Rose City Nursing And Rehab At Lancaster
Inspection history, citations, penalties and survey trends for this long-term care facility in Lancaster, Pennsylvania.
- Location
- 425 North Duke Street, Lancaster, Pennsylvania 17602
- CMS Provider Number
- 395177
- Inspections on file
- 31
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Rose City Nursing And Rehab At Lancaster during CMS and state inspections, most recent first.
A resident with dementia, Alzheimer’s disease, and a mood disorder exhibited escalating inappropriate and sexual behaviors over several months, including exposing genitals, making sexual gestures, entering female residents’ rooms, kissing another resident, rummaging through a roommate’s belongings, and masturbating in common and private areas. Nursing notes documented these behaviors and difficulty redirecting the resident, but there was no evidence that the primary physician was notified or that behavioral health services were provided during this period, despite prior psychiatric recommendations for ongoing monitoring and follow-up as needed. Behavioral services were not sought until after an incident in which the resident was found masturbating in another resident’s room with physical contact to that resident’s side.
The facility did not ensure that the Activity Director held the required certification or qualifications, as the individual in the role had not completed certification and lacked the necessary experience at the time of hire. Oversight by the Occupational Therapist was inconsistent and undocumented, and facility leadership confirmed the deficiency in meeting policy requirements.
A resident's medical records were not successfully transmitted to the hospital due to an unsuccessful fax attempt, lack of confirmation, and failure to verify receipt, resulting in a delay of care.
A resident who privately paid for care passed away, and the facility did not issue a required refund to the resident's representative within 30 days of discharge. Documentation and staff interviews confirmed the delay, with the refund being processed well after the regulatory deadline.
The facility did not complete annual performance reviews for five nurse aides, as required by regulation. A review of staffing records showed that these staff members did not have their performance reviews conducted within the last year, a fact confirmed by the Nursing Home Administrator.
The facility failed to ensure that medication regimen reviews were acted upon by a physician for several residents. Despite the clinical pharmacist making recommendations, there was no evidence in the residents' records that these were reviewed or addressed by the attending physician, as confirmed by the Nursing Home Administrator.
The facility did not ensure that five nurse aides completed the required 12 hours of annual in-service training, which includes dementia management and resident abuse prevention. Documentation review showed no evidence of completion, confirmed by the Nursing Home Administrator.
A facility failed to ensure accurate resident assessments for three individuals. One resident's MDS inaccurately showed no opioid use despite receiving Oxycodone, while two others were incorrectly listed with an MDRO diagnosis. These inaccuracies were confirmed through staff interviews.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in their care. A resident receiving oxygen therapy did not have a care plan for it, another with End Stage Renal Failure lacked a care plan for dialysis, and a third resident with significant weight loss had no nutritional care plan. These deficiencies were confirmed by facility staff.
The facility failed to follow physician-ordered fluid restrictions and medication schedules for two dialysis residents. One resident was observed with a large cup of water, contrary to fluid restriction policies, and missed doses of prescribed medications during dialysis days. Another resident's fluid intake was not documented as required. These deficiencies were confirmed by the Nursing Home Administrator.
The facility failed to monitor side effects of psychotropic medications for three residents, despite their diagnoses of major depressive disorder, anxiety disorder, and schizophrenia. The residents were prescribed medications such as Aripiprazole, Risperidone, Olanzapine, and others, but there was no evidence of monitoring for adverse effects, as confirmed by the DON.
The facility failed to properly store and label medications on the fourth-floor medication cart and in the second-floor medication room. Observations revealed undated insulin pens and vials, which should have been dated upon opening according to manufacturer's guidelines. Staff confirmed the oversight, indicating non-compliance with proper medication management protocols.
A resident experienced a significant weight loss, dropping from 192.3 pounds to 178.0 pounds, which was not communicated to the physician. This oversight was confirmed by the Nursing Home Administrator and the DON during a survey, indicating non-compliance with federal and state regulations.
A resident with Alzheimer's and alcoholic cirrhosis was observed wearing hand mitts without proper assessment or physician's order, violating their right to be free from unnecessary restraints. Staff used the mitts due to the resident's restless behaviors, but the facility failed to document the required evaluations and approvals.
A resident with severe cognitive impairment and dementia sustained an injury of unknown origin, and the facility failed to conduct a comprehensive investigation as required by their policy. The Director of Nursing confirmed that the protocol to interview staff from relevant shifts was not followed, leading to an incomplete investigation.
A facility failed to follow a physician's order for a resident's diabetic wound care. The resident, with ESRD and diabetes, missed wound treatments on several days in April, including non-dialysis days, without documented reasons. The DON confirmed the lapses but could not provide explanations for all missed treatments.
A resident with Multiple Sclerosis and dementia did not have a current Smoking Safety Evaluation since July 2023, despite being required to follow a Smoking Agreement. The facility's management confirmed the lapse, which was previously cited as a deficiency.
The facility failed to monitor significant weight changes for two residents, leading to deficiencies in nutritional and hydration status. One resident experienced a 7.44% weight loss without a reweight or dietitian notification, while another had a 6.90% weight gain without rechecking. The facility did not follow its policy for weight assessment and intervention.
During a survey, it was found that the fire blanket cabinet in the 2nd floor Clean Linen Room of Rose City Nursing and Rehab at Lancaster was empty. This deficiency was confirmed by the Maintenance Director, indicating a failure to meet the required safety standards for the facility's operation.
The facility failed to maintain unobstructed egress, affecting two smoke compartments. A plastic chair blocked an exterior exit door on the Front Patio, and a padlock on the Kitchen walk-in refrigerator was not defeatable with the emergency release. These issues were confirmed by the Maintenance Director.
The facility failed to maintain the fire resistance of stairtower enclosures, affecting two smoke compartments. Observations revealed that stairtower doors in specific zones did not positively latch within their frames, as confirmed by the Maintenance Director.
The facility did not maintain the automatic sprinkler system free from extraneous weight, affecting one smoke compartment. White wires were found wire-tied to the sprinkler piping above the ceiling in the Zone 1 Corridor, near a resident room. The Maintenance Director confirmed the wires were supported by the sprinkler system.
