of Resident R4's progress notes revealed note dated November 30, 2023 (1:25 a.m.) Resident came out to desk yelling and swinging at staff. He attempted to leave and swing at staff intermittently. Nurse Supervisor was called, [male nurse] came to assist. Police was called, and on their arrival resident stayed quite. They stated that they could not take resident unless staff from this facility initiated a 302 through Crisis Intervention. An order to transport resident for evaluation was taken from attending on call. Resident was transported out of here via litter with relevant transfer information. Police were on hand to ensure resident did not attack EMT while being taken out of facility.
Review of Resident R4's clinical record revealed a nusing note dated November 26, 2023 (9:47 p.m.) [Hospital] Update: [Licensed staff, RN] - Resident taken off elopement precautions on 11/22. Barricaded himself in room and combative with staff on 11/23. Received IM medication. Appropriate conduct/elopement free expectations set with patient on 11/24. Resident remained calm/cooperative for almost 72 hrs.(hours) Seroquel and Zoloft added to medications. Pending discharge if continues to be stable.
Further review of Resident R4's clinical record revealed a Nursing Note dated November 20, 2023 (10:21 a.m.), [Hospital personnel] a care coordinator for behavioral health called this am to staff and requested additional info (information) from staff regarding res (resident) history and behaviors. [Hospital staff] stating res (resident) conts (continues) restraints due to combative with hospital staff.
Review of clinical record for Resident R4 revealed a progress note dated November 20, 2023 (3:30 a.m.) Physical Aggression initiated: Called into the 4th floor by the CNA of the unit. Upon arrival resident is noted to be very combative with staff. [Resident's] attempted to go through the balcony exit door (he/she) said (he/she) wants to jump. [Resident] knocked down the computer at the nursing station. [Resident] grabbed chairs to throw at the glass door. [Resident] grabbed a resident's walker from (him/her) as a result the resident sustain 2 skin tears on both of (his/her) wrists. One CNA (nursing assistant) jumped in front of the resident while the other Aid took the other resident to (his/her) room for safety. The Resident (aggressor) hit the aid with the walker on (his/her) back, pulled the CNA's hair and choking her. Unable to calm resident 911 is notified. 3:40 am: 1 officer arrived on scene. Officer called for back up a total of 8 officers plus 2 EMT personnels handcuffed resident and strapped (him/her) to the litter en route to LGH ER for evaluation.
Review of Resident R4's clinical record including care plan goals and interventions failed to reveal a care plan to address R4's aggressive behaviors.
An Immediate Jeopardy (IJ) situation was identified to the Nursing Home Administrator (NHA) on November 30, 2023, at 12:58 p.m., and the IJ template was presented to the NHA, regarding care plans for Residents CL1 and R4. The NHA was made aware that Immediate Jeopardy existed for the facility's failure to ensure a comprehensive care plan for resident with history of seeking and/or aggressive behaviors and an immediate action plan was requested.
The Nursing Home Administrator and facility's action plan included the following: 1). The facility is unable to correct deficient practice for CL1 and R4, both of whom are no longer in the facility. 2). DON (Director of Nursing) and designee will review all residents care plans to ensure care plans reflect specific aggressive behavior interventions are listed and have specific plans for follow up, if appropriate. To be completed by November 30, 2023. 3). DON and Designee will re-educate licensed staff to (A) Document aggressive behaviors, (B) Review resident care plans regarding specific behaviors, and (C) Update care plans to reflect new non listed behaviors and in using behavioral approaches. DON and designee will re-educate nursing staff to include, certified nursing assistants, to review Point of Care for their assigned residents in the resident [NAME] and tasks and refer to licensed staff. The education will occur prior to current staff leaving scheduled shifts and upon arrival for next scheduled shift. DON and designee will re-educate nursing staff on behavior policies and procedures to ensure resident safety and supervision. Department heads will re-educate their staff on behavior policies and procedures to ensure resident safety and supervision. Re-education expected to be completed by November 30, 2023 and 4). DON and/or designee will review the 24 hour notes to ensure residents care plans are updated to reflect non listed behaviors three times per week for two weeks, then weekly for two weeks, then monthly for two months. Results of audits will be submitted to monthly QAPI for review and recommendations.
The action plan was accepted on November 30, 2023 at 4:57 p.m.
On December 1, 2023 a review of audits, documentation of completed employee education and interviews with eight licensed and non licensed staff members revealed the facility had completed the interventions developed for the action plan.
