LANCASTER CARE AND REHABILITATION CENTER

Nursing Home Inspector

425 NORTH DUKE STREET
LANCASTER, PA 17602
Lancaster County
Phone: 717-397-4281
Provider Number: 395177
Last Inspection: 06/27/2017

About the Nursing Home

Number of Beds: 124
Number of Residents: 98
Beds Available: 26
Percent Occupancy: 79%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

26

Facility 		15

County 		23

PA 		20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 
26

2017		 28

2016		 28

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

6/27/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 8/11/2017
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 8/11/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 8/11/2017
 
Failed To: Ensure that residents receive proper treatment and assistive devices to maintain their vision and hearing. Isolated : Minimal 3 8/11/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 8/11/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 8/11/2017
 
Failed To: Develop a post-discharge plan with the resident and family for the resident's care after leaving the nursing home. Isolated : Minimal 3 8/11/2017
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 8/11/2017
 

4/7/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 5/25/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 5/25/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 5/25/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 5/25/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 5/25/2016
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 5/25/2016
 
Failed To: Provide or obtain dental services for each resident. Isolated : Minimal 3 5/25/2016
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 5/25/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 5/25/2016
 

7/2/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 8/26/2015
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 8/26/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 8/26/2015
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 8/26/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 8/26/2015
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 8/26/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 8/26/2015
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 8/26/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 8/26/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

5/7/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 5/19/2017
 

10/27/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 12/5/2016
 

10/12/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Honor a residents' rights as a residents of the nursing home, free of coercion and reprisal, and as citizens or residents of the United States. Isolated : Minimal 3 12/5/2016
 
Failed To: Help and prepare each resident for a safe and easy discharge or transfer from the nursing home. Isolated : Minimal 3 12/5/2016
 

6/2/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 6/24/2016
 
Failed To: Ensure that residents are safe from serious medication errors. Pattern : Minimal 4 6/24/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 6/24/2016
 

5/13/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Reasonably accommodate the needs and preferences of each resident. Isolated : Minimal 3 6/16/2016
 
Failed To: Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances. Isolated : Minimal 3 6/16/2016
 

3/9/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide residents with private access to a telephone. Pattern : Minimal 4 3/14/2016
 

1/12/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 2/29/2016
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 2/29/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 2/29/2016
 

12/15/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 1/29/2016
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 1/29/2016
 

12/12/2014 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 unknown
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 unknown
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg PA State Avg
Number of Residents 98 116.03 110.03
Registered Nurses 0.66 0.88 0.94
Licensed Practical / Vocational Nurses 0.90 0.97 0.85
Certified Nursing Assistants 3.05 2.56 2.26
Total Staff Hours 4.61 4.42 4.05

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% PA State Avg%
of high risk long-stay residents with pressure ulcers 2 3 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 95 97 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 83 97 95
of long-stay residents experiencing one or more falls with major injury 3 3 3
of long-stay residents who have depressive symptoms 2 2 2
of long-stay residents who lose too much weight 6 7 7
of long-stay residents who received an antianxiety or hypnotic medication 24 20 22
of long-stay residents who received an antipsychotic medication 25 13 15
of long-stay residents who self-report moderate to severe pain 8 7 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 20 18 20
of long-stay residents whose need for help with daily activities has increased 16 13 15
of long-stay residents with a catheter inserted and left in their bladder 2 1 1
of long-stay residents with a urinary tract infection 4 3 3
of low risk long-stay residents who lose control of their bowels or bladder 41 60 56
of short-stay residents assessed and appropriately given the pneumococcal vaccine 75 89 83
of short-stay residents who had an outpatient emergency department visit 17 7 10
of short-stay residents who made improvements in function 46 72 64
of short-stay residents who newly received an antipsychotic medication 0 1 1
of short-stay residents who self-report moderate to severe pain 19 15 15
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 51 88 82
of short-stay residents who were rehospitalized after a nursing home admission 19 14 20
of short-stay residents with pressure ulcers that are new or worsened 0 60 52