The facility failed to maintain the smoke resistance of smoke barrier walls, as observed with an unprotected penetration on the 2nd floor above the cross-corridor double doors near a resident room. This issue affected two of eight smoke compartments, compromising the smoke resistance of the barrier walls.
The facility failed to monitor the use of receptacle multipliers, resulting in an unprotected penetration of the smoke barrier wall. Observations revealed improper use of power strips and extension cords in one of the eight smoke compartments, not adhering to required UL standards for patient-care-related electrical equipment.
The facility failed to secure portable oxygen cylinders in multiple locations, including therapy and medicine rooms, and the Director of Nursing Office. Additionally, a receptacle multiplier was improperly used to supply power to a radio and camera by the Lobby fireplace. These issues were confirmed by the Maintenance Director.
The facility failed to provide documentation verifying that its emergency preparedness plan had been reviewed within the previous twelve months. This deficiency was confirmed during an interview with the Maintenance Director, affecting the entire component of the facility's emergency preparedness program.
A facility failed to comprehensively assess a resident who developed a pressure ulcer. The resident, with conditions including paraplegia and diabetes, had a pressure ulcer observed on the right buttock. While initial treatment was ordered, subsequent weekly skin reviews and documentation of the wound's condition were not completed, leading to a lack of continued assessment until the resident's hospital admission.
A safety deficiency was identified in a resident bathroom on the second floor, where a missing ceiling tile exposed pipes and a cracked plastic grab bar was observed. These issues were confirmed by the Nursing Home Administrator.
The facility failed to maintain appropriate dishwashing temperatures as required by policy. The dish machine's gauges were not working, and staff were unsure of the machine type. Attempts to measure temperature and use chemicals for sanitizing were inadequate, with the wash temperature not reaching the required 150 degrees Fahrenheit on 16 of 36 occasions. The deficiency was confirmed by the Food Service Director and the Nursing Home Administrator.
The facility failed to investigate and resolve resident grievances reported during several months due to high turnover in the social work department. Four residents reported filing grievances, but no records were found, and the facility administration could not provide evidence of investigations.
The facility failed to monitor the nutritional status of three residents, leading to significant weight loss without timely intervention. One resident experienced a 13.1% weight loss over one month, another had a 5.15% weight loss with discrepancies in recorded weights, and a third resident had a 7.34% weight loss with delayed dietitian documentation.
The facility failed to protect a resident with dysphagia and protein calorie malnutrition from abuse by a family member who forcefully fed the resident inappropriate food items, causing coughing and choking. Despite staff attempts to educate the family member, the abuse continued until the family member was eventually removed by the police.
The facility failed to review and revise a resident's care plan quarterly, as required. The care plan had a target date but lacked documented evidence of a care plan conference in the past year. This was confirmed by a social worker who acknowledged the care plan was out of date.
A Registered Nurse failed to follow professional standards by pre-preparing medications and administering them later, violating the facility's medication administration policy and the Pennsylvania Professional Nursing Practice Act.
A resident with a gastrostomy had medications administered incorrectly, resulting in a 25% medication error rate. A registered nurse crushed all medications together and mixed them with water before administering them via PEG tube, contrary to the facility's policy. This was confirmed by the DON and the Nursing Home Administrator.
The facility failed to complete a Speech Therapy Evaluation for a resident with Dysphagia and protein calorie malnutrition as ordered by the physician. The resident expired before the evaluation was conducted, and the Nursing Home Administrator and DON confirmed the evaluation was never completed.
Failure to Provide Timely Behavioral Health Services for Escalating Sexual Behaviors
Penalty
Summary
The facility failed to provide timely behavioral health services for a resident with Alzheimer’s disease, dementia, and a mood disorder who had severe cognitive impairment but was independent with transfers and walking. A psychiatry consult in April 2025 documented no mood or behavioral disturbances in the prior 30 days, discontinued sertraline, and recommended no psychotropic medications at that time, but advised continued monitoring and documentation of mood and behavioral disturbances with descriptions and whether the behaviors were redirectable, with follow-up as needed. Beginning in July 2025, nursing progress notes documented multiple episodes of inappropriate and sexual behaviors, including an allegation that the resident exposed his genitals to a female resident and initiation of 15‑minute checks. Subsequent nursing notes from September 2025 through January 2026 recorded repeated inappropriate sexual gestures, spitting, yelling, cursing, difficulty with redirection, entering female residents’ rooms and looking at them in bed, rummaging through a roommate’s personal items and food, kissing a female resident, masturbating in an elevator, and being found behind a door kissing and attempting to pull his pants down. An event report on February 2, 2026, documented that the resident was found in a female resident’s room masturbating, with one hand on the other resident’s side and her gown pulled down to the knee, though her brief remained intact. The behavioral notes did not show that the primary physician was notified of these escalating inappropriate and sexual behaviors, and review of records from July 19, 2025, through January 31, 2026, showed the facility did not provide behavioral services during this period despite the multiple documented episodes, only obtaining psychiatric follow-up after the February 2, 2026 incident.
Failure to Employ Qualified Activity Director
Penalty
Summary
The facility failed to employ an Activity Director with the appropriate certification or qualifications as required by both facility policy and regulatory standards. Review of records showed that the Activity Director accepted the position with the understanding that they would enroll in a certification program, but as of the time of the survey, they had not completed the certification nor could they specify the number of credits earned. The Activity Director reported only sporadic meetings with the Occupational Therapist who was temporarily assigned to oversee the department, and there was no documentation of these meetings. The Occupational Therapist confirmed that they had not met with the Activity Director regarding activities for at least a year and was unaware that oversight was still expected. Interviews with facility leadership confirmed that the Activity Director was not certified and had not met the alternative experience requirements at the time of hire. The facility policy required the Activity Director to be certified or have two years of relevant experience, but the individual in the role had not met these criteria upon assuming the position. There was also a lack of documentation and oversight regarding the activities program, as required by policy.
Failure to Transmit Medical Records to Hospital
Penalty
Summary
The facility failed to ensure that the treating hospital received the necessary medical records to provide continuity of care and appropriate treatment for a resident. A phone interview with the complainant revealed that the hospital did not receive the required records to initiate care. Review of the resident's clinical record showed no documentation verifying that the records were faxed to the hospital. Interviews with the DON and NHA indicated that the ADON attempted to fax the records, but review of the facility's fax log confirmed the transmission was unsuccessful. Further, the ADON did not wait for a fax confirmation sheet, and the facility did not contact the hospital to verify receipt of the records. As a result, the resident's medical records were not successfully transmitted, causing a delay in care.
