Below average — CMS composite of the measures below.
The next survey window likely opens 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 Avir At Lancaster during CMS and state inspections, most recent first.
A CNA used her personal phone to record residents and posted their images on a public social media account without permission. Surveyors observed photos of three residents with captions referencing memory care, and the CNA's login was visible on the account. One resident who was cognitively intact stated he never gave permission and considered it an invasion of privacy, while two residents with severe cognitive impairment could not meaningfully respond. The DON/Administrator confirmed the images were on the CNA's account, and the facility noted its handbook and resident rights policy prohibit sharing resident images or PHI on social media.
A resident with severe cognitive impairment, multiple comorbidities, and a history of falls was found with a swollen, bruised, and painful right leg and knee during care. A CNA notified an LVN, who assessed the resident and contacted hospice; a hospice RN assessed the resident and obtained a STAT x-ray order, but the x-ray vendor did not arrive as expected. Despite the STAT designation and subsequent instruction to use the facility’s own x-ray provider, the first x-ray was not performed until the next day, revealing a tibia fracture, and a second x-ray later that day showed a right knee fracture. Approximately 33 hours passed from the initial STAT x-ray request to the resident’s transfer to the ER, during which facility staff did not ensure timely completion of the ordered STAT imaging or clearly document follow-up, resulting in delayed diagnosis of the fractures.
A resident with severe cognitive impairment, prior femur fracture, dementia, epilepsy, and other comorbidities was care planned as a fall risk requiring frequent checks, increased supervision in staff-visible areas, and use of a low bed with a fall mat. Despite these interventions, the resident was seen on the floor by a roommate and later found by a CNA with a markedly swollen, painful right leg, screaming on touch, after apparently getting herself up from the floor and back into her wheelchair without staff assistance. The LVN and DON noted swelling, bruising, and twisting of the right knee, and staff acknowledged the resident sometimes got up without help and was occasionally found on the fall mat or in her chair. Although hospice ordered a STAT x-ray after being notified, the imaging was not completed until the next day, revealing fractures of the tibia and right knee, and the resident was not sent to the ER until many hours later. The facility’s investigation and observations showed no obvious environmental tripping hazards but confirmed that the fall was unwitnessed and that staff could not explain how or when the injuries occurred, demonstrating a failure to provide adequate supervision and a safe environment for this high-risk resident.
Failure to Provide Left-Hand Contracture Splint: A resident with severe cognitive impairment, wheelchair use, and a left-hand contracture did not have a splint or other device in place despite an OT plan calling for a hand roll splint for contracture management. Staff across nursing and rehab reported they had not seen the splint or been told the resident needed one, and the DON and ADON stated it was important to prevent worsening of the contracture and skin breakdown. The DOR said the resident was supposed to wear the splint for 2 to 3 hours a day or as tolerated, but she could not locate it in the room.
Kitchen equipment and steam table sanitation were not maintained during lunch meal preparation. A staff member used a food processor/blender with white build-up inside the handle while pureeing food, and pureed trays were placed into steam table compartments containing brown-tinged water and food particles. The DON stated kitchen staff were responsible for cleaning equipment, and records showed the steam table cleaning schedule was not current.
Failure to Care Plan Left Hand Contracture: A resident with severe cognitive impairment, dementia, diabetes, and a seizure disorder had a left hand contracture that was not addressed in the care plan. Although OT documented a splint goal for contracture management, the care plan and physician orders did not include the contracture or measurable interventions, and staff interviews showed the resident was not wearing a splint and nursing staff were unaware of any order or plan for it.
Improper oral feeding attempt for a resident ordered NPO with a feeding tube. A CNA tried to feed a resident regular-texture food even though the resident had a g-tube, was on continuous tube feeding, and had NPO orders due to dysphagia. The resident pushed the CNA's hand away, and the CNA later said she had mixed the resident up with her roommate and should have checked with another staff member after noticing the feeding pump at the bedside.
