Nursing Investigation Results -

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

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ROSE CITY NURSING AND REHAB AT LANCASTER
Inspection Results For:

There are  218 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
ROSE CITY NURSING AND REHAB AT LANCASTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance Survey, and an Abbreviated Survey in response to two complaints completed on June 29, 2022, it was determined that Rose City Nursing and Rehab at Lancaster was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.


 Plan of Correction:


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:


Based upon review of facility policy and procedures, observation, and interview, it was determined that the facility failed to maintain appropriate infection prevention and control procedures to prevent spread of Covid 19 at the facility.

Findings include:

Review of facility policy and procedure titled Coronavirus and Covid-19 Vaccine Policy, revised 3/11/2022, revealed "Visitors will be subject to all applicable screening and restriction criteria as per the most current CDC, Federal, State and/or Local guidance; Educate and communicate with staff on Covid-19 along with Infection Prevention practices such as: handwashing, isolation practices/protocols; Proper PPE [personal protective equipment] and usage."

Further review of this policy revealed "The safest approach is for everyone, regardless of vaccination status, to wear a face covering or mask while in communal areas of the facility. Facilities must permit residents to leave the facility as they choose. Should a resident choose to leave, the facility should remind the resident and any individual accompanying the resident to follow all recommended infection practices including wearing a face covering or mask, physical distancing, and hand hygiene and to encourage those around them to do the same."

Observation on the first day of the survey, June 26, 2022, revealed signs throughout the facility indicating the facility was in "yellow" status.

Interview with Employees E4 and E5 on June 26, 2022, at 9:30 a.m. revealed surgical masks and no additional face coverings, i.e., goggles or face shields were appropriate for the level of infection control present in the facility.

Interview with the Nursing Home Administrator on June 26, 2022, at 11:00 a.m. confirmed that surgical masks were appropriate and face shields and goggles were not required.

Observation on June 26, 2022, at 2:30 p.m. of the front porch area of the facility revealed approximately seven residents sitting in the front porch area not wearing any face masks.

On the second day of the survey, June 27, 2022, State surveyors were informed that N95 masks and face shields/goggles were required throughout the facility due to the facility's yellow status.

Observation of group meeting held on June 27, 2022, at 11:00 a.m. revealed seven residents in attendance at the meeting not wearing face masks.

Observation of medication administration on June 27, 2022, at 9:30 a.m. revealed one nurse being reminded to wear a face shield, however, no face shield was immediately available.

Observation of physician arriving at facility on June 28, 2022, revealed the physician attempting to walk past the reception desk wearing a surgical mask. The physician was stopped at that time and was required to go through the facility's screening process. The physician did not have an N95 mask or face shield and heard to inquire as to why these items were required since the physician visits at least two times per week and was not required to wear them previously.

Observation on June 29, 2022, at approximately 8:30 a.m. of the facility parking lot revealed a resident ambulating in the parking lot with a therapy department employee. The resident was not wearing a face mask and the therapy department employee was wearing an N95 mask which was pulled down below the employee's chin.

Observation on all days of the survey of the front porch area in the afternoon revealed all residents on the porch were not wearing face masks.

The above information was conveyed to the Nursing Home Administrator and the Director of Nursing on June 29, 2022 at 12:05 p.m.

The facility failed to maintain the PPE requirements that were set forth by the facility to prevent the spread of Covid-19.

28 Pa. Code 201.18(b)(1)(2)(3) Management








 Plan of Correction - To be completed: 07/28/2022

1. Employees E4, E5, and physician were immediately educated on proper use of PPE.

2. Residents did not suffer ill-effects from employees not using proper PPE. Facility completed baseline audit to ensure infection control policies were in place and up to date.

3. Facility implemented immediate infection control plan of daily huddles for each shift to make staff aware of current PPE and COVID 19 protocols for the area they are working. Facility will educate all staff regarding infection control related to appropriate PPE for COVD 19 zones to ensure professional standards necessary for proper infection control by July 21st 2022.

4. A root cause analysis will be completed and submitted to QAPI committee by July 21st 2022.

5. The leadership team will conduct daily rounds throughout the facility to ensure the appropriate infection control procedures for infection control related to appropriate PPE for COVID 19 nursing units are being performed by all appropriate staff on each unit. Ad hoc education will be provided to persons who are not correctly utilizing proper infection prevention/control practices.