Failure to Timely Refund Resident Payment After Discharge
Penalty
Summary
The facility failed to provide a refund to a resident's representative within 30 days of the resident's discharge, as required by federal regulations. The resident was admitted on 5/9/25 and passed away in the facility on 5/28/25. Documentation showed that the resident had privately paid for care. The Business Office Manager (BOM) confirmed that a refund request was submitted to the financial office on 6/11/25, and a follow-up request for an update was made on 8/5/25. The refund was ultimately processed and provided to the resident's representative on 8/6/25, which exceeded the 30-day requirement. During interviews, the BOM and the Director of Nursing both confirmed that the facility did not issue the refund within the required timeframe. The deficiency was identified for one of three residents reviewed, and the failure to comply with the 30-day refund policy was substantiated by both documentation and staff interviews.
Plan Of Correction
1. Resident R1's representative was issued a refund on 08-06-2025. 2. BOM performed an audit on 08-06-2025 of any potential refunds that are due to current and discharged residents. Rose City is working on one refund currently that is within the allotted time frame for re-imbursement. 3. NHA will educate the BOM to ensure all refunds are addressed timely. NHA will reach out to Accounts Payable if there are delays in reimbursements to ensure timely distribution. 4. BOM will perform weekly audits to ensure that any potential refunds are addressed per regulations. Audits will be weekly for two weeks, then every two weeks for two weeks, then monthly for one month. Results of audits will be submitted to monthly QAPI for review and recommendations.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to conduct annual performance reviews for five nurse aides, identified as Employees E5, E6, E7, E8, and E9, as required by regulation §483.35(d)(7). This deficiency was identified through a review of staffing records and performance reviews, which revealed that these staff members did not have their performance reviews completed within the last year. The Nursing Home Administrator confirmed during an interview that the performance reviews for these staff members were not conducted.
Plan Of Correction
1. Facility completed performance reviews on Employee 5, Employee 6, Employee 7, Employee 8, and Employee 9. 2. All employees reviewed and those needing a performance review will be completed. 3. NHA and HR to educate department leaders on completing annual reviews for respective staff and departments. 4. NHA, HR, or designee, will perform random audits to ensure employee reviews are done annually around their hiring anniversary date weekly for 2 weeks, then monthly for 2 months. Results of audits will be submitted to monthly QAPI for review and recommendations.
Failure to Act on Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that medication regimen reviews were acted upon by a physician for five residents. The facility's policy requires that a clinical pharmacist reviews the residents' medication regimens and sends recommendations to the facility. The clinical nurse is then responsible for reviewing these recommendations and contacting the physician for further orders. However, for Residents 37, 43, 59, 75, and 84, there was no evidence in their clinical records that the recommendations made by the pharmacist were reviewed or addressed by the attending physician. The medication regimen reviews for these residents were completed on various dates, and recommendations were made, but the clinical records lacked documentation of the reviews, recommendations, or any actions taken by the physician. An interview with the Nursing Home Administrator confirmed that there was no evidence that the pharmacy recommendations were addressed by the physician, indicating a failure in the facility's process to ensure that medication regimen reviews are properly acted upon.
Plan Of Correction
1. Residents 37, 43, 59, 75, and 84 were reviewed by pharmacist. Recommendations forwarded to physician for review and orders were written as indicated/recommended. 2. Facility performed an audit of current residents' pharmacy recommendations completed to ensure physician reviewed and orders written as indicated/recommended. 3. Pharmacy consultant was requested by DON to send pharmacy recommendations to DON, then DON will print our recommendations and present to physician for review and written orders. 4. DON, or designee, will perform random weekly audits for 2 weeks, then monthly audits for 2 months to ensure pharmacy recommendations are completed by physician and orders entered as indicated. Results of audits will be presented at monthly Quality Assurance and Improvement Plan meetings for review and recommendations.
Failure to Complete Required Annual Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that five nurse aides, identified as Employees E5, E6, E7, E8, and E9, completed the required 12 hours of annual in-service training. This training is mandated to ensure the continuing competence of nurse aides and must include dementia management, resident abuse prevention, and care for cognitively impaired individuals. A review of the training documentation for these employees revealed no evidence of completion of the required training hours. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Plan Of Correction
Facility staff were re-educated on annual education trainings. No harm to current residents related to cited deficient practice. Human Resources Director re-instituted annual education for all Rose City Staff. NHA re-educated staff on annual education requirements. Those staff members that have their anniversary month between now and next April 2026 will have to complete another annual education training in their hire month anniversary to remain educated every 12 months. NHA, or designee, will audit weekly for 2 weeks, then monthly for 2 months to ensure that all new hires receive general orientation to include all necessary trainings and then add to monthly trainings listings for following years on their hire date anniversary month. Results of audits will be submitted to monthly Quality Assurance and Improvement Plan meetings for review and recommendations.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments, affecting three residents. For Resident 32, the quarterly Minimum Data Set (MDS) dated February 8, 2025, inaccurately indicated that the resident was not receiving opioids, despite physician orders and medication administration records showing that the resident was prescribed and received Oxycodone HCl 5 mg daily, except on two specific days in April 2025. This discrepancy was confirmed through an interview with a licensed employee. For Residents 52 and 67, their quarterly MDS assessments inaccurately listed an active diagnosis of multi-drug resistant organism (MDRO). However, a review of their active diagnosis lists showed no evidence of such a diagnosis. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that neither resident had a current MDRO diagnosis, and the MDS assessments were inaccurate. These findings indicate a failure to maintain accurate clinical records as required.