Expired ondansetron and naproxen were found in the North Hall nurse medication cart during observation. The LVN responsible for checking the cart said she checks it daily but forgot that morning, and the DON said nurses were expected to remove expired meds and nursing mgmt was to monitor this monthly. Training records showed the LVN attended cart-auditing training that included removing expired meds, and the facility policy required outdated meds to be returned to or destroyed per the dispensing pharmacy's instructions.
A resident with cognitive and visual impairments received cash withdrawals from the trust fund without the required witness signature, as mandated by facility policy. The business office manager often dispensed funds without a second staff member present, and several transactions lacked proper documentation. Although the resident was able to account for her money and provide receipts, the facility failed to consistently follow procedures for safeguarding resident funds.
A resident with end stage renal disease and anxiety disorder, who was cognitively intact, did not receive monthly statements of personal funds held by the facility for several months despite requesting them. The Business Office Manager confirmed the absence of statements and could not provide evidence that the required information was given, resulting in the resident lacking knowledge of his account balance.
A resident with dementia and psychiatric diagnoses was physically and allegedly sexually assaulted by another resident with a known history of inappropriate sexual behavior. The assaulted resident was found with bruises and red marks on her neck and reported being choked and touched inappropriately. The perpetrator, also cognitively impaired, denied involvement. The facility had previously identified the perpetrator's behavioral risks but did not maintain enhanced supervision or preventive interventions, and staff had not been fully trained on resident-to-resident abuse prevention at the time of the incident.
The facility failed to deliver mail to residents within the required twenty-four hours, as per their policy. Interviews and observations revealed that residents did not receive mail regularly, with some never receiving it. The AD and BOM confirmed irregular mail distribution, typically once a week, with delays for weekend deliveries. An observation showed undelivered mail from the previous Friday. The ADM was unaware of the current mail policy, leading to potential impacts on residents' well-being.
The facility failed to maintain a safe and clean environment in resident bathrooms, with issues such as grime buildup, missing baseboards, gaps around toilets, and insect presence. Residents reported seeing insects and having holes in their bathroom walls. Staff were aware of these issues, but repairs had not been completed due to time constraints.
The facility failed to meet food safety standards, with issues such as improper thawing of lunch meat, inadequate labeling of food items, and improper storage of raw meat. Open items in refrigerators and freezers were not sealed, and dented cans were not stored properly. The ice machine was unclean, indicating lapses in maintenance. Staff interviews revealed non-compliance with the facility's food service policy.
The facility failed to maintain an effective pest control program, resulting in live roaches and flies in shower rooms and resident rooms. Observations and resident reports indicated the presence of pests, but there was no consistent documentation or reporting in the maintenance log. Staff interviews revealed a lack of awareness and use of a pest sighting log, and pest control visits were not documented beyond July 2024.
A resident with significant mobility impairments suffered a fracture due to an improper transfer by a CNA who was unaware of the resident's need for a mechanical lift. Despite existing protocols and available information on transfer requirements, the CNA attempted a manual transfer, resulting in injury. The incident revealed a failure to adhere to safety procedures and communication lapses within the facility.
The facility failed to protect the personal property of two residents, resulting in the loss of clothing items. One resident with depression and intellectual disabilities lost several clothing items, while another with schizophrenia and dementia was missing shoes, a jacket, and shorts. Staff interviews revealed issues with labeling and returning clothing, and the ADM was unaware of a grievance regarding missing items.
A resident's grievance about missing clothing was not resolved in a timely manner, as required by the facility's policy. The grievance, filed by the resident's family, was not documented or addressed within the specified timeframe, and the grievance log was incomplete. The new administrator was unaware of the issue until the survey and had not contacted the family member who filed the grievance.
A facility failed to complete a mandatory inventory form for a resident with depression and mild intellectual disabilities, leading to incomplete medical records. Staff interviews revealed that the inventory form, which should have been completed upon admission and updated with new items, was missing from the resident's EMR. This oversight could risk the loss of personal items, as the facility's policy required nursing assistants to assist with inventorying residents' personal effects.
