Lancaster Health Services

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that 1 (R8) of 5 residents drug regimen was free from unnecessary drugs. R8 was prescribed Risperidone for verbal and physical aggression. The facility failed to adequately monitor R8's response to Risperidone and failed to recognize adverse consequences of Risperidone therapy including lethargy, decreased Activities of Daily Living (ADL) function and decreased oral intake. The facility failed to adjust R8's Risperidone when R8 presented with adverse consequences. R8 was administered Risperidone (Antipsychotic) daily starting on 6/22/25 following two days of intermittent verbal and physical aggression. Following initiation of Risperidone, R8 presented with lethargy, decreases in activity participation, ADL abilities and oral intake. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 39 of 39 residents. Surveyor observed food to have been removed from the original packaging and not dated with an expiration date, an open date, or a use by date. Evidenced by: Facility policy, entitled Food Storage, date revised 8/16/2022, states in part: .13. Frozen Foods: .c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. Example - Undated food removed from original packaging On 8/4/25 at 9:35 AM, during the initial tour of the kitchen, Surveyor observed in the freezer the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect 2 of 16 sampled residents (R4 and R22) and 13 residents who eat in the main dining room. R4 voiced concerns with his cold food not being cold enough. R22 voiced concerns with vegetables being mushy. Surveyor conducted 1 test tray for the main dining room which was not palatable. Evidenced by: Facility policy, entitled Food Storage, last revised 8/16/2022, includes, in part: . 12. Refrigerated food storage: b. TCS (time/temperature control for safety) foods must be maintained at or below 41 degrees Fahrenheit unless otherwise specified by the law. Periodically take temperatures of refrigerated foods to assure temperatures are maintained at or below 41 degrees Fahrenheit. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the resident's right to request, refuse, and/or discontinue treatment and to formulate an advanced directive for 2 of 12 residents (R2 and R32) reviewed. R2 and R32's charts did not contain current copies of their advanced directive and/or did not contain evidence of advanced care planning, other than code status, for a time when they are not able to make their own healthcare decisions. Evidenced by:On 8/7/25 at 11:08 AM, ADON D (Assistant Director of Nursing) informed surveyor that they did not have an advanced directive policy. The facility admission Agreement, indicates, in part: Advanced Directives Policy and Record: Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure care plans were reviewed and/or revised for 2 of 16 (R8 and R9) residents reviewed. Facility staff did not revise R8's care plan to address his hospice status and did not have the hospice agency care plan available for facility staff. R9's comprehensive care plan does not include a focus, goal or interventions for depression. Evidenced by: The facility policy titled, “Comprehensive Care Plan,” indicates, in part: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment…Policy Explanation and Compliance Guidelines: …5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors in 29 opportunities that affected 2 out of 7 supplemental residents (R23 & R25) included in the medication pass task, which resulted in an error rate of 6.9%. R23 received insulin from an insulin pen that had not been primed prior to use. R25 did not receive the correct dose of Vitamin D3. Evidenced by: The facility policy entitled, Medication Administration General Guidelines, dated 1/2025, states, in part: .Policy: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices. Procedures:. Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. 9. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure they followed standards of practice for an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 (R21) of 8 supplemental residents reviewed for antibiotic stewardship. R21 was diagnosed with a urinary tract infection. The physician ordered the antibiotic Bactrim DS (trimethoprim/sulfamethoxazole). The urine culture and susceptibility indicated the bacteria causing R21's urinary tract infection was resistant to Bactrim DS. After this result, R21's ordered antibiotic was not changed. Evidenced by: The facility's Antibiotic Stewardship Program policy, dated 11/18/22, states, in part: Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately for 2 of 3 residents reviewed for abuse (R1 and R2). An allegation of abuse was made by CNA G (Certified Nursing Assistant) regarding CNA F, five days after the alleged incident occurred. CNA C had knowledge of an allegation of abuse involving CNA F and R2, and this was not reported. Laundry/Hskp D (Laundry/Housekeeper) witnessed and had knowledge of a potential abuse situation with CNA F and did not report this to anyone.

Inspectors wroteBased on interview and record review, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for 2 of 3 residents (R1 and R2). An allegation of abuse was made by CNA G (Certified Nursing Assistant) regarding CNA F five days after the alleged incident occurred with R1. The facility did not interview all staff, who had knowledge of other allegations. CNA C and CNA E had knowledge of an allegation of abuse involving CNA F and R2, and this was not investigated. Housekeeper D witnessed and had knowledge of a potential abuse situation with CNA F, and this was not investigated.