483.10(f)(4)(ii)-(v) REQUIREMENT Right to Receive/Deny Visitors: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.
483.10(f)(4) The resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident.
(ii) The facility must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident's right to deny or withdraw consent at any time;
(iii) The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident's right to deny or withdraw consent at any time;
(iv) The facility must provide reasonable access to a resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time; and
(v) The facility must have written policies and procedures regarding the visitation rights of residents, including those setting forth any clinically necessary or reasonable restriction or limitation or safety restriction or limitation, when such limitations may apply consistent with the requirements of this subpart, that the facility may need to place on such rights and the reasons for the clinical or safety restriction or limitation.
Observations:


Based on review of facility policy, clinical record, information submitted by the facility, and staff interviews, it was determined that the facility failed to ensure visitors had access to the resident for one of 20 residents reviewed (Resident 81).

Findings include:

Review of the facility's Admissions Notice Packet revealed that the resident has the right to say who may or may not have access to the facility for the purpose of visiting the resident. This included family, relatives, or others.

Review of Resident 81's admission MDS (Minimum Data Set - periodic assessment of resident needs) dated May 5, 2022, revealed a BIMS (Brief Interview for Mental Status) score of 15/15, indicating resident was cognitively intact.

Review of Resident 81's clinical record revealed that on June 22, 2022, an allegation of abuse involving the resident's visitor was reported. Resident 81 denied any abuse and no evidence of abuse was noted. Review of information submitted by the facility on June 22, 2022, confirmed that there was an allegation of abuse and that the visitor could not return to the facility to visit.

Review of progress note of June 26, 2022, revealed that the resident's visitor was in the facility to visit in the lounge.

Surveyor attempted to interview Resident 81 on June 28, 2022, at 1:20 p.m., but resident refused to answer any questions.

Interview with Employee E5 on June 29, 2022, at 9:25 a.m. confirmed that visitor was not permitted to visit during investigation, but now is permitted to have supervised visits even though investigation did not confirm abuse.

Interview with Nursing Home Administrator on June 29, 2022, at 10:13 a.m. confirmed that visitation was denied for a "very short period of time", but is now allowed to have supervised visits.

Pa Code 201.18 (b)(2) Management

Pa Code 201.29 (a)(j) Resident Rights

Pa Code 201.30 (a) Access requirements


 Plan of Correction - To be completed: 07/28/2022

1. Resident 81 can visit with loved one unsupervised.
2. Facility followed abuse policy by having stopped visits then supervised visits until abuse investigation completed.
3. NHA educated Director of Nursing and Social Services Director on finishing an investigation timely to ensue residents can see their visitors per their request.
4. NHA/designee will audit abuse investigations weekly for 4 weeks and then monthly for 2 months to ensure they are finished timely, and residents have access to their visitation as permitted.
5. Audits will be submitted to QAPI for review.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:


Based on observation and staff interview it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on one of four nursing units (Third Floor).

Findings include:

Observations conducted during an environment tour of the facility on June 26, 2022, at approximately 9:30 a.m. on the third floor resulted in finding a hole in the bathroom wall in room 304. The hole was located behind the bathroom sink, measuring 3 feet wide by 2 feet high, exposing wooden studs and metal plumbing pipes. There was a thin sheet of particle board leaned up against the wall covering roughly 90% of the hole.

An interview conducted with the Director of Nursing (DON) resulted in a non-dated or signed statement "Room 304- This room needed several areas fixed. This included several areas around the window, on the wall and in the bathroom. This took time to complete. The resident was discharged 6/1/2022. We had to purchased and gather the supplies needed. We then started on the area of greatest concern. We had several days of rain and humidity that created a waiting period of drying. We also found a leak that needed fixed and the area needed to dry as well"

An interview with the facility's maintenance director conducted on June 29, 2022, revealed the hole in room 304 has existed for over a month and that there was no reason, why it was taking so long for the wall to be repaired.