The facility failed to store and handle food according to professional standards, as observed in their kitchen and storage areas. Withered and exposed food items were found in the refrigerator, dry storage, and outside freezer. The Dietary Manager acknowledged the responsibility for proper food storage to prevent food-borne illnesses, as per the facility's policy and FDA guidelines.
A facility failed to ensure a resident's advance directive was accurately documented, leading to a discrepancy between the care plan's DNR status and the physician's Full Code orders. Despite procedures to ensure accurate documentation, the resident's end-of-life wishes were not properly reflected in the electronic medical record, risking non-compliance with their preferences.
A facility failed to maintain a homelike environment for a resident with severe cognitive impairment, as a significant hole in the wall of the resident's room went unnoticed by both the Maintenance Supervisor and the Administrator. Despite daily rounds, the need for repair was not identified, violating the facility's policy on providing a safe, clean, and comfortable environment.
A resident with severe cognitive impairment and multiple health conditions experienced weight loss due to the facility's failure to administer the prescribed tube feeding regimen. The resident was supposed to receive two cans of Jevity 1.2 four times a day but was only receiving one can during certain feedings due to reported intolerance, which was not documented or communicated to the physician. This led to a risk of increased weakness and weight loss.
A CNA failed to perform proper hand hygiene while providing incontinent care to a resident, leading to an infection control deficiency. The CNA did not wash hands or change gloves during the care process, despite recent infection control training. The DON confirmed that staff are expected to follow hand hygiene protocols to prevent infection spread.
The facility failed to maintain a safe and comfortable environment due to disrepair of ceiling tiles. Observations revealed a swooping, discolored tile and an unsecured tile in hallways where residents walked. The Maintenance Supervisor was aware of the issues but cited surveyor presence as a barrier to repairs. The Administrator also knew of the needed repairs, expecting prioritization by the Maintenance Supervisor.
Resident Photos Posted on Social Media Without Permission
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of 3 residents when CNA-A used her personal phone to record them and posted their images on a public social media platform without permission from the residents or their representatives. Surveyors observed public social media photos showing Resident #1 smiling toward the camera with a caption referencing memory care, Resident #2 standing in the hallway with a caption about a song bringing back old memories, and Resident #3 standing in the hallway with a walker with a caption about memory care and songs. CNA-A's login identification was visible under the social media logo on the account. Resident #1's record showed he was admitted with diagnoses of paranoid schizophrenia and major depressive disorder and had a BIMS score of 14, indicating he was cognitively intact. During interview, he stated he had not given anyone permission to record him and post it on the internet, and said it would be an invasion of his privacy. Resident #2's record showed diagnoses of intermittent explosive disorder, dementia, and major depressive disorder, with a BIMS score of 06 indicating severe impairment. During attempted interview, she did not respond to questions about the video and repeatedly stated she wanted to go smoke her cigarette. Resident #3's record showed diagnoses of schizophrenia and schizoaffective disorder, with a BIMS score of 03 indicating severe impairment. During attempted interview, she did not respond to questions about the video posted on social media. During telephone interview, CNA-A stated she took pictures of residents and employees while they were dancing during a pizza party, but denied posting residents' pictures on her social media page even after being shown the images from her account. The Administrator stated he was notified that CNA-A had posted photos of residents on social media, reviewed the images, and confirmed CNA-A's face was on the right side of the residents' photos. The ADON stated a CNA had sent her the picture and that she did not notify the Administrator until the next day. The report also included CNA-A's signed acknowledgment of the facility handbook prohibiting uploading resident images or PHI to social media, along with the facility's policy stating residents have a right to privacy and that violations may result in disciplinary action.
