Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Country Village Center, Genesis Healthcare during CMS and state inspections, most recent first.
Failure to inform a resident and/or the resident's representative of the risks and benefits of psychotropic medications. The resident had orders for Buspirone, Lamotrigine, and Ziprasidone for anxiety and bipolar disorder, but the medical record contained no documentation that the resident or representative was informed of the risks and benefits. The DON confirmed the lack of documentation.
Improper disposal of medications was observed for a resident during med administration. An LPN discarded a multivitamin tablet in a sharps container, and another LPN discarded an open bottle of OTC aspirin into an unlabeled waste bin attached to the med cart. The facility policy stated that medications are to be placed in labeled disposal bins and not disposed of in sharps containers or common waste.
A resident with an indwelling urinary catheter was not placed on EBP as required by the facility policy. Staff did not know the resident’s EBP status, an LPN confirmed the resident was not on EBP, and observations found no EBP sign, PPE cart, or PPE supplies outside the room. The resident’s record included a foley catheter care plan with an EBP intervention, and the IP confirmed residents with indwelling catheters should be on EBP.
Failure to Offer and Document COVID-19 Vaccination Education and Status: Two residents had documentation of prior COVID-19 vaccination, but there was no record they were offered or educated about the next dose recommendations. An LNA also reported not being informed that the 2024/25 COVID-19 vaccine was available and had not been asked to sign a declination, while the Administrator stated the facility does not offer the vaccine to employees or track declinations.
The facility failed to store food safely in the main kitchen and two kitchenettes, with expired items found in the milk cooler and refrigerators. Observations included expired prune juice, yogurt, hydrolyte water, Chick-fil-A sauce, and green beans. Staff confirmed these findings, which violated the facility's food handling policies and the Food Code 2017.
The facility failed to follow CDC guidelines for hand hygiene and PPE use for residents on TBP and EBP. Observations showed that isolation gowns were unsuitable for exposure to bodily fluids, and staff did not adhere to proper PPE protocols. A Licensed Nurse Assistant did not discard or disinfect their face shield after exiting a COVID-19 positive room, and a Licensed Nursing Assistant failed to use full PPE and perform hand hygiene during meal service. These actions indicate significant lapses in infection control measures.
The facility inaccurately coded MDS assessments for two residents. One resident's discharge was incorrectly recorded as to a hospital instead of home, and another resident was wrongly coded for using bed rails as a restraint, despite no supporting documentation. These errors were confirmed by the MDS Coordinator.
Failure to Inform Resident of Risks and Benefits of Psychotropic Medications
Penalty
Summary
The facility failed to inform Resident #3 and/or the resident's representative of the risks and benefits of psychotropic medications. Review of the resident's active physician orders showed Buspirone 5 mg three times daily for anxiety with a start date of 6/24/25, Lamotrigine 100 mg once daily for bipolar disorder with a start date of 6/25/25, and Ziprasidone 60 mg twice daily with meal or snack for bipolar disorder with a start date of 6/24/25. Review of the medical record on 9/11/25 found no documentation that Resident #3 or the resident's representative was informed of the risks and benefits of these medications. During interview on 9/11/25 at approximately 11:25 a.m., the DON confirmed the findings and was unable to provide documentation that the resident or representative had been informed.
Improper Disposal of Medications During Administration
Penalty
Summary
The facility failed to properly dispose of medications for 1 of 4 residents observed during medication administration, involving Resident #23. During observation of medication administration, Staff F, an LPN, poured two tablets of multivitamin into a medicine cup and discarded one tablet into the sharps container. The observation also revealed an open bottle of OTC Aspirin EC 81 mg with no visible expiration date on the bottle. Staff G, also an LPN, took the open bottle and discarded it in an open waste bin attached to the medication cart that had no label. Staff F confirmed the observation. The facility policy titled Disposal of Medication Waste stated that medications not returned to the pharmacy are to be placed in labeled medication disposal bins, solid dosage medications are to be removed from their original containers before disposal, and medications are not to be disposed of in common areas, resident trash cans, or sharps containers.
Failure to Implement EBP for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for a resident with an indwelling urinary catheter. Review of the facility policy titled "Enhanced Barrier Precautions" showed that residents with a wound or indwelling medical device should use EBP if they do not meet criteria for Contact Precautions. Observation of the resident revealed an indwelling urinary catheter, but no EBP signage, PPE cart, or PPE supplies were posted or present in or outside the room. Staff interviews showed that an LNA was not aware whether the resident was on EBP, and an LPN confirmed the resident was not on EBP and stated that residents on EBP would have a sign posted and a PPE cart outside the room. The resident’s medical record later showed a foley catheter care plan with an intervention for EBP, yet another observation still found no EBP signage or PPE cart outside the room. The Infection Preventionist confirmed that residents with indwelling catheters should be on EBP.
