Pennsylvania Department of Health
ROSE CITY NURSING AND REHAB AT LANCASTER
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ROSE CITY NURSING AND REHAB AT LANCASTER
Inspection Results For:

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ROSE CITY NURSING AND REHAB AT LANCASTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on an abbreviated survey completed on February 10, 2026, in response to a two complaint at Rose City Nursing and Rehab at Lancaster, it was determined that the facility was not in compliance under the requirement of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the PA 28 Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.40 REQUIREMENT Behavioral Health Services:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

�483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.

Observations: Based on observation, clinical records review, and staff interviews, it was determined that the facility failed to provide behavioral services in a timely manner for one out of three residents reviewed (Resident 1). Findings: A review of the facility's policy titled "Behavioral Health Services", undated, revealed the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Review of Resident 1's diagnosis list revealed the following diagnoses: Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Dementia (A term used to describe a group of symptom affecting memory, thinking and social abilities severely enough to interfere with daily life), and Mood Disorder (A mental health condition that primarily affects your emotional state). Review of Resident 1's Annual Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated December 31, 2025, revealed the resident had severe cognitive impairment and was independent with transferring and walking. Review of Resident 1's Psychiatrists' consult, dated April 30, 2025, revealed the residents did not have mood or behavioral disturbances documented for the last 30 days. The same note revealed Sertraline (A medication used to treat depression) was discontinued in April 2025. Assessment and Plan include: "No psychotropic medication (A prescription drugs that manage mental health conditions by altering brain chemicals to improve mood) recommended at this time; Recommend continued monitoring and documenting of mood and behavioral disturbances with description of behavior and if redirectable; and follow up as needed". Review of Resident 1's nursing progress note dated July 19, 2025, at 10:38 p.m., revealed "Female resident made an allegation, stating that this resident pulled his pants down and showed her his penis". The same note revealed, "This resident is now on 15 minutes check". Further review of Resident 1's nursing progress note dated September 7, 2025, at 9:13 p.m., revealed "Inappropriate sexual gestures, spitting, yelling, cursing". Further review of Resident 1's nursing progress note dated September 28, 2025, at 9:57 p.m., revealed "The resident has been acting inappropriately towards staff and other residents. He was found opening the doors of female residents, looking at them in bed". The same note revealed that the resident was difficult to redirect. Nursing progress note dated November 3, 2025, at 6:38 p.m., revealed "Client observed rummaging through the roommate's personal items and personal food stash". Nursing progress note dated December 16, 2025, at 10:30 p.m., revealed "Received verbal report that on dayshift, client was kissing another female resident. No behaviors involving other residents this shift". Nursing progress note dated December 30, 2025, at 2:19 p.m., revealed "Resident found jerking himself off in the levator by staff, redirected to go to his room". Nursing progress note dated January 31, 2026, at 10:22 p.m., revealed "Seen behind the door, kissing and attempting to pull his pants down. Redirected due to inappropriate behavior". A review of facility documents revealed an "Event Report" and investigation dated February 2, 2026, stating that at 2:15 p.m., on the same day, Resident 1 was found in a female resident's (Resident 2) room masturbating with one of his hands, with his other hand on Resident 2's side. The report indicated that Resident 2's gown was down to the knee, but the brief was intact and not open. Resident 1's hand was on Resident 2's side above the brief. Resident 1 was removed from Resident 2's room and was placed on 1:1. The physician and family were notified. The above behavioral notes dated September 7, 2025, September 28, 2025, November 3, 2025, December 16, 2025, December 30, 2025, and January 31, 2026, failed to reveal that the primary physician was notified of the resident's inappropriate/sexual behaviors. Further review of the nursing progress notes from July 19, 2025, until January 31, 2026, revealed that the facility did not provide Resident 1 with behavioral services despite multiple episodes of inappropriate/sexual behaviors until after February 2, 2026, the incident when the resident was found masturbating in another female resident's room. Review of Resident 1's psychiatry note dated February 9, 2026, revealed "[resident] seen today for psychiatric follow-up per facility request due to recent increase in sexually inappropriate behaviors". The same note revealed: "Plan and Assessment: Dementia with behavioral disturbances ongoing, disease progressing as expected, consider Sertraline as recommended". The additional plan includes "Recommend continuing 1:1 for safety related to sexually inappropriate behavior. An observation was conducted on February 10, 2026. at 10:00 a.m., and 1:00 p.m., revealed Resident 1 was lying in bed, with a 1:1 staff supervision. The resident was calm and quiet and refused to answer questions. The above findings were conveyed to the Nursing Home Administrator on February 10, 2026, at 2:00 p.m. The facility failed to ensure Resident 1 was provided with timely behavioral services for increasing inappropriate /sexual behaviors. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Plan of Correction - To be completed: 03/09/2026

1. Resident 1 has been placed on 1:1 supervision since 02-02-2026. Resident 1 was seen by psych services 02-09-2026 and new orders for new medications started.
2. Facility completed in house audit to ensure no other residents were noted with inappropriate behaviors.
3. DON, or designee, will educate nursing staff on facility behavioral Health services policy. DON, or designee, will educate facility staff on notifying RN supervisor if they observe any resident displaying inappropriate behaviors to others. DON, or designee, will educate RN supervisors on appropriate follow through when notified of residents being inappropriate, to include notifying psych services.
4. DON, or designee, will perform audits 3 times a week for 2 weeks, then weekly for 2 weeks, then monthly for 2 months ensuring any inappropriate behaviors are being addressed per facility policy. Results of audits will be presented to monthly QAPI for review and recommendations.