The Immediate Jeopardy was lifted on December 1, 2023 at 1:03 p.m. after confirmation that the action plan was implemented and the Nursing Home Administrator and Director of Nursing were informed the residents were no longer in Immediate Jeopardy.
The facility failed to ensure and implement comprehensive care plans for Residents CL1 and R4 which resulted in CL1 fatally choking on a sandwich and R4's admission to hospital for physically aggressive behaviors toward staff and a resident.
The Immediate Jeopardy was lifted at 1:03 p.m.
28 Pa. Code 201.18 (b)(1)(e)(1) Management
28 Pa. Code 211.5(h)Clinical records
28 PA Code 211.11(d) Resident care plan
28 Pa. Code 211.12(d)(5) Nursing Services
Previously cited 5/30/2023
28 Pa. Code 211.12(d)(1)(3) Nursing Services
28 Pa. Code 211.12(c) Nursing Services
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
Based on facility documentation, clinical record review and staff interviews it was determined the facility failed to implement appropriate monitoring, supervision, and safety measures to prevent Resi...
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Based on facility documentation, clinical record review and staff interviews it was determined the facility failed to implement appropriate monitoring, supervision, and safety measures to prevent Resident CL1, with known seeking behaviors and receiving a specialty diet, from obtaining a sandwich from an unsupervised cart. Resident CL1 ingested the sandwich which caused resident to choke on the food and expire. This failure placed residents at the facility in an Immediate Jeopardy situation for one of one resident identified as being at risk. This incident has been identified as past non-compliance.
Findings Include:
Review of the clinical record revealed Resident CL1 had diagnoses including but not limited to Dysphagia (inability/difficulty swallowing), Schizophrenia (mental illness characterized by loss of reality contact, delusions, hallucinations and/or feelings of persecution), Bipolar Disorder (mental illness characterized by extreme mood swings), Anxiety (intense, persistent, and excessive worry and fear about everyday situations), and Depression (loss of pleasure or interest in activities for long periods of time).
Review of Resident CL1's quarterly comprehensive Minimum Data Set (MDS- assessment tool used to facilitate the management of resident care) dated August 23, 2023, revealed a BIMS of 09, indicating moderate cognitive impairment.
Review of Resident CL1's clinical record revealed resident's diet recommendation was downgraded on April 11, 2023, to regular diet, pureed texture and thin consistency, due to an episode of swallowing difficulty with soft food (noodle).
Review of Resident CL1's behavior care plan revealed a history of rejecting care, and noncompliance related to Depression, Schizophrenia, Anxiety, ineffective coping skills, and poor impulse control.
Review of Resident CL1's clinical record revealed on September 20, 2022, Resident CL1 required a Heimlich maneuver to remove a glob of magic cup (pudding consistency).
Further review of Resident CL1's clinical record revealed in March of 2023, resident was noted to have seeking behaviors to include entering residents' rooms, taking personal items from tables, closets, bins.
Additional review of Resident CL1's clinical review revealed a progress note dated April 26, 2023, Resident CL1 was noted to make repeated requests for non-compliant food and was taking items (spoons, cups, etc) from nursing carts. The progress note continued that the behaviors are considered normal for resident.
Interview conducted with non licensed Employee E3, on November 15, 2023, at 7:24 p.m. revealed Resident CL1 was hungry all the time. [Resident] would tell us [resident] was hungry right after[resident] ate. [resident] would regularly take items off the food cart, and we would take the food away from [resident].
Review of facility provided documentation including witness statements revealed, on October 25, 2023, approximately 1:22 p.m. the resident self- propelled to the end of the hallway where a nurse aide had placed discarded meal items. Resident CL1 was observed by another resident with a (peanut butter and jelly) sandwich and reminded Resident CL1 to not eat the sandwich then left to inform staff.
Further review of facility documentation revealed Resident CL1 was discovered by a nurse aide at 1:30 p.m. slumped over in wheelchair unresponsive. Nurse aide attempted to arouse Resident CL1 but was unsuccessful. Licensed nursing staff arrived and performed Heimlich maneuver. No other interventions were noted to be used. Resident was pronounced dead at 1:41 p.m. with EMS present.
Review of Resident CL1's clinical record revealed the coroner attested death certificate which indicated death was caused by aspiration of food bolus.
An Immediate Jeopardy (IJ) situation was identified to the Nursing Home Administrator (NHA) on November 15, 2023, at 6:37 p.m., and the IJ template was presented to the NHA, regarding supervision of Resident CL1. The NHA was made aware that Immediate Jeopardy existed for the facility's failure to ensure the implementation of supervision and safety measures to prevent Resident CL1 from obtaining inappropriate food items and supervision of the food carts which presented choking hazards and an immediate action plan was requested.