Plan Of Correction
1. Resident 32, Resident 52 and Resident 67 MDS's were corrected at time DOH surveyor presented issue to MDS Coordinator and NHA. 2. MDS Coordinator performed an audit of all current and open resident MDS's to ensure accuracy. No further discrepancies noted. 3. NHA, or designee, will re-educate MDS Coordinator to ensure accurate MDS's are completed and submitted. 4. NHA, or designee, will perform weekly random audits for two weeks, then monthly random audits for two months for accuracy before submission. Results of audits will be presented at monthly Quality Assurance and Improvement Plan meetings for review and recommendations.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in their care. Resident 32 was observed receiving oxygen therapy at 4 liters per minute via nasal cannula, as per a physician's order from June 2024. However, the resident's active care plan did not include any interventions or plans for this oxygen therapy. This was confirmed by the Nursing Home Administrator during an interview. Resident 37, diagnosed with End Stage Renal Failure, undergoes hemodialysis three times a week and has a dialysis shunt in the left upper arm. Despite these significant medical needs, there was no comprehensive care plan addressing the dialysis or the presence of the shunt. This oversight was confirmed by the Director of Nursing. Additionally, Resident 91 experienced significant weight loss, as noted in the quarterly MDS and a weight change note, yet there was no care plan to address this nutritional issue, which was also confirmed by the Director of Nursing.
Plan Of Correction
1. Resident 32 care plan was updated to include oxygen therapy; Resident 37 care plan was updated to include dialysis and the presence of dialysis shunt; Resident 91 care plan was updated to include resident's weight loss. 2. Facility performed house audit to ensure care plans were accurate. Current residents and new admit residents are at risk for not having a comprehensive care plan. 3. NHA, or designee, will educate department leaders and DON, or designee, will educate licensed staff on policy for developing comprehensive care plans for residents. 4. NHA, DON, or designee, will perform random audits of current and new admit residents to ensure comprehensive care plans are done, weekly for 2 weeks, then monthly for 2 months. Results of audits will be submitted to monthly QAPI for review and recommendations.
Failure to Follow Dialysis Residents' Fluid and Medication Orders
Penalty
Summary
The facility failed to adhere to physician-ordered fluid restrictions and medication schedules for two residents requiring dialysis. Resident 37, diagnosed with End Stage Renal Failure and dependent on hemodialysis, was observed with a large cup of water in their room, contrary to the facility's policy on fluid restriction. The resident reported inconsistent refilling of the water cup by staff and a lack of education on fluid consumption limits. The clinical records did not show monitoring of the resident's fluid intake, and the prescribed 1500 ml fluid restriction was not followed. Additionally, the resident's medications, Gabapentin and Calcium Acetate, were not administered as scheduled during dialysis days, resulting in ten missed doses. Resident 56, also diagnosed with end stage renal disease, had a physician's order for a daily fluid restriction of 2 liters. However, the Medical Administration Record did not document the amount of fluid consumed by the resident each shift, indicating a failure to monitor and adhere to the fluid restriction. Interviews with the Nursing Home Administrator confirmed these findings, highlighting the facility's failure to ensure that the physician's orders for fluid restrictions and medication administration were followed for both residents.
Plan Of Correction
1. Facility cannot retroactively document fluid restrictions documentation for resident 37 and resident 56. The times for resident 37's gabapentin and calcium acetate were changed to non dialysis times. 2. Facility completed an audit of residents on fluid restrictions for proper documentation of fluid intake and no other discovered. Current and new admit dialysis residents could be at risk for proper documentation of fluid restrictions and medication administration while at dialysis. 3. DON, or designee, will educate nursing staff on policy "encouraging and restricting Fluids." 4. DON, or designee, will perform random audits of fluid restrictions in cc's weekly for 2 weeks, then monthly for 2 months. DON, or designee, will perform random audits to ensure dialysis residents do not have orders to administer medications while at dialysis. Results of audits will be submitted to monthly QAPI for review and recommendations.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications were monitored for side effects, as required by their policy. This deficiency was identified for three residents. Resident 37, diagnosed with major depressive disorder with severe psychotic symptoms, was prescribed Aripiprazole, an anti-psychotic medication, but there was no evidence of monitoring for side effects from January 23, 2025, to April 23, 2025. Similarly, Resident 43, who has anxiety disorder and major depressive disorder, was prescribed Risperidone, another anti-psychotic medication, but was not monitored for side effects from April 3, 2025, to April 23, 2025. Resident 59, with diagnoses including anxiety disorder, schizophrenia, and depression, was prescribed multiple psychotropic medications, including Olanzapine, Rexulti, Remeron, Sertraline HCL, and Clonazepam. However, there was no evidence in the clinical records that Resident 59 was monitored for side effects of these medications. The Director of Nursing confirmed that these residents were not monitored for side effects from the use of antipsychotic medications, which is a violation of the facility's policy and regulatory requirements.
Plan Of Correction
1. Facility cannot retroactively add in monitoring of psychotropic medication side effects for resident 37, resident 43 and resident 59. 2. Current residents receiving psychotropic medications are at risk to have side effects monitoring of psychotropic medications. Facility performed an audit to ensure those residents on psychotropic medications have side effect monitoring included in clinical records. 3. DON, or designee, will educate licensed nursing staff on ensuring residents on psychotropic medications have orders for monitoring side effects. 4. DON, or designee, will perform weekly audits for 2 weeks, then monthly for 2 months to ensure side effects monitoring is being completed on psychotropic medications. Results of audits will be submitted to monthly Quality Assurance and Improvement Plan meetings for review and recommendations.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications on the fourth-floor medication cart and in the second-floor medication room. During an observation on the fourth-floor medication cart, it was found that a Novolog Insulin pen, a Lantus Insulin pen, and a Basaglar Insulin pen were opened and undated. Employee E10, a licensed nurse, confirmed that these insulin pens should have been dated when opened. Similarly, an observation in the second-floor medication room refrigerator revealed an opened and undated PPD vial and an Acetylcysteine vial. Employee E11 confirmed that these medications should have been dated upon opening. The manufacturer's guidelines for these medications specify that they must be discarded after a certain period once opened. Novolog, Lantus, and Basaglar Insulin pens should be discarded 28 days after opening, while the PPD vial should be discarded after 30 days due to possible oxidation and degradation. The Acetylcysteine vial should be used immediately after opening and discarded after four days. The failure to date these medications upon opening indicates non-compliance with the manufacturer's guidelines and the facility's responsibility to ensure proper medication management.
