Conestoga View April 22, 2020

The former Conestoga View Nursing and Rehabilitation, 900 E. King St., Lancaster Township, seen here in April 2020, was sold in spring 2021 to a new owner and now is called Lancaster Nursing and Rehabilitation Center.


As Tom Lisi reported in this week’s Sunday LNP | LancasterOnline, “Two Lancaster Nursing and Rehabilitation Center residents recently ended up in an emergency room due to the facility’s failure to keep them safe, one after nursing home officials failed to act for more than 12 hours after learning he had gone missing from the facility. The incidents that led to the emergency room visits, laid out in reports by state inspectors, as well as interviews ... paint a worrisome picture of conditions inside the 446-bed operation, which came under new ownership in April.” The East King Street facility previously was called Conestoga View.

More than 12 hours.

A lot can happen in 12-plus hours, especially to someone who’s medically vulnerable.

As Lisi reported, staff at Lancaster Nursing and Rehabilitation Center “did not contact police for more than 12 hours after a quadriplegic man in a battery-operated wheelchair didn’t return or answer his phone after a permitted leave from the home that was to last a few hours.” His leave was on Sept. 22. He wouldn’t be located until the next day.

“This is outrageous conduct,” David Hoffman, a former chief counsel at the Pennsylvania Department of Aging and federal prosecutor, told Lisi.

As Lisi reported, Hoffman’s consulting firm has served as a court-appointed monitor of long-term care facilities.

Continued Hoffman: “To not call the police — I’m just stunned, I’m stunned by it.”

We are, too. And appalled.

‘Immediate jeopardy’

Lancaster Nursing and Rehabilitation Center rightfully was slapped with a $32,500 fine for that infraction, which was deemed an instance of putting residents in “immediate jeopardy,” one of the highest-level violations defined in federal rules.

Unbelievably, the top administrators at Lancaster Nursing and Rehabilitation Center were informed sometime after 11 p.m. that the resident had failed to return to the facility — but did not direct staff to contact the police until around 6:30 the next morning.

Three hours later, Lisi reported, “administrators learned the man was at an area emergency room saying he had been robbed and punched in the face.”

Medical staff could not find any injuries. But we’re guessing the man was rattled, at the very least.

As the state inspectors’ report noted, “This failure placed 44 of 352 residents at high risk of potential for accidents, injury, or serious harm.” Forty-four was the number of residents who had permission from a doctor to leave the nursing home by themselves at that time.

That’s not all that happened to this particular resident.

In August, one account noted, his wheelchair battery died and he fell asleep outside the nursing home — in the rain.

Another account from a nurse’s notes said a “concerned neighbor” called the facility and said the man’s wheelchair had stranded him by a park and he needed help back “from an intersection.”

Can you imagine the indignity of this? It’s awful.

Medication mix-up

According to state inspectors, another resident needed a transfusion of red blood cells after receiving a blood-thinning medication meant for another resident.

We found the details of this incident to be harrowing.

As Lisi reported, this resident “mistakenly received another resident’s doses of Coumadin, a powerful blood thinner meant to treat blood clots, on Aug. 2 and 3.”

Note that’s two days and doses, plural.

Lisi continued: “The resident was only responsive when aroused the next day, and staff sent him to the emergency room, according to the report.”

A nursing home with hundreds of beds likely must manage thousands of medications. It should have a strict system of supervision, administration and checks to ensure there are no such mix-ups.

If these were our parents receiving such shoddy care, we’d be incensed.

We’re incensed as it is.

New ownership

We worried last spring when the facility, then Conestoga View, was sold by Complete Healthcare Resources to New Jersey-based Imperial Healthcare Group, a company with a troubling track record.

It seems we were right to be worried.

The new ownership group includes Chaim “Charlie” Steg of Lakewood, New Jersey.

Steg is scheduled to be sentenced Thursday after pleading no contest in June to three counts of reckless endangerment, according to the state Attorney General’s Office.

Those counts “stem from a 2017 investigation that found that had Steg acted on pleas for more staffing, three residents would not have died from preventable injuries caused by neglect at a Philadelphia-area nursing home he managed,” Lisi noted.