The Nursing Home Administrator and facility's action plan which included the following: DON (Director of Nursing) performed an audit of all current residents identified on pureed diets and a history of impulsive behaviors. DON and designee provided education to nursing and dietary staff for juice and meal cart distributions, collections, and supervision. Revised policy and procedure began on October 25, 2023 and will continue with all new agency staff and new hires and will be reviewed during annual re-education. Policy and Procedures include appropriate supervision of residents during delivery and pick up of meal carts. All staff educated prior to leaving their current shift and prior to oncoming shift. DON and designee will audit weekly for four weeks, then monthly for two months. Dietary manager will audit weekly for four weeks then monthly for two months to ensure that dietary staff are not leaving (meal) carts on the (nursing) floors unattended. Audits started October 26, 2023 and will continue through December 2023. Results for audits will be presented to monthly QAPI for review and recommendations.
The facility identified the jeopardy at the time of the incident, October 25, 2023. The facility conducted a full audit of current residents' pureed diets and impulsive behaviors. The audit was completed on October 25, 2023. The facility began education on October 25, 2023, of current dietary and nursing staff as well as nursing agency staff regarding newly implemented food service procedure which includes supervision of food delivery and disposal from each nursing unit. The education of the staff was completed on October 27, 2023. Daily audits were conducted of meal services and supervision of residents during the service and disposal of meal items. The facility continued with daily audits for four weeks and will continue weekly audits to ensure ongoing compliance as reviewed by facility Quality Assurance team.
Facility staff was educated on the following: supervision of residents and food during meal services. The staff were also educated on the new procedure for distribution of meal services and retrieval of food trays/meal items at the end of the meal service. The staff were educated on residents who receive speciality diets and have seeking behaviors need supervision including meal service. The administration educated 67 facility staff and nine agency staff. The staff were educated before starting of the scheduled shift.
Interviews conducted by surveyors on November 15 and November 16, 2023 of 15 staff including three Registered Nurses, nine nurse aides, one housekeeper, and one Licensed Practical Nurse. The interviews revealed the education provided to the staff at the time of incident included change in meal service and resident supervision. Assigned personnel monitor and supervise drink carts and discarded meal items during clean up.
The Immediate Jeopardy was lifted on November 16, 2023, at 10:35 a.m., after confirmation that the action plan was implemented and completed.
28 Pa. Code 201.18 (b)(1)(e)(1) Management
28 Pa. Code 211.5(h)Clinical records
28 Pa. Code 211.12(d)(5) Nursing Services
Previously cited 5/30/2023
28 Pa. Code 211.12(d)(1)(3) Nursing Services
28 Pa. Code 211.12(c) 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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on clinical records and interviews with staff it was determined that the facility failed to ensure physician orders were followed for one resident out of five residents reviewed (Resident R2)
Fi...
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Based on clinical records and interviews with staff it was determined that the facility failed to ensure physician orders were followed for one resident out of five residents reviewed (Resident R2)
Findings include:
Based on the clinical record reviews the Resident R2 was admitted to the facility May 6, 2022, with the following (but not limited to) diagnosis: orthostatic hypotension (form of low blood pressure that happens when you stand up from sitting or lying down). Further review of the clinical record reveals a physician orders dated June 24, 2023 for Midodrine HCl Tablet 2.5 MG Give 3 tablet by mouth before meals Hold: SBP > (greater) 120/80 related to orthostatic hypotension.
Review of the Medication Administration Record for July 2023 revealed that Midodrine was not held on the following days and times for a blood pressure greater than 120/80. For the 6:00 a.m. administration July 2, 2023 with a blood pressure of 134/86 and July 17, 2023 for a blood pressure of 137/85. For the 10:00 a.m. administration time the medication was given on July 1, 2023 with a blood pressure of 144/86; July 18, 2023 for a blood pressure of 131/82 and July 29, 2023 for a blood pressure of 147/81. Resident R2 was given the medication Midodrine five doses outside the physician identified parameters.
An interview with the Director of Nursing on November 16, 2023, confirmed that the medication should have been held on the dates above.
The facility failed to ensure physician orders were followed for Resident R2.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.12(c) Nursing services
28 Pa. 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
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility documentation it was determined that the facility failed to ensure...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility documentation it was determined that the facility failed to ensure residents were free from significant medication errors for one of three residents reviewed. (Resident R1).
Findings include:
Review of Resident R1's clinical record revealed resident was admitted to the facility on [DATE].
