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A patient at Pleasant Acres Nursing and Rehabilitation Center had to undergo surgery to replace a failed pacemaker after nursing home staff neglected to monitor the device for proper functioning, according to a recent state inspection report.

The findings of the state Department of Health report are in line with concerns raised by residents' family members and by nurses in recent months about declining quality of care and low staff numbers.

In a June interview, Tammy Snyder said her mother, Ethyl Worfel, who has Alzheimer's, had been a patient at Pleasant Acres for about five years.

Before Premier Healthcare Management took ownership of the nursing home in October 2018, the home had a totally different environment, Snyder said.

"It’s not like we did not have issues, but they were manageable," she said. "If I would bring something to someone’s attention, it would be addressed."

Snyder said Friday that the conditions became so bad at the nursing home that in late August she removed Worfel from Pleasant Acres and began caring for her at home.

The facility was privatized when Premier purchased it from York County for $33.5 million. 

After Premier took over, staff turnover increased, Snyder said, and there didn't seem to be enough people to make sure Worfel was being properly fed and clothed, and her patient care plan wasn't being followed.

"There just aren’t enough staff to provide for all of the needs of every resident," she said.

Inspectors from the Health Department visited the nursing home on Aug. 29 in response to complaints, according to the state report. The report, which was made publicly available about 40 days later, identified the errors as a "pattern" causing "serious harm."

The pacemaker patient, identified as "Resident 359," suffers from an irregular heartbeat and has a pacemaker to treat the condition.

She was found lying on the floor next to her bed on Aug. 20 and was subsequently transferred to the hospital, according to the report.

On the way to the hospital, the patient reportedly had a seizure. When she was admitted to the hospital, doctors diagnosed her as having a failed pacemaker and she underwent surgery to replace the device.

More: Pleasant Acres sued by estate of woman who died after fall there

More: Families claim poor care, unsanitary conditions at Pleasant Acres

According to the report, the patient told state inspectors on Aug. 28 that when she was in the hospital, hospital staff told her that the pacemaker clinic hadn't received any pacemaker transmissions to monitor the device's functioning since Jan. 9, 2019, when she was admitted to Pleasant Acres.

There were 19 other residents with pacemakers at Pleasant Acres who were at risk to be in an "immediate jeopardy" situation because of the nursing staff's failure to monitor the patients' pacemakers, according to the report.

One of those patients had a pacemaker inserted in June 2018. Pacemaker checks scheduled for May 13, Aug. 12 and Aug. 27 were not completed, and Pleasant Acres did not tell the patient's doctor about the missed appointments, according to the report.

Premier CEO Lisa Sofia said Friday she'd be able comment on the report more fully once the company filed its response, which is due by Thursday, Oct. 17, with the Health Department.

Even before Premier bought the nursing home, it could be difficult to find staff to fill second shift, said Beth Rineholt, who was a nurse at Pleasant Acres when she spoke to The York Dispatch in June.

The heavy workload makes it difficult to retain employees, she said.

"I guess there’s always a risk of breakdown when you don’t have enough staff," Rineholt said.

Sofia said Friday the company has filled 82 of the approximately 150 staff positions that were vacant when Premier privatized the facility.

Prior to the privatization of Pleasant Acres, the county had been paying millions of dollars in annual subsidies to keep the nursing home afloat.

In June, family members of several residents went to the county board of commissioners and said the quality of care at the nursing home had decreased significantly since Premier took over.

Some claimed their relatives were living in unsanitary conditions with dirty floors, dirty dishes and soiled laundry. Other complaints included low staff numbers and injuries occurring during routine care procedures, with some residents allegedly not getting enough to eat.

On Aug. 29, inspectors reportedly found a patient's open leg wound uncovered during their visit, even though the patient's physician directed staff to keep the wound covered with antibacterial dressing.

Another resident reportedly didn't receive his lunch tray on Aug. 29 until the inspectors said something to a nurse's aide.

More: York County made $33.5M on nursing home sale: Where did the money go?

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