Plan Of Correction
1. The novolog Insulin that was opened and not dated was discarded. The lantus insulin that was opened and not dated was discarded. The basaglar insulin kwikpen that was not dated when opened was discarded. The Apisol that was not dated when opened was discarded. The Acetylcysteine that was not dated when opened was discarded. 2. Facility completed a house audit and no other multi-dose vials were discovered not dated when opened. 3. DON, or designee, will educate licensed staff on dating multi-dose vials when they open them. 4. DON, or designee, will perform random audits to ensure multi-dose vials are dated when opened weekly for 2 weeks, then monthly for 2 months. Results of audits will be submitted to monthly QAPI for review and recommendations.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to comply with the requirement to notify a physician of significant changes in a resident's condition. Specifically, the facility did not inform the physician about a significant weight loss experienced by a resident. The resident's weight dropped from 192.3 pounds on August 2, 2024, to 178.0 pounds on October 8, 2024, indicating a 7.4 percent weight loss. This significant change in the resident's physical status was not communicated to the physician, as confirmed by the review of the clinical records. During an interview with the Nursing Home Administrator and the Director of Nursing, it was confirmed that the physician was not notified of the resident's weight loss. This oversight was identified during a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance Survey, and three complaint investigations completed on April 25, 2025. The deficiency was noted under the federal regulation 42 CFR Part 483, Subpart B, and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulation.
Plan Of Correction
1. The physician was notified of Resident 34 significant weight loss on 05/01/2025. No new orders at that time. 2. Facility audit was completed to determine if any other residents trigger for significant weight loss, and none determined. 3. DON, or designee will educate nursing staff on obtaining resident weights as ordered and will educate nursing staff on weight policy. 4. DON, or designee, will randomly audit resident weights weekly for 2 weeks, then monthly for 2 months. Results of audits will be submitted to monthly QAPI for review and recommendations.
Failure to Ensure Resident's Freedom from Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of restraints, as evidenced by the use of hand mitts without proper assessment, physician's order, or notification to the responsible party. The resident, who was admitted with a diagnosis of Alzheimer's disease and alcoholic cirrhosis of the liver, was observed on multiple occasions wearing hand mitts while lying in bed. The facility's policy on the use of restraints requires a pre-restraining assessment, a physician's order, and consent from the resident or their representative, none of which were documented in this case. Interviews with staff revealed that the hand mitts were used due to the resident's restless behaviors, such as hitting themselves and grabbing during feeding. However, a review of the clinical records showed no assessment or physician's order for the use of the mitts, and the Director of Nursing confirmed these omissions. This lack of compliance with the facility's restraint policy resulted in the resident being restrained without the necessary evaluations and approvals, violating their right to be free from unnecessary restraints.
Plan Of Correction
1. Resident 74 discharged on 04/28/2025. 2. Facility audit was done to ensure other current residents had restraints. No other residents observed with restraints. Current and new admitted residents may be at risk for restraints. 3. DON, or designee, will educate nursing staff restraint policy, to include (1) if restraints are necessary, then the restraint assessment will be completed per guidelines and (2) a physician order will be obtained. 4. DON, or designee, will perform random audits of all new admissions to ensure no need for restraints weekly for 2 weeks, then monthly for 2 months. Results of audits will be submitted to monthly QAPI for review and recommendations.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a comprehensive investigation into an injury of unknown origin for a resident with severe cognitive impairment and a diagnosis of dementia. The facility's policy requires that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source be thoroughly investigated by the administrator or designee. However, in this case, the investigation was not completed as required. The resident's quarterly Minimum Data Set (MDS) indicated severe cognitive impairment. A nursing progress note revealed that the resident had a hematoma and bruise on the forehead, with an assessment suggesting the injury was likely caused by hitting the head against a wall or headboard. The Director of Nursing confirmed that the protocol to interview staff from the relevant shifts to determine the cause of the injury was not followed, resulting in an incomplete investigation.
Plan Of Correction
Facility cannot retroactively investigate resident 47's bruise of unknown origin. 2. DON performed a facility audit to ensure current residents have no bruises of unknown origin. None were found. Current and new admit residents are at risk for bruises of unknown origin. 3. DON, or designee, will educate facility staff on Policy of bruises of unknown origin when they observe a bruise on a resident. DON, or designee, will educate staff on providing a written statement regarding observed bruises. 4. DON, or designee, will perform random audits of nursing notes and incident reports for bruising of unknown origin weekly for 2 weeks, then monthly for 2 months. Results of audits will be submitted to monthly QAPI for review and recommendations.
Failure to Follow Physician's Order for Diabetic Wound Care
Penalty
Summary
The facility failed to adhere to a physician's order for the treatment of a diabetic wound on a resident's left lateral foot. The resident, who has End Stage Renal Disease and diabetes, requires hemodialysis three times a week. The physician's order, dated March 14, 2025, specified that the wound should be cleansed with normal saline solution, covered with collagen, and dressed daily and as needed. However, the Treatment Administration Record for April 2025 showed that the wound care was not performed on April 3, 6, 10, 11, and 12. On April 3 and 12, the treatment was not done due to the resident's leave of absence for dialysis, but there was no documentation explaining the lack of treatment on April 6, 10, and 11. An interview with the Director of Nursing confirmed that the wound care was not administered on the dialysis days of April 3, 10, and 12, but the DON could not provide documentation for the missed treatments on April 6 and 11, which were non-dialysis days. This oversight indicates a failure to follow the prescribed wound care regimen, as required by the physician's order, for the resident's diabetic wound.
Plan Of Correction
1. Facility cannot retroactively provide wound care to a resident 37 left lateral foot. Wound treatment orders for resident 37 were changed to daily treatment dressing changes to time when not at dialysis. 2. Current and new admit dialysis residents with wound orders could be at risk for wound care during dialysis. Facility audit of dialysis residents was completed to ensure no treatments are to be done when a resident is at dialysis. 3. DON, or designee, will educate licensed staff on policy for wound care and documentation. 4. DON, or designee, will perform random audits on wound treatment care and documentation to ensure treatments are being completed weekly for 2 weeks, then monthly for 2 months. Results of audits will be submitted to monthly QAPI for review and recommendations.