As a condition of his probation, which will follow his sentence of six to 23 months of house arrest, he is no longer managing Lancaster Nursing and Rehabilitation Center or any other nursing homes in the commonwealth.

He is barred by the probation agreement from being a majority owner of any nursing homes in Pennsylvania for five years.

So there’s that, at least.


Gwendolyn Bowers told LNP | LancasterOnline about her experience as a rehabilitation patient at Lancaster Nursing and Rehabilitation Center after knee replacement surgery in June.

Bowers said she could see that the staff had an enormous workload. It took her two hours to get her pain medication after she called for it.

Worse, she said it took her two days to get a bottle of water, and only got it when a staff member gave her a bottle of water of her own. She said she wasn’t given a chance to shower until five days after she was admitted.

“I survived, I’m good. I can handle damn near anything,” Bowers told LNP | LancasterOnline. “But I’ve always been an advocate for the vulnerable.”

Which we appreciate. But no one should be asked to handle “damn near anything” at a rehabilitation facility.

As Lisi reported, an annual state Department of Health inspection in June cited Lancaster Nursing and Rehabilitation Center for maintaining direct-care staffing levels below the state’s requirement of 2.7 hours per resident. In the span of two weeks, state health officials found the facility averaged 2.4 hours per resident.

Gov. Tom Wolf’s administration announced in July that it intended to increase the requirement to 4.1 hours per resident.

Long-term care facility operators have complained about that change, because staff already is hard to find. But if a facility can’t find and pay for adequate staffing, perhaps it shouldn’t be in the business of providing care.

Lisi interviewed Patricia Norcross, whose 100-year-old mother, Dorothy, is a resident at Lancaster Nursing and Rehabilitation Center. She has been prevented from seeing her mother regularly because of COVID-19.

Norcross said there is not enough staff to help her mother get out of bed on a regular basis, let alone provide activities. When her mother developed a skin tear and a bruise that enveloped her forearm, Norcross suspected her mother had fallen, but she received no such notification from the facility.

A staff member told Norcross that her colleagues had departed for better-paying jobs elsewhere. No wonder.

Last month, Norcross finally got to visit her mother in her room for the first time in almost two years, she told Lisi. She said she later came back and spent six hours cleaning the room.

Norcross said she has fought with administrators for permission to help with her mother’s care. But her requests have been repeatedly denied because of concerns regarding the spread of COVID-19 — even though, as Lisi pointed out, federal authorities released guidance in March 2021 saying facilities can take steps to allow compassionate caregivers in nursing homes, even during an outbreak.

Norcross said she was told that the owners “don’t want it.”

Apparently, the facility’s leadership doesn’t want to answer questions from LNP | LancasterOnline, either.

As Lisi reported, Howard Hay, executive director of Lancaster Nursing and Rehabilitation Center, did not respond to an email with questions.

‘Educate and audit’?

As Lisi reported, federal and state health officials can do more than just fine long-term care facilities for violations. They can ban them from admitting new patients; impose additional monitoring; and even install a temporary replacement to lead the facility’s operations.

“It’s unclear if health officials did anything else to sanction Lancaster Nursing beyond the $32,500 fine this year,” Lisi noted.

The September state inspectors’ report said Lancaster Nursing and Rehabilitation Center reviewed the conditions of residents who are allowed to leave the facility on their own and educated staff on the policy, Lisi reported. “The administrators also pledged to report the results of random audits of the logs that show residents are signing out and back into the facility.”

But as Hoffman, the former chief counsel at the state Department of Aging, told Lisi, those measures don’t address why the problems occurred in the first place.

“ ‘Education and audit’ without identification of the underlying causes for systemic failures is not going to fix this,” he said.


We are left with the following questions: Why aren’t state officials doing more to address the conditions at Lancaster Nursing and Rehabilitation Center? Why does Lancaster County still lack a public health department that could work to ensure that at least a baseline of care is maintained at the facility?

And one more: Why aren’t elected officials more concerned about the care being given to Lancaster County’s poorest and therefore most vulnerable elderly?

We’d love answers. So, too, would Lancaster Nursing and Rehabilitation Center residents and their loved ones.

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