Delay in STAT X-ray Completion and Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to provide timely radiology and diagnostic services to meet a resident’s needs after new swelling, bruising, and pain were identified in the resident’s right leg and knee. The resident was an elderly female with traumatic cerebral hemorrhage, a prior left femur fracture, anxiety disorder, hypothyroidism, dementia, and epilepsy, who was severely cognitively impaired and unable to verbally respond, requiring at least supervision or partial assistance for bed mobility and transfers. Her care plan included fall-related interventions such as keeping the bed in the lowest position, use of a fall mat, frequent checks, increased supervision, and evaluation of the environment after falls, as well as monitoring for altered neurological status. On the morning in question, a CNA observed that the resident’s right leg appeared larger than the left and that the resident screamed when her leg was touched during incontinence care. The CNA reported this to an LVN, who assessed the resident and noted swelling, bruising, and a twisted appearance of the right knee and leg. The LVN notified hospice, and the hospice RN came to the facility, assessed the resident, and obtained a STAT x-ray order. The hospice RN then left the facility after calling in the STAT x-ray order. Later that evening, while charting, the hospice RN called the facility and learned that the x-ray technician had not arrived and that the x-ray had not been completed. The hospice RN then instructed facility staff to request x-rays from the facility’s own x-ray provider and sent the STAT x-ray order to the facility. Despite the STAT designation, the first x-ray was not performed until the following morning, approximately 24 hours after the initial STAT x-ray request. That x-ray showed a fractured tibia, and the physician then ordered an additional x-ray of the right knee, which was performed later that afternoon. The repeat x-ray results, received that evening, showed a fractured right knee, and the physician then ordered the resident sent to the ER. In total, about 33 hours elapsed between the original STAT x-ray request and the resident’s transfer to the hospital. Interviews with the DON and LVN indicated that the facility deferred to hospice for treatment decisions for hospice residents, that the facility was responsible for carrying out hospice orders, and that there was no clear documentation of which staff followed up on the delayed x-ray or when. The facility’s own policy required staff to process test requisitions and arrange for tests, and to immediately communicate critical values to the provider, but the STAT x-ray was not obtained or resulted in a timely manner, leading to a delay in diagnosis of the resident’s right femur and right knee fractures.
Unwitnessed Fall and Delayed Diagnostic Response for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe environment and adequate supervision to prevent accidents for a cognitively impaired resident with a history of falls and significant medical conditions. The resident was an elderly female with traumatic cerebral hemorrhage, prior left femur fracture, dementia, epilepsy, anxiety disorder, and hypothyroidism. Her MDS showed severe cognitive impairment (BIMS 00) and functional dependence, requiring at least supervision or touching assistance for bed mobility and partial/moderate assistance for transfers and sit-to-stand. Her care plan, updated after a prior fall beside the bed, identified her as a fall risk and included interventions such as frequent checks at least every two hours, increased supervision by placing her in staff-visible areas, use of a low bed with a fall mat, and evaluation of the environment after falls. Despite these identified risks and interventions, the resident was reported by her roommate to have been seen on the floor on the morning of 04/06/26, with the roommate unsure how she ended up there. The resident reportedly got herself up from the floor and back into her wheelchair without staff assistance. Staff interviews indicated that the resident was known to get on and off the bed without assistance and was sometimes found on the fall mat or in her chair, despite encouragement to ask for help. On the morning of 04/06/26, a CNA discovered that the resident’s right leg was visibly more swollen than the left and that she screamed when her leg was touched during incontinence care. The CNA notified the LVN, who assessed the resident and noted a swollen, bruised, and twisted right knee and leg. The environment around the resident’s bed was observed by the Administrator, DON, and LVN, who all reported seeing a low bed with a fall mat beside it and a wheelchair near the head of the bed, and they stated they did not observe tripping hazards. However, the resident’s care plan called for increased supervision and frequent checks, and staff acknowledged that the resident was a fall risk who sometimes got up without assistance. The facility’s own investigation documented that the resident had been seen on the floor and had then gotten herself back into her wheelchair, yet no staff member could explain when or how the injury occurred. Subsequent x-rays revealed an acute distal femoral fracture and a fractured right knee, consistent with a serious injury following an unwitnessed fall, demonstrating that the resident did not receive adequate supervision to prevent accidents as required by her assessed needs and care plan. In addition to the supervision concerns, there was a significant delay between the initial recognition of the injury and completion of diagnostic imaging and transfer to the hospital. Hospice was notified around midday on 04/06/26 and ordered a STAT x-ray, but the x-ray was not completed until the following morning, approximately 24 hours after the initial request. The first x-ray showed a fractured tibia, and a repeat x-ray later that day showed a fractured right knee. The resident was not sent to the emergency room until that evening, approximately 33 hours after the original x-ray request. During this period, the resident received multiple doses of morphine for pain and shortness of breath. The report identifies that the facility failed to ensure the resident received adequate supervision when she experienced a fall that resulted in fractures to her right thigh and right knee, placing residents at risk for injuries and a decline in health. The facility’s fall management policy identified risk factors such as cognitive impairment and neurological disorders and required staff to monitor and document residents’ responses to fall-prevention interventions and to re-evaluate interventions if falls continued. In this case, the resident had a documented history of falls, severe cognitive impairment, and neurological conditions, and her care plan specified increased supervision and environmental evaluation. Nonetheless, the fall that led to her fractures was unwitnessed, the exact circumstances were unknown to staff, and the resident was able to get herself up from the floor without staff involvement. These facts, combined with the delayed diagnostic response after the injury was identified, form the basis of the cited deficiency for failure to maintain a safe environment and provide adequate supervision to prevent accidents.