Failure to Offer and Document COVID-19 Vaccination Education and Status
Penalty
Summary
The facility failed to ensure that residents were offered the COVID-19 vaccine or provided education regarding the benefits, risks, and potential side effects associated with the vaccine for 2 of 5 residents reviewed for immunizations, and failed to implement policies and procedures on COVID-19 immunization for 1 of 1 staff reviewed. Current CDC guidance reviewed by surveyors stated that people ages 65 years and older are up to date when they have received 2 doses of any 2024-2025 COVID-19 vaccine 6 months apart. The facility policy titled COVID-19 Vaccination stated that centers will provide the opportunity to receive COVID-19 vaccination following CDC recommendations, based on the patient's vaccination history, and that employees who consent to vaccination but cannot obtain it through personal providers or community sources should consult their supervisor regarding alternate sources. Resident #20, born in 1939, had documentation showing receipt of the 2024-2025 Pfizer COVID-19 vaccine on 9/26/24, but there was no documentation that the resident was offered or educated about the next dose recommendations. Resident #39, born in 1950, had documentation showing receipt of the 2024-2025 Pfizer COVID-19 vaccine on 9/24/24, but there was no documentation that the resident was offered or educated about the next dose recommendations. Staff B, the Infection Preventionist, confirmed there was no documentation that either resident was offered or educated about the next dose recommendations. Staff A, an LNA, had a last COVID-19 vaccination date of 6/1/22 and stated that they were not provided information that a COVID-19 vaccination was available for 2024/25 and had not been asked to sign a declination. Staff C, the Administrator, stated that the facility does not offer COVID-19 vaccinations to employees or track or obtain a declination.
Failure to Store Food Safely in Kitchen and Kitchenettes
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety, as observed in the main kitchen and two kitchenettes. During an inspection, it was found that the main kitchen milk cooler contained an open and an unopened container of Grave prune juice with a manufacturer's use-by date of 8/10/24, and ten single-serve containers of Dannon Light and Fit yogurts with a use-by date of 4/2/24. In the Cohass Unit kitchenette refrigerator, an open container of Hormel thick and easy hydrolyte water with a handwritten open date of 6/19/24 was found, despite manufacturer's instructions to discard it within 10 days of opening. Additionally, an open container of Chick-fil-A sauce with a use-by date of 12/18/23 was observed. In the Notchway Unit kitchenette refrigerator, a storage container of green beans labeled with a resident's name and the dates 8/28/24-8/30/24 was found, which should have been discarded by 8/30/24. Staff B, the Dietary Manager, confirmed these findings during the inspection. The facility's policy on food handling, revised in 2018, states that foods marked with a manufacturer's use-by date can be used until that date if properly stored and not combined with other foods. The policy for foods from visitors, revised in 2019, requires daily monitoring and discarding of any food items stored for over seven days. The Food Code 2017 emphasizes that manufacturer's use-by dates are recommendations for maintaining product quality and safety.
Inadequate PPE and Hand Hygiene Practices
Penalty
Summary
The facility failed to adhere to CDC guidelines for hand hygiene and the use of appropriate Personal Protective Equipment (PPE) for residents on Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP). Observations revealed that the isolation gowns used were thin and not suitable for situations involving exposure to blood or bodily fluids. Interviews with staff confirmed that these gowns were the only ones available and were used for all residents on TBP and EBP, regardless of the risk of exposure to bodily fluids. Further observations noted that staff did not follow proper PPE protocols. A Licensed Nurse Assistant was seen exiting a COVID-19 positive resident's room without discarding or disinfecting their face shield before entering another resident's room. Additionally, during meal service, a Licensed Nursing Assistant entered a COVID-19 positive room without full PPE and failed to perform hand hygiene before assisting residents in COVID-19 negative rooms. Interviews with staff revealed a lack of awareness regarding the necessity of donning full PPE and performing hand hygiene between patient interactions. The facility's policy on infection prevention and control, as well as CDC guidelines, emphasize the importance of using appropriate PPE and performing hand hygiene to prevent the spread of infections. However, the facility's practices did not align with these guidelines, as evidenced by the improper use of gowns and failure to adhere to hand hygiene protocols. The observations and interviews highlight significant lapses in infection control measures, particularly in the context of managing residents with COVID-19 and those on TBP and EBP.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for two residents. For one resident, the Discharge MDS was incorrectly coded as discharged to a Short-Term General Hospital, while the Discharge Summary indicated the resident was discharged home. This discrepancy was confirmed by the MDS Coordinator. For another resident, the Quarterly MDS inaccurately indicated the use of bed rails as a restraint, despite no medical record or care plan supporting the use of restraints. This error was also confirmed by the MDS Coordinator.
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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) |
|---|---|---|---|---|
| Morrison Nursing Home | 8.8 mi | ★★★★★ | 7 | 0 |
| Coos County Nursing Home | 19.8 mi | ★★★★★ | 5 | 0 |
| Saint Vincent Rehabilitation & Nursing Center | 20.4 mi | ★★★★★ | 0 | 0 |
| Lafayette Center | 20.5 mi | ★★★★★ | 0 | 0 |
| Pines Rehab & Health Center | 20.6 mi | ★★★★★ | 2 | 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.