Review of Resident R1's clinical record including the Physician order Sheet revealed diagnoses including but not limited to following: Hypo-Osmolality (low water in the blood) and Hyponatremia (low concentration of sodium in the blood); Chronic Obstructive Pulmonary Disease (long term progress lung disease with limited air flow limitation); Encephalopathy; Idiopathic Epilepsy; Chronic Respiratory Failure; Morbid Obesity; Asthma; Hyperlipidemia; Bipolar Disorder (mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows); Obstructive Sleep Apnea; Muscle Weakness; Hypertension (high blood pressure); Dysphagia (Difficulty swallowing); Chronic Pain Syndrome; Overactive Bladder; Anemia; Transient Alteration of Awareness.
Review of Resident R1's clinical record revealed the resident has a BIMS (Brief Interview of Mental Status) of 12 out of 15 which indicates functioning cognitive function.
Review of information dated October 15, 2023 submitted by the facility on October 16, 2023 revealed, [Resident] [date of birth ] was given another residents medications that included Baclofen (Muscle Relaxant), Effexor [Antidepressant], Lovaza [prescription fish oil containing omega-3 acid ethyl [NAME]], Ropinole [medication used to treat Parkinson's disease], Glimiperide [antidiabetic medication used to control high blood sugar], risperidone [used to treat a certain mental/mood disorder called schizophrenia], Singulair [ used to control and prevent symptoms caused by asthma], Multivit [Vitamin]. Dr called Orders to monitor and do q [every] shift vital signs and blood sugar levels q shift. Blood sugars were not effected noted to be 193, Blood pressures were stable all day Next of kin was notified. Son was aware of the medications and that the doctor want us to monitor in house. Resident was not symptomatic, on any level.
Review of clinical record of Resident R1 revealed that on October 14, 2023 approximately 2:51 p.m. Registered Nurse, Employee E5 administered medications that were to be given to a different resident. Further review of Resident R1's clinical record failed to reveal time of notification to the attending physician. Review of clinical record revealed Resident R1's blood pressure at the time to be 140/80 an pulse rate to be 70 bpm (beats per minute).
Interview conducted with Registered Nurse employee, E5, on November 15, 2023 at 3:33 p.m. revealed, it was [Resident R1]. It was a med (medication) error. I pulled the meds thinking it was a different room. I counted the shower room as a resident room. I knew it was wrong immediately after administering the medication. I told the nursing supervisor and got vitals immediately. I talked to the doctor and told him the meds that i gave in order of the least effect to the ones that may cause more serious issues. The vitals were stable. I checked on [Resident] every 15 minutes. I did not write them all down. I was late on treatments but I was concerned for [Resident]. I noticed that [resident] was a little sleepy and informed the doctor. I believe it was on the 3-11 p.m shift but i was working a double (2 shifts). I was educated by the Director of Nursing and the 5 R's (for medication administration).
Further review of facility submitted information revealed, Resident did not have any symptoms for 36 hours At 36 hours resident became lethargic and started to slur words. BP was elevated to 245/194 Orders to send to ER (Emergency Room) for evaluation Resident is currently in observation for hypernatremia. Education done for the 5 rights of medication administration to that nurse and is ongoing in this facility.
Review of Resident R1's clinical record revealed an eInteract Transfer Form which indicated, New Order, send resident out to ER for evaluation of stroke.
Review of Resident R1's clinical record including progress notes revealed a Nursing Note dated October 15, 2023 (9:36 p.m.) indicating, Resident room mate called the Med (medication) nurse and said that resident is talking funny. Resident was not talking funny after I gave [resident] medication. Med nurse went to asses resident. Resident slurring [resident] words, was able not able to lift [resident] head up, v/s [vital signs] bs [blood sugar] 193, P75 [Pulse], Pulse ox 94 on cpap (machine that provides a continuous supply of oxygen to the body as you sleep), b/p [blood/pressure] 245/190. Resident has a change in mental status. Called 911.
Interview conducted on November 15, 2023 at approximately 6:35 p.m. when the above information was present to Nursing Home Administration and Director of Nursing.
28 Pa. Code 211.10(c) resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services
CONCERN
(E)
📢 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
Administration
(Tag F0835)
Could have caused harm · This affected multiple residents
Based on job description reviews, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility by implementing monitoring, supervision, and e...
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Based on job description reviews, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility by implementing monitoring, supervision, and effective safety measures to
for a resident who demonstrated food seeking behavior, which resulted in harm to Resident CL1 as evidenced by the death of Resident CL1. The Administration failure resulted in an immediate jeopardy situation for Resident CL1.
