A month after an owner of Lancaster Nursing and Rehabilitation Center was sanctioned for three deaths tied to under-staffing at a Darby nursing home, state inspectors found that Lancaster Nursing and Rehabilitation, formerly known as Conestoga View, was not properly staffed for nearly two weeks.
The details are laid out in the first state Department of Health inspection since April’s change of ownership to Imperial Healthcare Group. At that time the company listed as its registered agent Lakewood, New Jersey, resident Chaim “Charlie” Steg.
In June, the state attorney general’s office announced that Steg pleaded no contest to three counts of reckless endangerment stemming from the deaths of three Darby, Delaware County, nursing home residents who died of preventable injuries when Steg managed the home, which was understaffed, according to the criminal complaint.
As part of Steg’s plea, Steg has to pay $15,000 in restitution to victims’ families, and is no longer allowed to operate, manage or be a majority owner of any nursing home in the state for five years, according to a spokesperson from the attorney general’s office.
He remains a minority owner, according to a DOH spokesperson, and appears to have been CEO and president of Imperial for at least part of the state DOH’s in-person inspection that turned up understaffing at Lancaster Nursing and Rehabilitation, a 446-bed facility at 900 E. King St. In Lancaster Township.
Of the 14 days state inspectors reviewed, 13 of them did not meet staffing standards under state law, which require 2.7 hours of direct care for each resident at nursing facilities per day.
For the days between May 16 to May 22, and those between May 29 and June 4, the facility averaged about 2.4 hours of direct care per resident, according to the report.
Most nursing home facilities in Lancaster County show staffing ratios between three and five staff hours per resident, according to the DOH website.
Levels at 2.4 hours per resident, or even lower, as inspectors detailed on certain days in May and June, is “alarmingly low,” said David Hoffman, a former chief counsel at the Pennsylvania Department of Aging and federal prosecutor. Hoffman’s consulting firm has served as a court-appointed monitor of long-term care facilities.
To residents and their family members at LNRC, “at those moments it must’ve felt like a ghost town,” inside the facility, Hoffman said.
It’s unclear if state regulators issued any fines or sanctions as a result of the June inspection. A spokesperson for DOH told LNP|LancasterOnline that the agency can’t comment further on inspection reports, and any such sanctions would appear in a monthly press release.
A spokesperson for the company that bought LNRC in April, Lakewood, New Jersey-based Imperial, said the people in the best position to respond to questions about the inspection report weren’t available to comment Tuesday.
The deaths at the St. Francis Center for Rehabilitation & Health Care in Darby occurred, the complaint said, because Steg ignored warnings from care staff to increase dangerously low staffing. One victim, an 86-year-old woman, ultimately died of septic shock after developing bed sores that exposed tendon and bones, according to the criminal complaint against the New Jersey man.
Steg was in charge of operations at St. Francis, and the ownership and management entity also reached a $1 million settlement with the attorney general’s office.
A DOH spokesperson confirmed to LNP|LancasterOnline that Steg is no longer a majority owner of LNRC, but he is still one of five owners of the facility.
In June, a spokesperson representing Imperial Healthcare provided a statement to LNP|LancasterOnline from Leon Tarlow, who said Steg was stepping down from leadership positions at Imperial and Tarlow would become its interim president and CEO.
Before its ownership and name change, the nursing home also experienced an extremely trying period during the start of the coronavirus pandemic. As one of the largest nursing homes in the Pennsylvania, LNRC saw the sixth-most COVID deaths of any long-term care facility in the state.
Steg also has had an ownership interest in Newport Meadows Health and Rehabilitation Center, formerly Harrison House, in Christiana since January 2020, according to the U.S Centers for Medicare & Medicaid Services.
‘We don’t know what’s happening’
Inspectors finished their work, which included reviews of policies and clinical records, as well as staff and resident interviews, at LNRC on June 7, according to DOH records. State officials don’t release the results of those findings until 41 days later, in order to give nursing home managers a chance to respond and explain how they will correct any documented problems.
Diane Menio, executive director at CARIE, an advocacy group for the elderly based in Philadelphia, said the state's staffing requirement of 2.7 direct-care hours per resident, per day, is already too low. If such low staffing is the norm at LNRC, she said, it means there’s not enough staff to document other problems or prevent them in the first place.
“If they're consistently understaffing, we don't know what's happening, and people aren't getting the care they need,” Menio said.
Inspectors also documented some troubling findings about individual residents at the LNRC. One person with a lot of medical problems and a history of weight issues had lost 16 pounds in a week, and did not receive any timely interventions. Another citation involved a resident who received a type of hand restraint with no documented consent.
Another person accidentally received two sets of different COVID-19 vaccine, according to the report. Health care staff that perform kidney dialysis treatment for a resident gave the person two shots of the Moderna vaccine without the knowledge that another set of staff had already given the individual two shots of the Pfizer vaccine.
LNRC responded that the resident “was assessed by a practitioner with no negative outcomes from receiving extra doses of COVID vaccine,” the report reads.
Other citations included the discovery of milk in the LNRC's kitchen that should’ve been discarded a week earlier, and food served at room temperature.
"The food is frequently room temperature, warm at best," one resident told state officials, according to the report.
Despite the vivid details in the report, it's hard to draw conclusions on what’s really going on inside the facility overall, Hoffman said.
That’s in part because the responses managers give are often vague and don’t deal with what led to the problem – whether it was a fluke or a systemic problem in need of a fix, he said.
Many of responses to inspectors’ citations include first a claim that the failure in compliance didn’t harm anyone, including when a citation found apple juice and potato salad were served at incorrect temperatures.
“Residents on third floor had no negative effects from receiving potato salad and apple juice out of temperature range,” the response reads. Then the managers' response says the facility will conduct a random audit, re-educate staff on standards, and finally do a “performance improvement plan” on food preparation.
The responses don’t mention whether if facility managers looked for a cause of the problem, or what results of the corrective steps will be shared with state officials, Hoffman said. Nor do state officials require such follow-up, he said.
“It's the same kind of responses that are routinely offered and aren't really that meaningful,” Hoffman said.
Menio called LNRC’s submitted responses, like the one about the potato salad and apple juice, “snarky.” The regulations for nursing homes aren’t just about bodily health, but also quality of life.
“That to me – it just shows the disregard for the seriousness of this work,” Menio said.
Republican state Sen. Scott Martin’s district includes LNRC. He said the inspection reports points to the importance of an inspection system, and that many nursing homes that rely on patients are struggling due to low reimbursement rates. Those rates are determined by state lawmakers and the governor.
“We need more advocates who are beating that drum of increasing reimbursement rates,” Martin said.
The office of Democratic State Rep. Mike Sturla, whose district also encompasses LNRC, did not respond to a request for comment.