Failure to Update Smoking Safety Evaluation for Resident
Penalty
Summary
The facility failed to ensure a current smoking assessment for a resident diagnosed with Multiple Sclerosis, major depressive disorder, and unspecified dementia. The resident, who is alert and oriented, reported leaving the premises to smoke in accordance with the facility's Smoking Agreement. This agreement stipulates that the resident must leave the property to smoke, not share smoking materials with other residents, and sign in and out for leave of absence as per policy. A review of the resident's clinical record revealed that the last Smoking Safety Evaluation was conducted in July 2023, with no subsequent evaluations completed. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the absence of a current Smoking Safety Evaluation for the resident since July 2023. This deficiency was previously cited in March 2024, indicating a recurring issue with management oversight.
Plan Of Correction
1. Resident 24 smoking assessment was completed. 2. Facility audit completed and no other residents at risk. 3. DON, or designee, will educate licensed staff regarding smoking assessment needing completed monthly for resident 24. 4. DON, or designee, will perform audits monthly and as needed on resident 24 for completion of smoking assessment. Results of audits will be submitted to monthly QAPI for review and recommendations.
Failure to Monitor Significant Weight Changes
Penalty
Summary
The facility failed to adequately monitor weight changes for two residents, leading to deficiencies in maintaining acceptable nutritional and hydration status. Resident 34, who has diagnoses including dysphagia, diabetes mellitus, and dementia, experienced a significant weight loss of 7.44% between August and October 2024. The facility did not record a weight for September 2024, did not reweigh the resident after the October weight was obtained, and failed to notify the dietitian of the weight loss. This lack of action was confirmed by the Nursing Home Administrator and Director of Nursing. Resident 79 experienced a significant weight gain of 6.90% over a 19-day period. The dietitian noted that the previous weight was likely inaccurate and that the resident continued to receive outside food and snacks despite counseling. However, the facility did not reweigh Resident 79 to confirm the significant weight change. The Director of Nursing confirmed that the weight was not re-checked after the significant change was identified.
Plan Of Correction
1. Facility cannot retroactively monitor weight loss and weight gain for resident 34 and resident 79. 2. Facility performed a house wide audit to ensure no other resident trigger for weight loss or weight gain. None found. 3. DON, or designee, will educate nursing staff on weight policy, to include reweights and notifications to dietician. 4. DON, or designee, will perform random audits to ensure weights/reweights are being obtained as ordered and notification to dietician, weekly for 2 weeks, then monthly for 2 months. Results of audits will be submitted to monthly QAPI for review and recommendations.
Fire Safety Equipment Deficiency
Penalty
Summary
The facility, Rose City Nursing and Rehab at Lancaster, was found to be non-compliant with the Life Safety Code requirements during a Medicare/Medicaid Recertification Survey. The survey identified a deficiency related to the facility's failure to meet the minimum standards for operation as required by the Department and other state and local agencies. Specifically, the deficiency was observed in the 2nd floor Clean Linen Room, where the fire blanket cabinet was found to be empty. This observation was made on April 8, 2025, at 11:22 AM, and was confirmed through an interview with the Maintenance Director at the same time. The absence of a fire blanket in the designated cabinet indicates a lapse in maintaining the necessary safety equipment, which is a requirement for the facility's operation to ensure the health and welfare of its residents.
Plan Of Correction
1. The fire blanket cabinet on the second floor clean linen room contains a fire blanket as of 04-14-2025. 2. Maintenance Director, or designee, will audit weekly for two weeks that there is a fire blanket in the containers labeled "fire blanket." Then audits will be monthly for 2 months and ongoing monthly. Results of audits will be submitted to monthly QAPI for review and recommendations.
Obstructed Egress and Locked Refrigerator in Facility
Penalty
Summary
The facility failed to maintain the means of egress as unobstructed and readily available for full and instant use, affecting two of eight smoke compartments. During an observation, a plastic chair was found obstructing the swing of an exterior exit door on the Front Patio. This was confirmed by the Maintenance Director. Additionally, an operable padlock hasp lock was installed on the Kitchen walk-in refrigerator, which could not be defeated with the emergency release from within the refrigerator, also confirmed by the Maintenance Director.
Plan Of Correction
1. a. The plastic chair was removed from within the swing of the exterior exit door on the front porch on 04/08/2025 at time of observation. b. The padlock on the walk-in refrigerator in the kitchen was removed on 04-09-2025. 2. Maintenance Director, or designee, will document and audit (a) there are no obstacles for exterior exit "swing area" and (b) there are no padlocks on walk-in refrigerator weekly for two weeks, then monthly for two months. Results of audits will be submitted to monthly QAPI for review and recommendations. a. A building wide audit of the exterior exit doors area was completed. Random audits will be done weekly to ensure there is no blockage of exterior exit doors "swing area."
Failure to Maintain Fire Resistance of Stairtower Enclosures
Penalty
Summary
The facility failed to maintain the fire resistance of stairtower enclosures, which affected two of eight smoke compartments. During an observation on April 8, 2025, between 11:11 AM and 11:16 AM, it was noted that the stairtower doors in specific locations did not positively latch within their respective door frames. Specifically, at 11:11 AM, the door in Zone 4, 3rd floor Stair 1, and at 11:16 AM, the door in Zone 3, 3rd floor Stair 2, were found to be deficient. This was confirmed through an interview with the Maintenance Director, who acknowledged that the stairtower doors did not latch properly within the door frames.
Plan Of Correction
1. The zone 4, third floor stair tower 1 door was repaired on 04/11 to ensure that it latches properly. The zone 3, third floor stair tower 2 door was repaired on 04/15 to ensure that it latches properly. 2. Maintenance Director, or designee, will audit weekly for two weeks, then monthly and submit audits to monthly QAPI for review and recommendations. a. A building wide audit of the stair tower doors latching properly was completed. Audits will be done monthly to ensure stair tower doors latch properly.
Deficiency in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain the automatic sprinkler protection system free from extraneous weight, which affected one of eight smoke compartments. During an observation on April 8, 2025, at 11:02 AM, it was noted that white wires were wire-tied to the sprinkler piping above the suspended ceiling in the Zone 1 Corridor, near Resident Room 412. An interview with the Maintenance Director at the same time confirmed that the wires were indeed supported by the sprinkler system.