Findings include:
Review of the job description for the Nursing Home Administrator (NHA) revealed the primary purpose of the job position is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times.
Review of the job description for the Director of Nursing (DON) revealed the purpose of the job position was to plan, organize, develop and direct the overall operation of the nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times.
The findings in this report identified the facility administration failed to implement interventions, supervision, and effective safety measures to effectively manage the facility by implementing monitoring, supervision, and effective safety measures to for a resident who demonstrated food seeking behavior, which resulted in harm of death to Resident CL1. The Administration failure resulted in an immediate jeopardy situation for Resident CL1. The Nursing Home Administrator and Director of Nursing failed to fulfill their essential job duties and ensure federal and state guidelines and regulations were followed.
Refer to F 689 and F 656
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(e)(1) Management
28 Pa. Code 210.18(b)(3)(e)(1) Management
28 Pa. Code 207.2(a) Administrator's Responsibility
28 Pa. Code 211.12(c) Nursing services
Previously cited 2/16/23, 6/29/22
28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 06/2/23, 6/29/22
28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 6/29/22; 1/19/23; 6/2/23
Jun 2023
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review it was determined the facility failed to ensure resident's electronic medical record accuratel...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review it was determined the facility failed to ensure resident's electronic medical record accurately reflected resident's Pennsylvania Orders for Life Sustaining Treatment (POLST) signed by resident's representative for one of 32 records reviewed (Resident 91).
Findings include:
Review of Resident 91's clinical record revealed a physician's order dated [DATE] indicating Resident 91 was a Full Code (requiring CPR and full treatment if life threatening issues occur).
Review of Resident 91's care plan dated [DATE] revealed Resident 91 was considered Full Code.
Review of Resident 91's clinical record revealed a Pennsylvania Orders for Life Sustaining Treatment (POLST) form dated [DATE] and signed by Resident 91's representative indicating Resident 91 was to be have DNR (do not resuscitate) status and receive comfort measures only.
Interview with the Nursing Home Administrator and Director of Nursing on [DATE] at approximately 11:00 a.m. failed to reveal information as to whether Resident 91 was to receive CPR or whether Resident 91 was to have a DNR status.
The facility failed to ensure resident's electronic medical record accurately reflected Resident 91's representatives wishes for life sustaining treatment.
28 Pa. Code 201.29(a)(j) Resident Rights
Previously cited [DATE]
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 review of facility policy, observation, and interview, it was determined that the facility failed to ensure adequate supervision of one of 22 residents reviewed (Resident 67).
Review of facil...
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Based on review of facility policy, observation, and interview, it was determined that the facility failed to ensure adequate supervision of one of 22 residents reviewed (Resident 67).
Review of facility policy, Picture/Video, Cell Phone, and Social Media Usage Policy, last updated March 11, 2022, revealed that staff cell phones may only be utilized on employee breaks and in designated areas. Cell phones must be turned off in resident care or work areas.
Review of facility policy, Frequent Monitoring Policy, last revised January 2020, revealed: If a resident is placed on one to one monitoring, an assigned staff member must remain with the resident at all times.
Interview with eight residents in a group setting on May 31, 2023, at approximately 1:30 p.m. revealed complaints of staff members frequently being on their cell phones during their shift.
Observation of Resident 67 on May 30, 2023, at 12:00 p.m. revealed the resident was on a one to one for behaviors. Observation at this time revealed nursing Employee E5 seated at a table outside the resident's room using a cell phone. Resident 67 was observed to leave the room and walk around Employee E5 at this time, while Employee E5 remained engaged with cell phone.
Observation of Resident 67 on May 31, 2023, at approximately 8:30 a.m. revealed nursing Employee E6 was at the end of the hall utilizing a cell phone and did not have eyes on Resident 67. Employee E6 eventually went to the table outside Resident 67's room and continued utilizing the cell phone.
Interview with the Director of Nursing on June 2, 2023, at approximately 9:50 a.m. confirmed that employees should not be on their cell phones during their shift and staff were not adequately supervising Resident 67.
28 Pa. Code 201.29(c) Resident rights
28 Pa. Code 211.10(d) Resident care policies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on review of facility policy, interview, and clinical record review, it was determined that the facility failed to provide documented evidence that consistent, adequate catheter care was provide...
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Based on review of facility policy, interview, and clinical record review, it was determined that the facility failed to provide documented evidence that consistent, adequate catheter care was provided to prevent urinary tract infections for one resident reviewed for urinary catheters (Resident 303).
