Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Landmark Of Lancaster Rehabilitation And Nursing C during CMS and state inspections, most recent first.
Open Doors and PPE Noncompliance During Droplet Precautions: The facility failed to follow CDC droplet precaution guidance when doors to rooms of residents with COVID-19 were observed open and one resident was seated at the doorway without a mask. Staff acknowledged the CDC signage required the door to remain closed and required PPE for entry, but an STNA entered one isolation room without full PPE because she said she was only peeking in. The DON stated the doors were left open because the residents were fall risks and safety was the priority.
Improper Storage of Refrigerated Medication: A box of Formoterol Fumarate Inhalation Solution labeled for a resident with COPD was found stored in the freezer compartment of a medication refrigerator despite a "Do Not Freeze" label. Frost and ice were observed on the box and vials, no thermometer was present in the unit, and staff interviews confirmed the medication should have been refrigerated per manufacturer instructions and that discontinued meds should be returned to the pharmacy.
The facility failed to maintain safe and appetizing food and drink temperatures, with observations showing milk, juice, and pureed pork tenderloin in the danger zone. Resident council minutes indicated ongoing concerns about food quality, and interviews revealed issues with cold food and inadequate portion sizes. The Dietary Manager, new to the position, acknowledged challenges in maintaining proper temperatures, while the Regional Dietary Manager had not yet visited the facility.
The facility failed to maintain food safety and hygiene standards, with observations of improperly labeled and expired food items, uncovered beverages, and unsanitary practices by kitchen staff. Opened food items lacked proper labeling, and expired products were found in the refrigerator. Staff were observed handling food without proper hygiene, such as not changing gloves or washing hands, and not wearing required hair restraints. Interviews revealed a lack of awareness and training among staff regarding food safety protocols.
The facility failed to maintain a safe, clean, and homelike environment, with surveyors observing scuff marks, sticky floors, and strong urine odors in multiple rooms. Residents and staff reported ongoing issues with cleanliness and maintenance, but these were not consistently reported or addressed. The Maintenance Director and housekeeping staff were aware of some issues but did not take adequate action to resolve them.
A resident with a positive COVID-19 diagnosis was under Special Droplet/Contact Precautions, but a State Registered Nurse Aide (SRNA) improperly removed and disposed of personal protective equipment (PPE) outside the resident's room, contrary to facility policy. The SRNA admitted to not remembering the correct procedure, and the Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed the breach in protocol, highlighting inconsistent compliance audits.
A resident's food preferences were not honored, as they frequently received bacon instead of their preferred sausage and occasionally received orange juice despite requesting it. The facility's policy required honoring food preferences, but this was not consistently followed. The Regional Dietary Manager acknowledged the issue, and the facility was undergoing a pilot program with contracted kitchen staff.
Open Doors and PPE Noncompliance During Droplet Precautions
Penalty
Summary
The facility failed to follow CDC infection-prevention guidance for droplet precautions by not ensuring that doors to resident rooms on droplet precautions remained closed. Multiple observations on 12/03/2025 showed the door to R88’s room, identified as a droplet precaution room, open at least halfway. On 12/04/2025, the door to Room E16 was observed wide open while the resident on droplet precautions for COVID-19 was seated in a wheelchair at the room’s threshold talking with staff and was not wearing a mask. The report also noted that CDC signage for Special Droplet/Contact Precautions instructed that the room door must remain closed and that anyone entering should clean hands, wear a mask, eye protection, gown, and gloves. The report identified three residents on droplet precautions for COVID-19: R34, R86, and R88. R34 had diagnoses including COPD, arthritis, and schizophrenia, with a BIMS score of 3 indicating severe impairment. R86 had diagnoses including hemiplegia of the non-dominant side, memory deficiency following cerebral infarction, and immunodeficiency, with a BIMS score of 12 indicating moderate impairment. R88 had diagnoses including Alzheimer’s disease, immunodeficiency, and cognitive communication deficit, and was assessed as severely impaired with no BIMS completed. Each resident’s physician ordered droplet isolation for COVID-19, and each care plan directed staff to initiate droplet isolation precautions each shift for 10 days and encourage the resident to stay in the room; the revised care plans also stated residents should be encouraged to wear masks before leaving the room. Staff interviews confirmed awareness of the precautions but also confirmed the observed practice did not match the posted guidance. STNA3 stated she entered R88’s room only to peek in and did not don PPE because she was not providing care, despite the signage directing staff to wear gown, gloves, mask, and eye protection. LPN8 stated staff were required to follow the instructions posted on the TBP signs and said the door to a droplet precaution room should be kept closed. The ADON/IP stated the observed open doors and unmasked resident at the threshold were not consistent with facility expectations and that staff should follow IPCP and posted CDC signage. The DON stated the doors were open because the residents were fall risks and said safety was the priority, while also stating staff should follow infection control policy and procedures. The Administrator stated it was her expectation that staff adhere to facility infection control policy and follow CDC and local health department guidance.
