Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lanfair Center For Rehab & Nsg Care Inc during CMS and state inspections, most recent first.
A resident with dementia, dysphagia, and acute kidney failure, who was at nutritional risk, did not consistently receive a physician-ordered nutritional supplement (Gelato) with meals. Observations and staff interviews confirmed the supplement was missing from meal trays, and the resident experienced a significant weight loss over three weeks.
A deficiency was identified when a nurse performed wound care for a resident with unhealed surgical wounds using only gloves and not a gown, despite facility policy and posted signage requiring both gown and glove use for Enhanced Barrier Precautions (EBP). The nurse later confirmed not following EBP, and review of policy and CMS guidance indicated EBP was required for residents with chronic wounds.
Surveyors found multiple open and undated food items in the refrigerator, pantry, and kitchen serving area, including deli sandwiches, deli meat, crackers, orange syrup, and bags of chips. The Dietary Manager confirmed these items were not labeled or dated as required by facility policy, affecting all residents except one who was NPO.
A resident with dementia and other mental health diagnoses was prescribed an antipsychotic for behaviors that were not consistently documented or monitored. Staff confirmed the medication was used for dementia, which is not an appropriate diagnosis for antipsychotic use, and that regular wandering was not properly recorded in the medical record.
The facility did not update the PASARR for two residents after significant changes in their mental health diagnoses, including the addition of schizoaffective disorder, anxiety disorder, and major depressive disorder. The most recent PASARR submissions for these residents did not reflect their current mental health status, as confirmed by the Regional Director of Social Services and Activities.
Two residents did not have comprehensive care plans addressing their specific needs: one resident's plan lacked individualized swallowing strategies recommended by ST despite a history of dysphagia and weight loss, while another resident's plan did not address c-pap use, with the device observed improperly stored and no physician orders in place. Facility staff confirmed these omissions, which were not in accordance with facility policy.
A resident with multiple medical conditions and physician orders for daily wound care did not receive wound treatments as prescribed. Observations showed that dressings remained unchanged for more than a day, despite documentation indicating otherwise. An RN confirmed that daily wound care was not performed according to orders.
Two residents experienced significant unplanned weight loss without the facility implementing or documenting individualized interventions or consistent weekly weight monitoring as required by policy. For one resident with dysphagia and multiple comorbidities, recommended swallowing strategies were not included in the care plan, and intake of nutritional supplements was not tracked. For another resident with malnutrition and diabetes, weekly weights and reweights were not consistently obtained after a marked weight loss, and supplement intake was inconsistent. Staff interviews confirmed lapses in monitoring and documentation.
Two residents did not receive appropriate respiratory care due to missing physician orders and lack of documentation. One resident received continuous oxygen therapy without proper documentation in the MAR, despite orders and observations indicating ongoing use. Another resident used a CPAP machine without a physician order or care plan, and the device was stored improperly on the floor without protection, contrary to facility policy.
Physicians did not provide clear medical reasons for declining pharmacy-recommended gradual dose reductions of psychotropic medications for two residents with dementia and psychiatric diagnoses. Instead, recommendations were declined with either no explanation or non-medical reasons, such as family requests, as confirmed by the DON.
A registered nurse failed to use required gloves and gown while performing wound care on a resident with multiple open wounds, despite facility policy and CDC guidance mandating Enhanced Barrier Precautions for such high-contact care activities. The resident had a history of fractures, falls, and skin conditions, and physician orders specified daily wound care for open wounds.
The facility failed to maintain the dish machine in safe operating condition, affecting all 74 residents. The machine had been broken for at least a month, requiring towels to prevent water backflow. The facility awaited corporate approval for repairs, using a three-sink hand washing protocol in the interim.
A CNA failed to perform proper hand hygiene during meal service, affecting four residents. The CNA wore gloves while delivering meal trays and did not change gloves or use hand sanitizer between residents, contrary to the facility's infection control policies. A Dietary Coordinator confirmed the CNA's non-compliance with the policies, which require hand hygiene between rooms and do not recommend glove use during tray service.
The facility failed to provide a dignified dining experience by serving meals on Styrofoam tableware and plastic cutlery due to a broken dish machine. Observations and interviews confirmed the use of disposable materials, affecting all residents. Residents reported difficulty eating with plastic utensils, and the facility's policy of using glassware and china was not followed.