Findings include:
Review of facility policy, Catheter Care, Urinary, last revised September 2014, revealed that catheter care, including date/time, who gave catheter care, any assessment data obtained while giving care, character of urine (color, clarity, odor), any problems notes, how the resident tolerated the procedure, should be documented in the resident's clinical record.
Interview with Resident 303 on May 31, 2023, at 12:00 p.m. confirmed the resident had a urinary catheter (a thin, flexible tube placed in the bladder through the urethra to drain urine). Further interview with Resident 303 revealed that staff were not consistent with providing catheter care.
Review of Resident 303's physician's orders, Medication and Treatment Administration Records, tasks, and care plan failed to reveal evidence that the resident was receiving routine catheter care.
Interview with the Director of Nursing on June 2, 2023, at 10:11 a.m. confirmed there was no documented evidence that catheter care was being provided to Resident 303.
28 Pa Code 211.12(d)(5) Nursing Services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on clinical record review and staff interview it was determined the facility failed to monitor and address changes of the nutritional status for five of 10 residents reviewed. (Residents 40, 42,...
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Based on clinical record review and staff interview it was determined the facility failed to monitor and address changes of the nutritional status for five of 10 residents reviewed. (Residents 40, 42, 62, 81, and 84)
Findings Include:
Review of facility policy and procedure titled Weight Assessment and Intervention, last revised March 2019, revealed weights should be completed monthly. Further review of the policy revealed that any weight change of 5 lbs. (pounds) or more since the last weight assessment will be retaken for confirmation. The nursing staff will measure resident weight on admission and then weekly for two weeks.
Review of Resident 40's weights revealed the resident was documented as weighing 102 lbs. on March 29, 2023. Further review of Resident 40's weights revealed the resident was documented as weighing 92.2 lbs. on April 2, 2023, a difference of 9.8 lbs. in three days. Further review of Resident 40's weights revealed a reweight was not obtained until April 19, 2023.
Interview with the dietitian, Employee E3, on June 2, 2023, at 10:35 a.m. confirmed a reweight was not obtained in a timely manner for Resident 40.
Review of Resident 42's weights revealed the resident was documented as weighing 94 lbs. on February 6, 2023. On March 17, 2023, the resident was documented as weighing 104.1 lbs., a difference of 10.1 lbs. since the last weight. On April 3, 2023, the resident was documented as weighing 104 lbs. On May 5, 2023, the resident was documented as weighing 95.3 lbs., a difference of 8.7 lbs. since the last weight.
Interview with the Registered Dietitian, Employee E3, on June 2, 2023, at 10:35 a.m. confirmed Resident 42 was not reweighed per facility policy.
Review of Resident 62's clinical record revealed there was no weight record for the month of March 2023.
Review of Resident 81's clinical record revealed there was no weight record for the month of March 2023.
Interview with Registered Dietitian, Employee E3 on June 2, 2023 at 10:30 a.m. confirmed there were no weights obtained for Residents 62 and 81 for the month of March 2023.
Review of Resident 84's clinical record revealed a hospital readmission weight on January 5, 2023, of 107.4 pounds. The next weight obtained on January 24, 2023, was 98.6 pounds (loss of 8.8 pounds or 8.2%). There was no documentation of a reweight being obtained or the weight loss being addressed.
Interview with Registered Dietitian, Employee E3, on June 2, 2023, at 10:28 a.m. indicated that weights should be obtained on readmission and weekly for four weeks. Employee E3 confirmed that a reweight should have been completed for Resident 84 and that the significant weight loss was not addressed.
483.25 Nutrition/Hydration Status Maintenance
Previously cited 6/29/22
28 Pa. Code 211.5(f) Clinical Records
Previously cited 6/29/22
28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 6/29/22
28 Pa Code: 211.10(c) Resident care policies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on clinical record review and staff interview it was determined the facility failed to have a consultant pharmacist provide a monthly medication review or respond to the recommendations made by ...
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Based on clinical record review and staff interview it was determined the facility failed to have a consultant pharmacist provide a monthly medication review or respond to the recommendations made by the pharmacist during the monthly medications review or five of 5 residents reviewed. (Residents 40, 58, 62, 82 and 87)
Findings include:
Review of Resident 40's clinical record failed to reveal any documented evidence that the pharmacist had reviewed or made recommendations for the physician. The surveyor asked for a year's worth of pharmacy reviews (June 2022 through June 2023) and did not receive any at the time of the survey exit (June 2, 2023 at approximately 2:30 p.m.)