Improper Storage of Refrigerated Medication
Penalty
Summary
Drugs and biologicals were not stored in accordance with product instructions when a box of Formoterol Fumarate Inhalation Solution labeled for Resident R10 was found in the freezer compartment of the Hall HSC medication refrigerator. The box also had a sticker stating, "Do Not Freeze," and when opened there was frost and ice buildup on the inside of the box, lid, and vials. The box was labeled as containing 120 vials before opening, and a count by an LPN and the State Survey Agent found 58 vials remaining. No thermometer was observed in the medication refrigerator/freezer. Facility policy required medications to be stored in a safe, secure, and orderly manner, with refrigerated medications kept in a refrigerator in the drug room, and stated that discontinued medications should not be used and should be returned to the pharmacy. R10 was admitted with COPD, diabetes, and chronic respiratory failure with hypoxia, and had an order for Formoterol Fumarate Inhalation Nebulizer Solution for COPD that was later discontinued. During interviews, the pharmacist stated the nebulizers should be refrigerated and not frozen because freezing affects efficacy, the LPN stated she did not know why they were in the freezer, and the DON and Administrator stated medications should be stored per manufacturer instructions and that discontinued medications should be disposed of or returned properly to the pharmacy.
Deficiency in Food Temperature Management
Penalty
Summary
The facility failed to ensure that residents received food and drink at safe and appetizing temperatures, as observed during a survey. During a lunch test tray observation, the temperatures of milk, juice, and pureed pork tenderloin were found to be in the danger zone, with milk at 55.5 degrees Fahrenheit, juice at 57 degrees Fahrenheit, and pureed pork tenderloin at 110 degrees Fahrenheit. The facility's policy on food storage did not specify point of service temperatures, and no policy related to food temperatures at point of service was submitted for review. Resident council minutes from February to April 2024 revealed ongoing concerns about improperly cooked and cold food, indicating a pattern of issues with food service temperatures. Interviews with residents and staff highlighted further deficiencies. Residents reported that food, such as hamburgers, was served too cold, and portion sizes were too small. The Dietary Manager, who had been in the position for only a month, acknowledged the need to keep milk on ice and to check meat temperatures more frequently. Cook1 described the process of maintaining food temperatures but noted that the steam table only kept food hot for a limited time. The Regional Dietary Manager had not yet visited the facility and was unsure if training for dietary staff had commenced. Attempts to contact the facility Dietician were unsuccessful, and the Administrator expressed expectations for meals to be served at optimal temperatures to prevent illness.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during an initial kitchen tour. The reach-in refrigerator contained several opened food items, including chocolate syrup, cottage cheese, shredded cheddar cheese, dairy drinks, whole milk, cake mix, and powdered sugar, none of which were labeled with the date opened or the date by which they should be discarded. Additionally, a gallon jug of thousand island dressing and a quart of sour cream were found opened and expired according to the manufacturer's expiration date. The walk-in refrigerator had trays with pre-poured portions of juice, tea, and milk without secure covers, and some cups were standing in liquid. Opened gallon jugs of milk and uncovered fruit cups and applesauce were also found without proper labeling. The walk-in freezer contained an opened bag of mixed frozen vegetables without an opened date. Further observations revealed unsanitary conditions and practices. The filter on the juice dispenser was covered with gray matter, indicating a lack of cleaning. During the lunch tray line, the same uncovered cups of juice, tea, and milk were placed on resident trays, with loose and missing lids being added as the drinks were served. Cook1 was observed leaving the steam table to obtain clean dishes without changing gloves or washing hands upon return, which could lead to contamination. Dietary Aide6, who had a beard, was seen plating beans without wearing a beard guard or hair net, and Dietary Aide1 was observed placing drinks and utensils on meal trays without gloves, while also touching their mask and face. Interviews with staff revealed a lack of awareness and training regarding proper food safety and hygiene practices. Cook1 admitted to being unaware of the need to wash hands and change gloves after leaving the steam table. Dietary Aide6 was not informed about the requirement to wear a beard guard and hair net, despite acknowledging the potential for hair contamination. The Dietary Manager, new to the position, recognized the need for improvements in food labeling, storage, and staff training. The Administrator confirmed expectations for staff to follow dietary policies and maintain hygiene standards, including wearing appropriate hair restraints and practicing good hand hygiene.