Failure to Provide Ordered Nutritional Supplement for Resident at Risk of Weight Loss
Penalty
Summary
A deficiency was identified when a resident with a history of dementia, dysphagia, and acute kidney failure, who was at nutritional risk, was not provided with nutritional supplements as ordered. The resident had a physician's order for a pureed diet, nectar thick liquids, and four ounces of Gelato, a high-calorie nutritional supplement, to be given with each meal. The care plan specifically included the provision of Gelato at all meals to prevent significant weight change. However, during multiple observations, the resident's meal trays did not include the ordered Gelato, and this omission was confirmed by both nursing and dietary staff. Review of the resident's weight records showed a significant weight loss of 7.6 pounds, or 5 percent, over a three-week period. Staff interviews confirmed that the Gelato was not consistently provided as ordered, and dietary staff acknowledged the supplement was not placed on the resident's tray during at least one observed meal. This failure to provide the prescribed nutritional supplement contributed to the resident's continued weight loss, as documented in the medical record and observed by surveyors.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
During the annual survey, it was observed that the facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for a resident with a history of orthopedic surgery and a surgical wound infection. The resident had been admitted with severe sepsis secondary to a right ankle wound infection, had undergone multiple surgeries, and was receiving ongoing wound care and antibiotics. Facility policy and CMS guidance both required the use of gown and gloves for high-contact care activities, such as wound care for residents with unhealed surgical wounds. Despite signage indicating EBP requirements, a registered nurse performed a dressing change using only gloves and did not wear a gown. The nurse confirmed after the procedure that she did not wear a gown and stated that the resident was not on EBP precautions, despite the presence of unhealed surgical wounds and posted signage. Review of facility policy and the CMS QSO-24-08-NH memo confirmed that EBP, including gown and glove use, was indicated for residents with chronic or unhealed surgical wounds. This incident was identified as a deficiency and was also noted as evidence of continued non-compliance from a previous survey.
Failure to Label and Store Food Items Properly
Penalty
Summary
Surveyors observed multiple instances of improper food labeling and storage throughout the facility. In the walk-in refrigerator, there was an undated jar of minced garlic, three open and undated deli sandwiches, and an open, undated package of deli meat. In the pantry, an undated half bottle of orange concentrated syrup and a large open, undated bag of crackers were found. Additionally, in the kitchen serving area, four large bags of chips were open and undated. These findings were confirmed by the Dietary Manager during interviews. The facility's policy requires all perishable food to be stored in a manner that optimizes food safety and quality, including labeling and dating opened food items, which was not followed in these instances. All residents in the facility, except for one who was nothing by mouth, were affected by these deficiencies, as the improper storage and labeling of food items could impact the safety and quality of food served.
Inadequate Diagnosis and Monitoring for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident had an appropriate diagnosis for the use of psychotropic medications and did not adequately monitor the resident's behaviors. The resident, who had diagnoses including dementia with psychotic disturbance, anxiety disorder, and major depressive disorder, was prescribed an antipsychotic (Quetiapine) for crying and restlessness related to dementia. However, documentation showed minimal recorded behaviors, with only two instances of restlessness noted by nursing staff and no behaviors documented by nurse aides over a one-month period. Progress notes were repetitive and lacked specific details about the resident's behaviors, such as wandering or taking items, despite these being described as regular occurrences. Observations confirmed that the resident was frequently wandering the unit, but this behavior was not consistently documented in the medical record. Interviews with facility staff verified that the antipsychotic was prescribed for dementia, which was not considered an appropriate diagnosis for such medication, and that behavior monitoring was insufficient. The lack of accurate and thorough documentation, as well as the use of psychotropic medication without a proper diagnosis, contributed to the deficiency identified during the survey.
Failure to Update PASARR Following Changes in Mental Health Diagnoses
Penalty
Summary
The facility failed to notify the state of changes in mental health diagnoses for two residents, as required by the Preadmission Screening and Resident Review (PASARR) process. One resident was admitted with multiple diagnoses, including dementia, epilepsy, bipolar disorder, and later developed schizoaffective disorder, anxiety disorder, and major depressive disorder. Despite these changes, the last PASARR submission was several years prior and did not reflect the updated diagnoses. Another resident, initially admitted with dementia and other conditions, was later diagnosed with major depressive disorder and anxiety disorder, but the most recent PASARR did not indicate any mental disorders. Interviews with the Regional Director of Social Services and Activities confirmed that PASARR updates were not completed when the residents' diagnoses changed.