Review of Resident 58's Medication Regimen Reviews revealed the pharmacist had recommendations for the physician on July 19, 2022, December 29, 2022 and May 28, 2023.
Review of Resident 58's clinical record revealed there was no response from the physician regarding the recommendations for Resident 58.
Review of Resident 62 ' s Medication Regimen Reviews revealed the pharmacist had recommendations for the physician on December 21, 2022 and July 18, 2023.
Review of the clinical record revealed there was no response from the physician regarding these recommendations.
Interview with the Director of Nursing on June 2, 2023 at 11:30 a.m. confirmed there was no documented evidence of a response by the physician to the recommendations made by the consultant pharmacist.
Review of Resident 82's clinical record revealed the only pharmacy review that was given to the surveyor was from March 2023. The surveyor asked for all pharmacy reviews from July 2022 through present (June 2023), and at the time of the survey exit (June 2, 2023 at approximately 2:30 p.m.) had only received one from March 2023.
Review of Resident 87's Medication Regimen Reviews revealed the pharmacist had recommendations for the physician on March 22, 2023.
Review of the clinical record revealed there was no response from the physician regarding the recommendations for Resident 87.
28 Pa Code 211.5(f) Clinical records
28 Pa Code 211.12(d)(3) Nursing Services
Feb 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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based upon review of facility policy and procedure, observation and clinical record review, it was determined the facility failed to complete tracheostomy site care causing a wound to resident's neck ...
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Based upon review of facility policy and procedure, observation and clinical record review, it was determined the facility failed to complete tracheostomy site care causing a wound to resident's neck for one of one resident reviewed (Resident 1).
Findings include:
Review of facility policy and procedure titled Tracheostomy Care revealed Tracheostomy care should be provided as often as needed at least once daily for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies.
The policy further revealed inspect skin and stoma site for signs and symptoms of infection, leakage, subcutaneous crepitus from dislodged tube.
The policy further revealed Remove neck ties and replace with clean ones.
Observation of Resident 1 on February 16, 2023 revealed tracheostomy ties in place with a dressing underneath the ties on the right side of the resident's neck.
Review of Resident 1's clinical record dated February 7, 2023 revealed wound found in folds of right neck where trach ties sit to keep trach in place. Called CRNP [Certified Registered Nurse Practitioner] to assess area. Noted that CNA [Certified Nurse Aide] expressed to this writer that resident pulls on these trach ties frequently. Wound needs to be packed. Then new trach tie of large band with foam/padding should be used instead of small band trach ties. Large band trach tie not available in-house supply. Resident sent out to hospital for this reason. Guardian aware.
Review of Resident 1's acute care facility records revealed complaint of wound to the right posterior aspect of the neck resulting from trach appliance.
Further review of Resident 1's acute care facility record dated February 7, 2023 revealed patient does have a large open wound posterior right neck from the tracheostomy.
Further review of Resident 1's acute care facility record dated February 7, 2023 revealed appears to have a right posterior neck wound from the strap of tracheostomy being too tight; open wound was packed; nursing home will be educated.
Further review of Resident 1's acute care facility record dated February 7, 2023 revealed wound to right posterior aspect of the neck with embedding of the trach tie.
Review of Resident 1's February 2023 Treatment Administration Record revealed an order for Trach Ties every evening shift every Tuesday and Friday. The TAR further revealed that Resident 1's trach ties were last changed on February 3, 2023, four days prior to Resident 1 being sent to the hospital.
Review of Resident 1's current plan of care revealed monitor skin integrity under and around trach; notify MD of any changes; trach care every shift and as needed.
Review of Certified Nurse Practitioner's note dated February 7, 2023 revealed floor nurse untied trach tie to right side of neck, then held trach in place as this provider and DON (director of nursing) worked to pull back trach tie to right side of neck and move resident neck and head in order to be able to visualize and assess. Resident manifested signs of pain when removing trach tie to right neck as evidenced by abruptly jerking away. Tie was adhered to skin due to serosanguinous drainage coming from wound along the site where trach tie was in place. Upon further exam, tie wa [was] embedded in the wound, which was approx. 5 mm deep.
The facility failed to inspect Resident 1's tracheostomy ties and skin under the tracheostomy ties for four days resulting in an open wound to Resident 1's right neck requiring an emergency room visit to an acute care facility and pain to Resident 1 resulting in harm to Resident 1.
483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition
28 Pa. Code 201.18(a)(b)(1) Management
Previously cited 6/29/2022, 9/13/2022
28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services
Previously cited 3/3/2021, 4/12/2021, 6/29/2022, 1/19/2023
Jan 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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based upon review of clinical records, it was determined the facility failed to administer medications according to physician orders for one of five residents reviewed (Resident R1).