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as observed during a survey conducted on July 9, 2024. The survey revealed multiple deficiencies, including scuff marks on resident room doors and floors, sticky floors, and a strong urine odor in several rooms and bathrooms. Specific rooms affected included PN9, PN10, PN12, PN13, PN14, PN15, PN16, and PN17. Additionally, the flooring outside Room PN13 was chipped, further contributing to the substandard environment. Interviews with residents and staff highlighted ongoing issues with cleanliness and maintenance. One resident reported that the floor in her room was usually sticky and that the water used for mopping was dirty. Another resident mentioned that scuff marks on the floor had been present since her admission in January 2024. Staff members, including SRNAs and LPNs, acknowledged awareness of the environmental issues but had not consistently reported them through the facility's work order system. The Maintenance Director confirmed that no current work orders for these issues existed, indicating a breakdown in communication and reporting processes. The facility's policies and procedures for maintaining a clean and safe environment were not effectively implemented. Housekeeping staff were aware of the sticky floors and urine odors but attributed these issues to the type of disinfectant used and resident incontinence. The Maintenance Director, who also oversaw housekeeping, admitted to focusing on larger issues and not addressing the chipped flooring or scuffed areas. The Director of Nursing and the Administrator both expressed expectations for a clean environment but were unaware of the specific deficiencies noted during the survey.
Improper PPE Handling in COVID-19 Precaution Room
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper handling of personal protective equipment (PPE) by a State Registered Nurse Aide (SRNA). During an observation, SRNA3 was seen exiting a resident's room, designated for Special Droplet/Contact Precautions due to a positive COVID-19 diagnosis, and removing her mask and gown in the hallway. She then carried the soiled PPE across the hall and used her gloved hand to engage a keypad, before disposing of the PPE in a trash receptacle in a biohazard room. This action was contrary to the facility's policy, which required the removal of PPE and hand hygiene to be performed inside the resident's room before exiting. The resident involved, identified as R78, had been admitted to the facility with diagnoses including metabolic encephalopathy, severe protein-calorie malnutrition, and major depression. The resident had a physician's order for Transmission Based Contact/Droplet Isolation due to a positive COVID-19 test. Signage on the resident's door clearly indicated the necessary precautions, including the requirement for staff to don and doff PPE at the door and perform hand hygiene upon entering and leaving the room. Interviews with SRNA3 and the Assistant Director of Nursing/Infection Preventionist (ADON/IP) revealed a lack of adherence to infection control protocols. SRNA3 admitted to not remembering the correct procedure for removing PPE and acknowledged disposing of PPE inappropriately. The ADON/IP confirmed that staff should remove PPE inside the room and perform hand hygiene immediately after. The ADON/IP also noted that while new hires were educated on PPE protocols during orientation, audits to ensure compliance were not consistently performed due to scheduling constraints.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident #8, who had specific dietary dislikes and requests. Despite having a documented preference for sausage over bacon and a request for orange juice, the resident frequently received bacon and occasionally received orange juice. Additionally, the resident expressed a dislike for cottage cheese and fruit for breakfast, yet these items continued to appear on their meal tray. The facility's policy required that food and beverage preferences be noted on the tray ticket and honored at meal services when possible, but this was not adhered to in the case of Resident #8. The deficiency was identified through observation, interviews, and record reviews. The Regional Dietary Manager acknowledged that residents' food preferences should be honored and confirmed the availability of both bacon and sausage each morning. However, there was a disconnect between the resident's documented preferences and what was actually served. The facility's process involved entering dietary orders and preferences into a computer system, which then printed tray cards for staff to follow. Despite this system, Resident #8's preferences were not consistently met. The facility was undergoing a pilot program with contracted kitchen staff, and the previous dietician had recently left, with the Regional Dietary Manager serving as the interim dietician.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stanford Crossing | 7.4 mi | ★★★★★ | 17 | 2 |
| Henson Park Health & Rehabilitation | 9.6 mi | ★★★★★ | 0 | 0 |
| Danville Centre For Health & Rehabilitation | 10.4 mi | ★★★★★ | 4 | 0 |
| The Terrace Nursing And Rehabilitation Center | 16 mi | ★★★★★ | 0 | 0 |
| Harrodsburg Health & Rehabilitation Center | 16.6 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.