Failure to Develop Comprehensive Care Plans for Swallowing Strategies and C-PAP Use
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents in the areas of swallowing strategies and c-pap use. For one resident with a complex medical history including cerebrovascular disease, dysphagia, and dementia, the medical record and speech therapy (ST) assessments recommended specific swallowing strategies such as a pureed diet with thickened liquids, no straws, small bites, and upright posture during meals. However, the resident's care plan did not include these individualized swallowing recommendations, despite documented weight loss and ongoing nutritional concerns. This omission was confirmed by facility staff during interviews. For another resident with multiple diagnoses including obstructive sleep apnea and a history of orthopedic aftercare, the care plan did not address the use of a c-pap machine. There were no physician orders for the c-pap, and observations revealed the c-pap mask was left on the floor under the bed without a protective bag. The absence of a care plan for c-pap use was confirmed by facility staff. Facility policy requires a comprehensive care plan to be developed within 21 days of admission and updated as the resident's condition changes. In both cases, the facility did not ensure that the care plans reflected the residents' current needs and recommendations, as evidenced by the lack of documented swallowing strategies and c-pap use in the respective care plans.
Failure to Provide Daily Wound Care as Ordered
Penalty
Summary
A resident with multiple medical conditions, including multiple pelvic fractures, pustular psoriasis, diabetes mellitus type 2, moderate protein malnutrition, hyperlipidemia, and low back pain, was admitted to the facility and had physician orders for daily wound care to the right dorsal foot and left lower extremity. The orders specified cleansing with in-house wound cleanser, application of SilvaSorb gel, and appropriate dressings to be changed daily and as needed. The resident's care plan also documented the presence of pressure injuries and pustular psoriasis, with interventions in place for wound management. Despite these orders, review of the treatment administration record indicated that wound care was signed as completed on a specific date. However, observations on subsequent days revealed that the dressings on the resident's left foot, left leg, and right foot were dated from a previous day, indicating that the daily wound care had not been performed as ordered. An RN confirmed that the dressings in place were not changed daily as required by the physician's orders, resulting in a failure to provide the prescribed wound care.
Failure to Implement and Monitor Individualized Nutrition Interventions After Significant Weight Loss
Penalty
Summary
The facility failed to develop and implement comprehensive and individualized interventions to prevent significant weight loss for two residents. For one resident with multiple complex medical conditions, including cerebrovascular disease, dysphagia, and dementia, there was a lack of documented evidence that swallowing strategies recommended by speech therapy were incorporated into the care plan. The resident experienced significant weight loss over several months, but weekly weights were not consistently obtained following these losses, and there was no documentation of individualized interventions after further weight decline. Additionally, the intake of nutritional supplements, such as Thrive Gelato, was not monitored, as the facility considered it part of fortified foods rather than a supplement, resulting in a lack of documentation regarding the resident's actual consumption. For another resident with diagnoses including moderate protein-calorie malnutrition and diabetes, there was a documented significant weight loss exceeding 11% in one month. Although the care plan called for weekly weights following significant weight changes, these were not consistently obtained. The dietitian recommended a reweight and an appetite stimulant, but the reweights were not completed, and weekly weights were not continued as required by facility policy. The resident's intake of nutritional supplements was also inconsistent, with documentation showing refusals and varied acceptance, but no further individualized interventions were implemented at the time of the deficiency. Interviews with facility staff, including the RD, DON, and nursing staff, confirmed that the required monitoring and documentation were not performed according to policy. Staff also indicated a lack of awareness or implementation of specific swallowing strategies for the resident with dysphagia, and there was confusion regarding the classification and monitoring of nutritional supplements. The facility's own policy required weekly weights and close monitoring after significant weight loss, but these procedures were not followed for the affected residents.
Failure to Ensure Physician Orders and Documentation for Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not ensuring proper physician orders and documentation for respiratory devices and oxygen therapy. For one resident with chronic obstructive pulmonary disease and other significant health conditions, there was a physician order for continuous oxygen at two liters via nasal cannula as needed, with instructions for nursing staff to check placement and record oxygen concentration every shift. However, the resident's Medication Administration Record (MAR) did not document oxygen use, despite multiple progress notes and observations indicating the resident was receiving oxygen at three liters per minute and wearing oxygen continuously. The program director confirmed the resident wore oxygen most of the time, but this was not reflected in the MAR, and the order was technically as needed, though the resident received it continuously. For another resident with a history of orthopedic aftercare, obstructive sleep apnea, and other comorbidities, there were no physician orders or care plan addressing the use of a CPAP machine. Observations revealed the CPAP mask was stored inappropriately on the floor under the bed without a protective bag. Interviews with the DON and regional nurse confirmed the lack of orders and improper storage. The facility's policy required a physician's order for CPAP/BiPAP devices, including machine settings, and monitoring of the resident's tolerance, but these standards were not met.