Failure to Provide Left-Hand Contracture Splint
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. Resident #44 was a male with diagnoses including diabetes, non-Alzheimer's dementia, and seizure disorder, and his quarterly MDS reflected a BIMS score of 3, indicating severely impaired cognition. The MDS also reflected that he used a manual wheelchair and had impairment on one side of the upper extremity and impairment on both sides of the lower extremities. Record review showed the resident's care plan identified self-care deficits and the need for assistance with ADLs, including bathing/hygiene with two staff, and included consultation with PT, OT, and ST as needed. An OT evaluation and plan of treatment documented a goal for the resident to maintain left hand ROM through use of a hand roll splint for contracture management. However, review of the resident's monthly physician orders for January 2026 showed no order in place for left hand contracture management or use of a splint. During observation on 01/13/26, the resident was in his wheelchair in the day room playing with a puzzle and had a left-hand contracture with no device in place. He was able to slowly open his fingers enough to show there were no skin issues or odors in the contracted hand, and he stated he had never had a device for the contracture. Staff interviews reflected that CNA A, LVN B, LVN C, the ADON, and the DON had not seen a splint on the resident's hand, and several stated they had not been told he needed one. The Director of Rehab stated the resident had a splint for the left-hand contracture and was supposed to wear it 2 to 3 hours a day or as tolerated if there was no pain or skin issues, but she could not recall the last time she saw him wearing it and could not locate it in the room. The facility policy on contracture management stated that splints, braces, therapeutic modalities, and nursing/therapy coordination were part of contracture management.
Kitchen Equipment and Steam Table Not Kept Clean
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during kitchen sanitation observations. During lunch meal preparation, a staff member pureed sweet potatoes, greens, and ham using a food processor/blender whose see-through handle had a white build-up inside it. The staff member stated the handle could be removed for cleaning but had not had time to clean it, and the Dietary Manager stated she was aware of how the handle looked and had ordered a new food processor about 2 weeks earlier. The kitchen steam table also had five compartments, and the last two compartments on the right contained a few inches of brown-tinged water with food particles at the bottom and floating in the water. The staff member placed pureed lunch trays into these dirty steam table compartments. During interview, she stated she noticed the dirty water while placing cooked food for lunch service and said it was the Cook's responsibility to clean the steam tables after every meal. The Dietary Manager stated the steam tables were wiped down after every meal and deep cleaned monthly, and that the water was emptied daily, but she could not recall the exact date it was last emptied. Facility records showed the steam table was last cleaned on Tuesday and the monthly degrease and polish was completed in December 2025.