28 Pa. Code 207.2(a) Administrator's responsibility


 Plan of Correction - To be completed: 07/28/2022

1. The hole in the bathroom wall in 304 was repaired and the hole located behind the bathroom sink in room 304 was repaired.
2. Facility completed a baseline audit of resident bathroom walls on 3rd floor to ensure any holes are repaired.
3. Facility implemented new system that department heads will complete room audits weekly to ensure holes are repaired immediately. Maintenance Directed educated on the importance of timely repairs and to make NHA aware when repairs cannot be completed timely.
4. NHA/designee will randomly audit resident bathroom walls weekly for 4 weeks then monthly for 2 months to ensure holes are repaired.
5. Audits will be submitted to QAPI for review.

483.25 REQUIREMENT Quality of Care: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.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review and review of facility documentation, it was determined that the facility failed to follow physician's orders for one of 20 residents reviewed (Resident 3).

Findings include:

Review of Resident 3's physician's orders revealed an order dated March 5, 2022, for Morphine Sulfate (narcotic pain reliever) 20 milligrams (mg) per milliliter (ml) give 10 milligrams (0.5 ml) sublingually (under the tongue) three times a day at 6:00 a.m., 2:00 p.m., and 10:00 p.m. Resident 3 also had a PRN (as needed) order dated January 31, 2022, for morphine sulfate 5 mg (0.25 ml) every four hours.

Review of Resident 3's clinical record revealed a progress note dated March 15, 2022, which stated: "Resident given wrong dose of PRN pain medications. All parties notified. No ill effects from error."

Review of facility documentation dated March 15, 2022 revealed "Nurse on unit found that staff has been giving 10 mg morphine prn instead of the ordered 5 mg. The routine dose is 10mg but the prn dose is 5mg."

Review of Resident 3's Controlled Substance Record revealed the resident received the incorrect dose of morphine sulfate on March 7, 2022 at 6:00 a.m. when the resident received 5 mg instead of 10 mg, March 14, 2022 at 6:00 a.m. when the resident received 5 mg instead of 10 mg, March 14, 2022 at 8:30 a.m. when the resident received 10 mg instead of 5 mg, March 15, 2022 at 1:00 a.m. when the resident received 10 mg instead of 5 mg, March 16, 2022 at 12:00 a.m. when the resident received 10 mg instead of 5 mg, March 26, 2022 at 9:00 a.m. when the resident received 10 mg instead of 5 mg, and April 4, 2022 at 8:15 a.m. when the resident received 10 mg instead of 5 mg.

Interview with the Nursing Home Administrator and Director of Nursing on June 29, 2022 at 1:28 p.m. confirmed that the facility failed to follow Resident 3's physician's orders for pain medication.

28 Pa. Code 211.12(c)(d)(1) Nursing services





 Plan of Correction - To be completed: 07/28/2022

1. Resident 3 did not suffer any ill effects from medication error.
2. Facility completed baseline audit of Morphine medication orders with straight and PRN dose to ensure they are labeled correctly on medication with correct narcotic sheet.
3. Facility implemented new system that when a new Morphine order is received from pharmacy the prior narcotic count sheet will be completed and new narcotic count sheet will be started with new label of narcotic. Licensed nursing staff were educated on this new process.
4. DON/designee will audit Morphine narcotic count sheets weekly for weeks and then monthly for 2 months.
5. Audits will be submitted to QAPI for review.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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.
483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on review of facility policy, clinical record review, and interview, it was determined that the facility failed to monitor and address significant weight loss in a timely manner for three of eight residents reviewed for nutrition (Residents 17, 57, and 79.)

Findings include:

Review of facility policy, "Weight Assessment and Intervention," last revised March 2019, revealed: "Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Physician and Dietitian. The Dietitian and/or Certified Dietary Manager will review the individual weight records to follow individual weight trends over time, making recommendations as appropriate."

Review of Resident 17's weights revealed on June 14, 2022, the resident was recorded as weighing 152.5 pounds (lbs.) On June 21, 2022, the resident was recorded as weighing 118.1 lbs. On June 23, 2022, the resident was recorded as weighing 113.6 lbs. On June 28, 2022, the resident was recorded as weighing 112.9 lbs.

Review of Resident 17's clinical record failed to reveal evidence that the physician or dietitian were made aware of the resident's weight loss.

Interview with the dietitian, Employee E3, on June 29, 2022, at 1:55 p.m. confirmed they were not notified of Resident 17's weight loss.