� 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations: Based on a review of staffing documents provided by the facility and staff interview, it was determined that the facility failed to provide one nurse assistant (NA) per 10 residents on the day shift for 5 of 14 days ( January 27, 30, 31, 2026, February 6, and 8, 2026) and one NA per 11 residents on the evening shift on 6 of 14 days (January 27, 28, 30, 2026, February 2, 6, and 9, 2025) as required. Findings include: A review of facility staffing documents provided by the facility from January 27, 2026, to February 9, 2026, revealed the facility failed to provide NA on the following shifts as required: Day shift: 1/27/26 1/30/26 1/31/26 2/6/26 2/8/26 Evening shift: 1/27/26 1/28/26 1/30/26 2/2/26 2/6/26 2/9/26 Nursing Home Administrator confirmed the above via email on February 10, 2026.

Plan of Correction - To be completed: 03/30/2026

1. Facility cannot retroactively correct the staffing schedule to meet the required CNA ratios for dayshift on 01/27/2026, 01/30/2026, 01/31/2026, 02/06/2026, and 02/08/2026; for evening shift on 01/27/2026, 01/28/2026, 01/30/2026, 02/02/2026, 02/06/2026, and 02/09/2026.
2. NHA, DON and staffing scheduler have weekday meetings to ensure CNA staffing ratios are above minimum requirements of 1CNA per 10 residents on dayshift, 1 CNA per 11 residents on evening shift, and 1 CNA per 15 residents on night shift
3. NHA, or designee, will educate Director of Nursing and nursing scheduler on CNA staff ratio requirements
4. NHA, or designee, will perform audits of CNA ratios for all three shifts 5 days a week for one week, then weekly for two weeks, then monthly for two months. Results will be submitted to monthly QAPI meetings for review and recommendations.

� 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations: Based on review of staffing documentation, it was determined the facility failed to ensure the adequate Licensed Practical Nurse (LPN) ratios were maintained according to State regulations for the two weeks reviewed (January 27, 2026, to February 9, 2026). Findings include: Review of staffing documentation revealed that the facility failed to meet the LPN ratio on the following dates and shifts: January 28, 2026 Day Shift January 29, 2026 Day Shift January 30, 2026 Day Shift January 31, 2026 Day Shift February 2, 2026 Evening Shift February 5, 2026 Evening Shift The above was confirmed by the Nursing Home Administrator on February 10, 2026.

Plan of Correction - To be completed: 03/30/2026

1. Facility cannot retroactively correct the staffing schedule to meet the required LPN ratios for dayshift on 01/28/2026, 01/29/2026, 01/30/2026, and 01/31/2026; for evening shift on 02/02/2026 and 02/05/2026.
2. NHA, DON and staffing scheduler have weekday meetings to ensure LPN staffing ratios are above the minimum requirements of 1 LPN per 25 residents on dayshift, 1 LPN per 30 residents on evening shift, and 1 LPN per 40 residents on nights shift
3. NHA, or designee, will educate the Director of Nursing and nursing scheduler on LPN staff ratio requirements
4. NHA, or designee, will perform audits of LPN ratios for all three shifts 5 days a week for one week, then weekly for two weeks, then monthly for two months. Results of audits will be submitted to monthly QAPI for review and recommendations

� 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations: Based on a review of facility staffing data, it was determined that the facility failed to meet the required PPD (Patient Per Day) hours of 3.20 for the two weeks reviewed (January 27, 2026, to February 9, 2026). Findings include: A review of the facility's staffing for January 27, 2026, to February 9, 2026, revealed that in the following days the facility had a PPD below 3.20. January 27, 2026 3.10 January 30, 2026 3.09 February 9, 2026 3.14 The above was confirmed by the Nursing Home Administrator on February 10, 2026.

Plan of Correction - To be completed: 03/30/2026

1. Facility cannot retroactively correct the staffing schedule to meet the required minimum PPD hours of 3.2 hours of direct resident care for each resident for 01/27/2026, 01/30/2026, and 02/09/2026.
2. NHA, DON, and staffing scheduler have weekday meetings to ensure daily PPD hours are above minimum requirements of 3.2
3. NHA, or designee, will educate Director of Nursing and nursing scheduler on daily PPD hour requirements
4. NHA, or designee, will perform audits of PPD hours 5 days a week for one week, then weekly for two weeks, then monthly for two months. Results of audits will be submitted to monthly QAPI for review and recommendations

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