Plan Of Correction
1. The white wires that were wire-tied to the sprinkler piping, above the suspended ceiling within Zone 1 corridor by resident room 412 was disconnected from the sprinkler piping on 04-08-2025, at time of observation. There are no wires resting on sprinkler piping. 2. Maintenance Director, or designee, will audit weekly for two weeks, then monthly for two months to ensure that the stair tower doors latch properly. Results of audits will be submitted to monthly QAPI for review and recommendations. a. Audits will be conducted whenever there is above ceiling work performed. An above ceiling process for vendors will be implemented so that when they perform above ceiling work, that the Maintenance Director will sign off there is no wiring laying on the sprinkler pipes before the vendor leaves the building.
Smoke Barrier Wall Penetration Compromises Safety
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barrier walls, which is a requirement for ensuring safety in the event of a fire. During an observation on April 8, 2025, at 11:20 AM, it was noted that there was an unprotected penetration in the smoke barrier wall on the 2nd floor. This penetration was located above the cross-corridor double doors near Resident Room 210 and involved a gray wire. This deficiency affected two out of eight smoke compartments within the component, compromising the smoke resistance of the barrier walls.
Plan Of Correction
1. The unprotected penetration of the second floor smoke barrier wall, above the cross-corridor double doors by resident room 210 around a gray wire was repaired using an approved through penetration fire stop system on 04-14-2025. The facility will maintain the rating of smoke barrier walls. 2. Maintenance Director, or designee, will audit weekly for two weeks, then monthly. Results of audits will be submitted to monthly QAPI for review and recommendations.
Improper Use of Electrical Equipment in Smoke Compartment
Penalty
Summary
The facility was found to have a deficiency related to the improper use of electrical equipment, specifically concerning the monitoring of receptacle multipliers. During an interview with the Maintenance Director, it was confirmed that there was an unprotected penetration of the smoke barrier wall. Observations and interviews revealed that the facility failed to adequately monitor the use of power strips and extension cords within one of the eight smoke compartments. The report highlights that power strips in patient care vicinities should only be used for movable patient-care-related electrical equipment and must meet specific UL standards. However, the facility did not adhere to these guidelines, leading to the deficiency.
Plan Of Correction
1. The receptacle multiplier, supplying electrical power to a radio and a camera by the Lobby fireplace was removed on 04-14-2025. 2. Maintenance Director, or designee, will audit weekly for two weeks, then monthly to ensure there are no receptacle multipliers being used in the facility. Results of audits will be submitted to monthly QAPI for review and recommendations. a. Maintenance Director, or designee, will perform weekly audits of facility areas for unauthorized electrical equipment that may be brought in by families for their loved ones.
Deficiency in Securing Oxygen Cylinders and Electrical Safety
Penalty
Summary
The facility was found to have deficiencies related to the handling and securing of portable oxygen cylinders. During an observation on April 8, 2025, between 10:50 AM and 11:27 AM, it was noted that portable oxygen cylinders were unsecured in various locations across the facility. Specifically, one cylinder was found unsecured in the 4th floor Therapy Room, two cylinders in the 4th floor Medicine Room, one cylinder in the 3rd floor Medicine Room, two cylinders in the 2nd floor Director of Nursing Office, and one cylinder in the 2nd floor Medicine Room. An interview with the Maintenance Director confirmed that these cylinders were not secured, which is a violation of the NFPA 99 standards for handling oxygen equipment. Additionally, a receptacle multiplier was observed supplying power to a radio and a camera by the Lobby fireplace, which was also confirmed by the Maintenance Director.
Plan Of Correction
1. The oxygen cylinders that were unsecured were secured and placed appropriately in racks on 04-08-2025. 2. Maintenance Director and Director of Nursing, or designees, will educate maintenance and nursing staff on properly securing oxygen cylinders. Maintenance Director will audit weekly for two weeks, then monthly to ensure that oxygen cylinders are properly secured in racks. Results of audits will be submitted to monthly QAPI for review and recommendations.
Failure to Review Emergency Preparedness Plan Annually
Penalty
Summary
The facility was found to be deficient in maintaining its emergency preparedness plan as required by federal regulations. Specifically, the facility failed to provide documentation verifying that the emergency preparedness plan had been reviewed within the previous twelve months. This deficiency was identified during a document review conducted on April 8, 2025, at 9:55 AM. An interview with the Maintenance Director on the same day confirmed the absence of documentation to verify the review of the emergency preparedness plan. This lack of documentation affects the entire component of the facility's emergency preparedness program, indicating non-compliance with the requirement to review and update the plan annually.
Plan Of Correction
1. The emergency preparedness plan was reviewed and signed off on and placed in the emergency preparedness binder on 04-09-2025. 2. NHA, or designee, will ensure that facility emergency preparedness plan is reviewed at QAPI when all other manuals, policy and procedures are reviewed and signed off by appropriate department directors on an annual basis in June during QAPI each year.
Failure to Document and Assess Pressure Ulcer
Penalty
Summary
The facility failed to comprehensively assess a resident who developed a pressure ulcer. The resident, who had diagnoses including paraplegia, type 2 diabetes, and peripheral vascular disease, was observed with a 3 cm by 2 cm open area on the right buttock on July 9, 2024. A treatment order was received on the same day to cleanse the area, apply barrier cream, and use a foam border, with instructions to discontinue when healed. However, the clinical record revealed that while a weekly skin review was completed on July 11, 2024, there was no subsequent documentation of weekly skin reviews or any further assessment of the wound, including its stage, description, infection, or pain, until the resident was admitted to the hospital on August 2, 2024. An interview with the Nursing Home Administrator confirmed the lack of documentation for the continued assessment of the resident's pressure ulcer.
Safety Deficiency in Resident Bathroom
Penalty
Summary
The facility failed to maintain a safe environment in one of the resident bathrooms on the second floor. During an observation on August 12, 2024, at 11:00 a.m., it was noted that a ceiling tile was missing in the bathroom of room [ROOM NUMBER], exposing pipes in the ceiling. Additionally, the plastic grab bar for the toilet was found to be cracked. These observations were confirmed in an interview with the Nursing Home Administrator later that day at 1:00 p.m.