Interview with Resident 57 conducted on June 27, 2022, at 8:59 a.m. revealed that the resident has had significant weight loss within the last six months. Resident 57 stated that they have lost 40 lbs. in six months.

Review of Resident 57's clinical record revealed On December 2, 2021, at 9:44 a.m. the resident weighed 173.5 lbs. and on June 23, 2022, at 1:34 p.m. the resident weighed 137.0 lbs. This indicated a significant weight loss of 21.04% over a six-month period.

Review of Resident 57's clinical record revealed there was no documented evidence that the weight change was addressed by the dietitian or the physician, and there were no new interventions in place to address this weight change.

Interview with the dietitian, Employee E3, on June 29, 2022, at 2:10 p.m. revealed that the dietitian was not aware if the physician was notified of Resident 57's significant weight loss. Employee E3 also stated that the resident's weight loss might be from Resident R57's frequent hospitalizations but is not certain.

Review of Resident 79's weights revealed on May 27, 2022, the resident weighed 148 lbs. On June 23, 2022, the resident weighed 133.3 lbs., a 9.93% loss in one month.

Further review of Resident 79's weights failed to reveal a reweight obtained following the June 23, 2022 weight.

Review of Resident 79's clinical record failed to reveal evidence that the physician or dietitian were made aware of the resident's weight loss.

Interview with the dietitian, Employee E3, on June 29, 2022, at 1:56 p.m. confirmed they were not notified of Resident 79's weight loss.

28 Pa. Code 211.5(f) Clinical Records

28 Pa. Code 211.10(c) Resident Care Policies

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services



 Plan of Correction - To be completed: 07/28/2022

1. Resident 17's MD and dietician were made aware of weight loss. Resident 57's weight loss addressed by dietician and physician and proper interventions in place. Resident 79's re-weight was obtained, MD and dietitian made aware of weight loss.
2. Facility completed baseline audit of residents with weight loss in the last 30 days to ensure the dietician and MD were made aware, proper interventions were put in place, and re-weights were obtained.
3. Facility implemented new system that communication in morning meeting regarding weight loss is added and tracked. Director of Nursing, Dietary Director, and dietician were educated on this new process.
4. ADON/designee will audit weight loss weekly for 4 weeks and then monthly for 2 months to ensure that dietician and MD are made aware, that re-weights are obtained, and that proper interventions are in place.
5. Audits will be submitted to QAPI for review.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:



Based upon observation, it was determined that the facility to appropriately label opened insulin pens and failed to properly store unopened insulin pens in two of two medication carts observed (2nd floor medication cart and 4th floor medication cart).

Findings include:

Observation of the second floor nursing unit medication cart on June 28, 2022 at 1:35 p.m. revealed two opened Novolog Insulin Pens with no pharmacy label and no resident name on either pen; one Levemir Insulin pen open with no open date indicated on the pen; one Lantus Insulin pen open with no pharmacy label and no resident name and one Lantus Insulin pen unopened with a "refrigerate until opened" label on the pen; and one Basaglar insulin pen opened with no open date, no pharmacy label and no resident name on the pen.

Observation of the fourth floor nursing unit medication cart on June 28, 2022, at 1:45 p.m. revealed one Levemir Insulin Pen unopened and unrefrigerated.

The above information was conveyed to the Nursing Home Administrator and Director of Nursing on June 29, 2022 at approximately 12:00 p.m.

The facility failed to properly label and store medications.

28 PA Code 201.14(a) Responsibility of Licensee

28 PA code 211.12(d)(1)(5) Nursing Services





 Plan of Correction - To be completed: 07/28/2022

1. The two insulin pens found on 2nd floor with no name or date were immediately thrown out and the insulin pen found on 4th floor that was not refrigerated was immediately thrown out.
2. Facility completed baseline audit of insulin pens on 2nd and 4th floor to ensure they were properly stored and dated correctly.
3. Facility implemented new system that nightshift nursing staff will check their med carts daily to ensure insulin pens are dated and stored correctly. Director of Nursing/designee educated licensed staff on this new process.
4. Director of Nursing/designee will randomly audit insulin pens on 2nd and 4th floor weekly for 4 weeks and then monthly for 2 months to ensue they are dated and stored properly.
5. Audits will be submitted to QAPI.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port