Findings include:...
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Based upon review of clinical records, it was determined the facility failed to administer medications according to physician orders for one of five residents reviewed (Resident R1).
Findings include:
Review of Resident R1's January 2023 physician orders revealed orders for Lantus SoloStar Solution Pen-injector 100 units/milliliter (ml) (insulin) 36 units to be administered at bedtime.
Review of Resident R1's January 2023 Medication Administration Record (MAR) revealed Resident R1 did not receive Lantus on January 9, 2023, at 9:00 p.m. as ordered by the physician.
Further review of Resident R1's January 2023 physician orders revealed an order for Risperdal (anti-psychotic medication) 0.25 milligrams (mg) to be administered along with 1 mg at bedtime.
Review of Resident R1's January 2023 MAR revealed Resident R1 did not receive Risperdal 1.25 mg on January 9, 2023, at 9:00 p.m. as ordered by the physician.
Further review of Resident R1's January 2023 physician orders revealed an order for Eliquis (blood thinner) 2.5 mg to be administered 2 times per day.
Review of Resident R1's January 2023 MAR revealed Resident R1 did not receive Eliquis 2.5 mg on January 9, 2023, at 9:00 p.m. as ordered by the physician.
Further review of Resident R1's January 2023 physician orders revealed an order for FiberCon Tablet 625 mg to be administered two times per day.
Review of Resident R1's January 2023 MAR revealed Resident R1 did not receive FiberCon Tablet 625 mg at 9:00 p.m. as ordered by the physician.
Further review of Resident R1's January 2023 physician orders revealed an order for Magnesium Oxide (supplement) 400 mg to be administered two times per day.
Review of Resident R1's January 2023 MAR revealed Resident R1 did not receive Magnesium Oxide 400 mg at 9:00 p.m. as ordered by the physician.
Review of Resident R1's clinical progress notes failed to reveal evidence the above medications were administered.
Interview with the Nursing Home Administrator and Director of Nursing on January 19, 2023 at 1:00 p.m. confirmed the above medications were not administered as ordered.
28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services
Previously cited 6/29/2022
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
- "What changes have you made since the serious inspection findings?"
- "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
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), $85,790 in fines. Review inspection reports carefully.
- • 38 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $85,790 in fines. Extremely high, among the most fined facilities in Pennsylvania. Major compliance failures.
- • Grade F (11/100). Below average facility with significant concerns.
Bottom line: Trust Score of 11/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Rose City Nursing And Rehab At Lancaster's CMS Rating?
CMS assigns ROSE CITY NURSING AND REHAB AT LANCASTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Rose City Nursing And Rehab At Lancaster Staffed?
CMS rates ROSE CITY NURSING AND REHAB AT LANCASTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 58%, which is 12 percentage points above the Pennsylvania average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 72%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Rose City Nursing And Rehab At Lancaster?
State health inspectors documented 38 deficiencies at ROSE CITY NURSING AND REHAB AT LANCASTER during 2023 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 36 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Rose City Nursing And Rehab At Lancaster?
ROSE CITY NURSING AND REHAB AT LANCASTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by LME FAMILY HOLDINGS, a chain that manages multiple nursing homes. With 124 certified beds and approximately 103 residents (about 83% occupancy), it is a mid-sized facility located in LANCASTER, Pennsylvania.
How Does Rose City Nursing And Rehab At Lancaster Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, ROSE CITY NURSING AND REHAB AT LANCASTER's overall rating (2 stars) is below the state average of 3.0, staff turnover (58%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Rose City Nursing And Rehab At Lancaster?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.
Is Rose City Nursing And Rehab At Lancaster Safe?
Based on CMS inspection data, ROSE CITY NURSING AND REHAB AT LANCASTER has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Rose City Nursing And Rehab At Lancaster Stick Around?
Staff turnover at ROSE CITY NURSING AND REHAB AT LANCASTER is high. At 58%, the facility is 12 percentage points above the Pennsylvania average of 46%. Registered Nurse turnover is particularly concerning at 72%. 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 Rose City Nursing And Rehab At Lancaster Ever Fined?
ROSE CITY NURSING AND REHAB AT LANCASTER has been fined $85,790 across 1 penalty action. This is above the Pennsylvania average of $33,937. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Rose City Nursing And Rehab At Lancaster on Any Federal Watch List?
ROSE CITY NURSING AND REHAB AT LANCASTER 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.