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Residents at 2 Lancaster County nursing homes die after workers violate patient transfer policies: reports

Intelligencer Journal - 12/31/2019

Two residents at separate Lancaster County nursing homes died after workers at each facility violated patient transfer policies, according to reports from the Pennsylvania Department of Health.

In each case, the residents died of what the coroner determined were traumatic neck injuries after falling while being transferred by one worker instead of the required two.

The reports do not name the residents or employees involved, but say the incidents happened Aug. 1 at Lancashire Hall and Sept. 8 at Mennonite Home Communities.

Fall not reported at Lancashire Hall

The Lancashire Hall resident fell shortly after 7 a.m., according to the report, which also says the nurse aid transferring the resident committed another violation by not notifying a nurse of the incident. The report says the nurse aide instead claimed the resident was found in bed bleeding from the forehead.


Star ratings Medicare gives nursing homes overall star ratings, with 1 being the poorest rating and 5 the best.

Here are the ratings as of Dec. 27, 2019.

1 star

* Rose City Nursing & Rehabilitation at Lancaster

2 stars

* Conestoga View

* Elizabeth Manor Healthcare & Rehabilitation Center

* Elizabethtown Healthcare & Rehab Center

* Harrison Senior Living of Christiana

* Lancashire Hall

* Manorcare Health Services Lancaster

* Susquehanna Valley Nursing & Rehabilitation Center

3 stars

* Kadima Rehabilitation & Nursing at Lititz

* Masonic Village at Elizabethtown

4 stars

* Gardens at Stevens

* Hamilton Arms Center

* St. Anne’s Retirement Community

* United Zion Retirement Community

5 stars

* Brethren Village

* Calvary Fellowship Homes Inc.

* Ephrata Manor

* Fairmount Homes

* Garden Spot Village

* Glen at Willow Valley

* Homestead Village Inc.

* Lakeside at Willow Valley

* Landis Homes

* Luther Acres Manor

* Maple Farm

* The Mennonite Home

* Moravian Manor

* Mt. Hope Nazarene Retirement Community

* Pleasant View Communities

* Quarryville Presbyterian Retirement Community

* Rehabilitation Center at Brethren Village LLC

* Zerbe Sisters Nursing Center


After the injury was treated not long after the fall, the report says the resident was found unresponsive at 4 p.m. the same day and was pronounced dead.

The report shows numerous meetings to re-educate staff held as part of the plan of correction, along with reviews extending one month before and six months after the incident.

It does not show what happened to the employee.

Lancashire Hall did not respond to a request for comment.

‘Sincere remorse’ at Mennonite Home

Staff responded immediately but the resident died an hour after falling at the Mennonite Home, according to the report.

A statement by the Mennonite Home in response to LNP’s request for comment described the situation as “an unfortunate and isolated incident due to the conduct of an employee who was terminated following a thorough investigation.”

“The entire Mennonite Home team is deeply saddened by this event, and we have expressed our sincere remorse to the resident’s family,” the statement said. “Mennonite Home Communities has a long and cherished history of providing outstanding care and we are committed to ensuring the safety and wellbeing of our residents and team members.”

A follow-up survey the department conducted Dec. 19 “validated that Mennonite Home successfully implemented the approved plan of correction,” which included education and audits, according to the statement.

That report has not yet been posted publicly.

Other inspections

Here is a list of the other inspection reports released since late October.

Conestoga View, 900 E. King St., Lancaster: Complaint inspections Oct. 1 and Oct. 31; two minimal harm deficiencies.

Elizabeth Manor Healthcare and Rehabilitation Center, 320 S. Market St., Elizabethtown: Standard inspection Sept. 27; three minimal harm deficiencies.

Elizabethtown Nursing and Rehabilitation Center, 141 Heisey Ave., Elizabethtown: Complaint survey Oct. 11; one minimal harm deficiency.

The Gardens at Stevens, 400 Lancaster Ave., Stevens: Complaint inspection Oct. 18; no deficiencies.

Hamilton Arms Center, 336 S. West End Ave., Lancaster: Complaint inspection Nov. 11; one minimal harm deficiency.

Harrison Senior Living of Christiana, 41 Newport Ave., Christiana: Complaint surveys Sept. 30 and Oct. 25; no deficiencies.

Kadima Nursing & Rehabilitation at Lititz, 125 S. Broad St., Lititz: Complaint and standard inspections Nov. 7; eight minimal harm deficiencies.

Lancashire Hall, 2829 Lititz Pike, Lancaster: Standard and complaint surveys Sept. 20; five minimal harm deficiencies.

Manorcare Health Services Lancaster, 100 Abbeyville Road, Lancaster: Standard and complaint inspections Aug. 28 and complaint inspections Sept. 18 and Nov. 6; ten minimal harm deficiencies.

Maple Farm, 604 Oak St., Akron: Standard inspection Sept. 27; one minimal harm deficiency.

Masonic Village at Elizabethtown, 1 Masonic Drive, Elizabethtown: Complaint inspection Oct. 18; no deficiencies.

Moravian Manor, 300 W. Lemon St., Lititz: Complaint inspection Sept. 10; no deficiencies.

Mt. Hope Nazarene Retirement Community, 3026 Mt. Hope Home Road, Manheim: Complaint inspections Sept. 25 and Nov. 5; no deficiencies.

Quarryville Presbyterian Retirement Community, 625 Robert Fulton Highway, Quarryville: Standard and complaint surveys Oct. 4; three minimal harm deficiencies.

Rose City Nursing & Rehabilitation at Lancaster, 425 N. Duke St., Lancaster: Complaint inspections Oct. 3 and Oct. 17 and Oct. 30; one deficiency.

Susquehanna Valley Nursing & Rehabilitation Center, 745 Chiques Hill Road, Columbia: Complaint survey Oct. 23; no deficiencies.


About the reports

Lancaster County has 32 nursing homes that are inspected by the state Department of Health.

Standard inspections are performed annually, unannounced. The department also does inspections when it receives complaints.

Deficiencies are ranked from least to most serious: potential harm, minimal harm, actual harm and immediate jeopardy.

Facilities average 9.2 deficiencies in Pennsylvania and 8.2 in the United States, according to Medicare.

Crédito: HEATHER STAUFFER | Staff Writer

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