Failure to Provide Medical Justification for Declining Pharmacy-Recommended GDRs
Penalty
Summary
The facility failed to ensure that physicians provided clear and medically justified reasons for not implementing pharmacy-recommended gradual dose reductions (GDR) of psychotropic medications for two residents. In both cases, the pharmacist had reviewed the residents' drug regimens and recommended dose reductions based on the absence of documented behaviors and the presence of dementia diagnoses. However, the physicians either declined the recommendations without providing any reasoning or cited non-medical reasons, such as family requests, without further explanation. For one resident with multiple diagnoses including dementia, psychotic disturbance, and major depressive disorder, the pharmacist recommended reducing the dose of Quetiapine on several occasions, but the physician either gave no reason or referenced family wishes for not making changes. Another resident with severe cognitive impairment and several psychiatric diagnoses was also recommended for dose reductions of Duloxetine and Olanzapine, but the physician again declined without providing a medical rationale, sometimes citing resident or family requests. The DON confirmed that GDR recommendations were declined without appropriate medical reasoning.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency was identified when a registered nurse performed wound care on a resident with multiple open wounds, including on the right dorsal foot and left lower extremity, without following Enhanced Barrier Precautions (EBP) as required by both facility policy and CDC guidelines. The nurse acknowledged during the procedure that EBP, specifically the use of gloves and a gown during high-contact resident care activities such as wound care, was not followed. The resident involved had a medical history that included multiple pelvic fractures, repeated falls, generalized pustular psoriasis, and edema. Physician orders directed daily wound care for open wounds, which required cleansing, application of Silvasorb, and appropriate dressings. Despite these orders and the facility's policy, the required personal protective equipment was not used during the observed wound care procedure.
Dish Machine Maintenance Failure
Penalty
Summary
The facility failed to maintain the dish machine in the kitchen in safe operating condition, which had the potential to affect all 74 residents residing in the facility. During an observation, a bright red sign was noted on the dish machine instructing staff not to remove towels placed at its base to prevent water backflow. The Dietary Coordinator confirmed that the dish machine was broken and had been in this condition for at least a month. The facility was using a three-sink hand washing protocol for dishes while awaiting corporate approval for a repair bid submitted by an outside vendor. The Maintenance Coordinator stated that the dish machine had been replaced a year ago and broke down shortly after the warranty expired. The machine had been non-operational for at least four weeks. The Administrator confirmed the breakdown and the expiration of the warranty. A review of the repair bid revealed that several components of the dish machine needed replacement, including the air trap, O-ring, booster heater, booster tank, and drain pump. The proposal for repairs was valid until a specified date but had not yet been signed by the facility.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by staff during meal service, affecting four residents on the Pleasantville Unit. During an observation, a Certified Nursing Assistant (CNA) was seen wearing gloves while delivering meal trays to multiple residents without removing the gloves or performing hand hygiene between each resident. This action was confirmed by a Dietary Coordinator who was present during the meal service and observed the CNA's failure to adhere to the facility's infection control policy. The facility's policy on Room Tray Service, dated November 2017, requires nursing staff to follow infection control protocols, including using hand sanitizer between rooms and washing hands if they touch anything other than the tray. The policy does not recommend wearing gloves during tray service. Additionally, the facility's Hand Washing/Hand Hygiene policy emphasizes that gloves do not replace handwashing and that staff should use an alcohol-based hand rub after contact with inanimate objects in the resident's vicinity. The CNA's actions were not in compliance with these policies, leading to the deficiency.
Deficiency in Dignified Dining Experience Due to Use of Disposable Tableware
Penalty
Summary
The facility failed to provide residents with a dignified dining experience by serving meals on Styrofoam tableware and cups with plastic cutlery. This issue was observed in three residents during meal service and had the potential to affect all 74 residents in the facility. Observations revealed the use of Styrofoam and aluminum trays in the meal preparation area, and interviews with staff and residents confirmed the use of these materials due to a broken dish machine. The dish machine had been out of service for at least a month, and the facility was awaiting corporate approval to fix it. Residents expressed difficulty in eating meals with plastic cutlery, particularly with cutting meat, and one resident was unable to open the aluminum tray on her own. The facility's policy from November 2017 stated that meals should be served on glassware and china or dining ware, which was not being followed. The Administrator confirmed the dish machine had been broken since June 2024 and that the facility had been using disposable dinnerware since then. This deficiency was investigated under Complaint Number OH00159475.
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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) |
|---|---|---|---|---|
| The Springs At Wyandot Trail | 1.4 mi | — | 1 | 0 |
| Buckeye Care And Rehabilitation | 1.7 mi | ★★★★★ | 23 | 0 |
| Main Street Terrace Care Center | 1.9 mi | ★★★★★ | 14 | 0 |
| Luxe Rehabilitation And Care Center | 4.9 mi | ★★★★★ | 3 | 0 |
| Arbors At Carroll | 5.8 mi | ★★★★★ | 1 | 0 |
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