Inspectors wroteBased on interview and record review, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 3 residents (R1) reviewed for pain. The facility failed to re-evaluate the effectiveness of R1's pain medication within one hour of being administered, failed to offer non-pharmacological interventions related to pain management, and failed to consult with R1's Medical Doctor when her pain rating was consistently above her goal rate of 2 out of 10. This is evidenced by: Facility did not provide a policy related to pain rating and pain assessment. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Type 2 diabetes, pain in right knee, pain in left knee, and other chronic pain. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit accurate data to Centers for Medicare and Medicaid Services (CMS) mandatory Payroll Based Journal (PBJ) for Quarter 4 2023, Quarter 1 2024, and Quarter 2 2024. This had the potential to affect all 38 residents.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. This occurred for 1 of 3 sampled residents (R6) who is prescribed a prophylactic antibiotic without adequate indications for its use. R6 returned from the hospital with an order for a prophylactic antibiotic (Cephalexin). No diagnosis was listed for this order. No stop date was listed for this order. This is evidenced by Facility policy and procedure entitled Antibiotic Stewardship Program, dated 11/18/22, states in part: Prescriptions for antibiotics shall specify the dose, duration, and indication for use. R6 was admitted to the facility with diagnoses that include chronic respiratory failure, respiratory failure with hypoxia, hypertension, congestive heart failure, chronic kidney disease, and Alzheimer disease. [...]

Inspectors wroteBased on random observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases and infections. Staff did not perform hand hygiene when warranted when providing cares for 3 of 3 residents (R24, R27, and R3). Staff did not perform sanitizing of durable medical equipment to prevent the spread of infection when warranted between 2 residents (R3 and R24). This is evidenced by: The facility policy entitled Hand Hygiene revised on 11/02/22 states in part . • All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. [...]

Inspectors wroteBased on interview and record review, the facility did not immediately report alleged violations of abuse to the State Agency and local law enforcement for 2 of 3 reportable incidents (R8 and R9). On 3/21/24, R8 reported that he was unable to find the cash that he kept in his room. R8 indicated that there was a grand that he was unable to locate. NHA A failed to report this Suspicion of a Crime to local law enforcement and the State Agency. On 3/16/24, R9's daughter called the facility to report that R9's wedding ring was missing. NHA A failed to investigate the allegation or report this Suspicion of a Crime to local law enforcement and the State Agency. This is evidenced by: The facility's policy and procedure, Abuse, Neglect, Exploitation Policy, last revised 7/15/22, states in part, the following: Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is stored and distributed in accordance with professional standards for food service safety. This has the potential to affect all 33 residents who reside in the facility. Surveyor observed DA F (Dietary Aide) during dishwashing. Surveyor observed DA F go from working with dirty dishes to clean dishes four times without washing hands in between. Evidenced by: The facility policy titled, Cleaning Dishes Dish Machine, with a reviewed date of 7/13/22, includes, in part: Policy Explanation and Compliance Guidelines .2. The person loading dirty dishes will not handle the clean dishes unless they change into a clean apron and wash hands thoroughly before moving from dirty to clean dishes .10. [...]

Inspectors wroteBased on observation, interview and record review, the facility has not established 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, this has the potential to affect all 33 residents (R) in the facility. The facility's staff infection control line list contained missing and/or incorrect information. Dietary Aide H returned to work sooner than current infection control standards of practice recommend. The facility's monthly infection control rates were not calculated according to current standards of practice and rates were not segregated for specific infection types. Staff administered R86's eye drops without gloves or proper hand hygiene. [...]

Inspectors wroteBased on interview and record review, the facility must develop policies and procedures to ensure that residents and/or resident responsible party receives education regarding the benefits and potential side effects of the immunization prior to offering the immunization and documentation is noted in the medical record on whether the resident received or declined the immunization. This affected 1 of 5 residents (R9) reviewed for pneumococcal immunizations of 16 sampled residents. R9 did not have the pneumococcal immunization and no documentation in R9's record. This evidenced by: The facility policy, entitled, Pneumococcal Vaccine (Series), with a revised date of 2/20/23, states, in part: Policy: It is our policy to offer our residents and staff immunization against pneumococcal disease in accordance with current CDC (Centers for Disease Control) guidelines and recommendations. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure all staff who provide care to the residents were fully vaccinated for COVID-19. This had the potential to affect all 33 residents. Cook D, with a date of hire of 7/14/22, was not fully vaccinated for COVID-19 while working in the facility and did not have a temporary delay or exemption from receiving the COVID-19 vaccination. This is evidenced by: The facility policy, Employee COVID-19 Vaccinations, with a revised date of 10/24/22, indicates, in part: Policy: It is the policy of this facility to ensure that all eligible employees are vaccinated against COVID-19 as per applicable Federal, State and local guidelines . Compliance Guidelines: 1. [...]