Failure to Maintain Appropriate Dishwashing Temperatures
Penalty
Summary
The facility failed to maintain appropriate temperatures during dishwashing, as observed during a survey. The facility's policy required a minimum wash temperature of 150 degrees Fahrenheit and a minimum rinse temperature of 180 degrees Fahrenheit for high-temperature dish machines. However, the dish machine's gauges were not working, and staff were unsure whether the machine was a high-temperature or low-temperature model. Staff attempted to use a thermometer to measure the temperature and switched to using chemicals for sanitizing, but they had no way to measure the concentration of the sanitizer. The Dish Machine Temperature Log for March 2024 revealed that the wash temperature did not reach 150 degrees Fahrenheit on 16 of 36 occasions. Interviews with the Food Service Director (FSD) and the Nursing Home Administrator confirmed that the minimum dish machine temperatures had not been met. The FSD indicated that maintenance had adjusted the water temperature earlier in the month when temperatures were noted to be below the minimum. The repair company was called on March 13, 2024, and had been working on the machine on March 14, 2024. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged that the minimum dish machine temperatures had not been met.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to demonstrate efforts to respond and resolve resident complaints raised at resident group meetings. This was evidenced by a review of the minutes from Residents' Council meetings, grievances lodged with the facility, and staff and resident interviews. Four residents reported filing grievances during the months of August 2023 through December 2023, but the facility's grievance log showed no recorded grievances for these months. The social worker, who started working at the facility in late December 2023, confirmed that the previous social worker did not keep any copies or lists of grievances for the specified months and was unable to provide evidence that grievances were investigated or resolved during that period. The Nursing Home Administrator (NHA) revealed that the facility had experienced high turnover in the social work department, with three social workers since May 2023. This turnover contributed to the failure to investigate and resolve resident grievances. The NHA confirmed that the facility administration could not provide evidence of grievance investigations for the months in question. This deficiency was cited under 28 Pa. Code: 201.18(e)(4) Management, 28 Pa. Code: 201.29(i) Resident Rights, and 28 Pa. Code: 211.12(d)(3) Nursing Services.
Failure to Monitor Nutritional Status
Penalty
Summary
The facility failed to monitor the nutritional status of three residents, leading to significant weight loss without timely intervention. Resident 53 experienced a 13.1% weight loss over one month, with no re-weight to confirm the accuracy of the readmission weight. The resident was sent to the hospital before a re-weight could be obtained. Resident 69 had a 5.15% weight loss over one month, with no re-weight to confirm accuracy, and subsequent weights were not addressed by the dietitian. Additionally, there was a discrepancy in the recorded weights, with no weight obtained on January 12, 2024, despite a dietary entry indicating a weight loss and an increase in tube feeding rate for added calories. Resident 87 was admitted with a weight of 128 pounds, which dropped to 118.6 pounds by December 2, 2023, a significant weight loss of 7.34%. There was no further documentation by the dietitian until January 3, 2024, which did not address the significant weight loss. The resident was not admitted to hospice until January 11, 2024, yet the dietitian's notes mentioned a hospice evaluation. The facility's failure to obtain re-weights and admission weights per policy, along with delays in interventions by the clinical dietitian, were confirmed by the Nursing Home Administrator and the Director of Nursing.
Failure to Protect Resident from Abuse by Family Member
Penalty
Summary
The facility failed to protect Resident 91 from abuse by a family member. Resident 91, who had diagnoses including dysphagia and protein calorie malnutrition, was observed being forcefully fed by a family member on multiple occasions, causing the resident to cough and choke. Despite staff attempts to educate the family member, the inappropriate feeding continued. An incident on a specific date led to the family member being physically removed by the police, but prior to this, no effective measures were taken to prevent the family member from feeding the resident inappropriate food items. The facility's inaction allowed the abuse to continue, as evidenced by multiple staff witnesses and documented incidents in the clinical record.
Failure to Review and Revise Care Plan Quarterly
Penalty
Summary
The facility failed to review and revise the care plan for Resident 53 quarterly, as required. The care plan had a target date of December 29, 2023, but there was no documented evidence of a care plan conference in the past year. This was confirmed during an interview with Social Worker E3, who acknowledged that Resident 53 had not had a care plan conference in the past year and that the care plan was out of date.
Failure to Follow Medication Administration Protocol
Penalty
Summary
The facility failed to ensure that a Registered Nurse met professional standards during medication administration for one resident. According to the Pennsylvania Professional Nursing Practice Act and facility policy, medications should be administered at the time they are prepared and not pre-poured. However, during an observation on March 15, 2024, a Registered Nurse was found to have pre-prepared medications for a resident, which were left unlabeled and uncovered in a medication cup. The nurse then proceeded to administer medications to two other residents before returning to administer the pre-prepared medications to the initial resident. An interview with the Director of Nursing and the Nursing Home Administrator confirmed that the Registered Nurse did not follow professional standards by not administering the medications at the time they were prepared. This action was in violation of the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, and the facility's own medication administration policy.
Medication Administration Error Due to Policy Violation
Penalty
Summary
The facility failed to administer medications accurately to a resident with a gastrostomy, resulting in a medication administration error rate of 25%. The facility's policy on Enteral Tube Medications Administration requires that crushed medications are not mixed together and that each medication is administered separately to avoid interaction and clumping. However, during an observation, a registered nurse was seen crushing all the medications together and mixing them with water before administering them through the resident's PEG tube. This action was confirmed to be against the facility's policy by the Director of Nursing and the Nursing Home Administrator. The resident involved had a diagnosis of gastrostomy and had physician orders allowing medications to be crushed and administered via PEG tube. The medications prepared and administered incorrectly included midodrine, Eliquis, glycopyrrolate, a multivitamin, Senna plus, iron sulfate, and Phos-Nak Packet. The medications were all crushed together, mixed with water, and administered in one solution, contrary to the facility's policy. This incident was confirmed through staff interviews and a review of the facility's policy and procedures.
Failure to Complete Speech Therapy Evaluation
Penalty
Summary
The facility failed to ensure a Speech Therapy Evaluation was completed as ordered for a resident diagnosed with Dysphagia and protein calorie malnutrition. The physician's orders included a speech evaluation and treatment, but the clinical record did not show evidence that the evaluation was completed. The resident expired before the evaluation was conducted. The Nursing Home Administrator and Director of Nursing confirmed that the speech evaluation was never completed as per the physician's order.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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