Failure to Care Plan Left Hand Contracture
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #44 that included measurable objectives and timeframes to address his left hand contracture. The resident’s quarterly MDS reflected severe cognitive impairment with a BIMS score of 3, use of a manual wheelchair, and impairment to both lower extremities and one upper extremity. His care plan, last edited on 09/01/25, addressed self-care deficits and assistance with ADLs, including bathing/hygiene with two staff, and noted PT, OT, and ST as needed, but it did not address the left hand contracture or any interventions for it. Record review showed an OT evaluation and plan of treatment dated 06/18/25 from the previous therapist that included a goal for the resident to maintain left hand ROM using a hand roll splint for contracture management. However, the monthly physician orders for January 2026 did not address the left hand contracture or any contracture management device. During observation on 01/13/26, the resident was in a wheelchair in the day room working on a puzzle; his left hand was contracted and he did not have a contracture management device in place. He was able to slowly open his fingers enough to show no skin issues or odors in the hand, and he stated he had never had a device in place for the contracture. Staff interviews reflected inconsistent awareness of the resident’s contracture management needs. A CNA stated he had never seen the resident wear a device, though the resident would allow staff to clean inside his hand. The Director of Rehab stated the resident had a splint for the left hand contracture and was supposed to wear it for 2 to 3 hours a day or as tolerated if there was no pain or skin issues, but she was unsure who was responsible for applying it and could not locate it in the room. Multiple nursing staff stated they had never seen the resident with a splint and had not been told he needed one. The DON, ADON, and MDS Nurse each stated they were not aware the resident lacked a care plan for the contracture, and the MDS Nurse stated that if the resident had a contracture, there should have been a care plan. The facility policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident.
Improper oral feeding attempt for a resident ordered NPO with a feeding tube
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for Resident #8, a female resident with diagnoses including heart failure, diabetes, non-Alzheimer's dementia, and schizophrenia. Her quarterly MDS reflected long- and short-term memory impairment and that she was on a feeding tube. Her care plan stated she was NPO due to oropharyngeal dysphagia, with bolus/continuous feeding per schedule and NPO diet orders, and her monthly order summary reflected NPO diet, NPO texture, NPO consistency, and continuous tube feeding from 7 PM to 7 AM. During observation, CNA E had a tray of regular-texture food on the resident's nightstand and was trying to feed Resident #8, who pushed the CNA's hand away. A feeding pump was present at the bedside and was turned off. CNA E stated she had also tried to feed the resident the day before and later said she had mixed up Resident #8 with her roommate and should have checked with another staff member because she noticed the feeding pump. Interviews with LVN B, LVN C, the ADON, and the DON confirmed Resident #8 was NPO and had a feeding tube, and staff stated there was a risk of aspiration if the resident ate solid food. The facility policy on enteral nutrition stated adequate nutrition support through enteral feeding would be provided as ordered.
Expired Medications Left in Nurse Medication Cart
Penalty
Summary
The facility failed to ensure all drugs and biologicals were stored securely and had acceptable labeling for 1 of 3 medication carts reviewed, the North Hall nurse medication cart. During observation on 01/14/2026 at 8:26 AM, the North Hall nurse medication cart contained 30 tablets of ondansetron 4 mg with an expiry date of December 2025 and 29 tablets of naproxen 250 mg with an expiry date of December 2025. During interview on 01/14/2026 at 8:40 AM, the LVN responsible for checking the cart for expired medications stated she checked the cart daily but had forgotten to check it that morning. She stated she had received training on checking carts for expired medications but could not recall when. On 01/15/2026 at 3:37 PM, the DON stated nursing staff were expected to check their carts often and remove expired medications, and that nursing management was responsible for monitoring this monthly. She stated the last cart check was on 01/12/26 and thought those medications had been missed. Record review showed the facility's 10/27/25 training on auditing carts included that expired medications should be removed from nurses' carts, and the LVN was in attendance. The facility's Medication Storage policy dated February 2023 stated that discontinued, outdated, or deteriorated medications or biologicals should be returned to or destroyed per instructions from the dispensing pharmacy.
Failure to Follow Policy for Resident Trust Fund Disbursements
Penalty
Summary
The facility failed to properly safeguard and manage the personal funds of a resident by not following its own policy requiring two staff signatures when cash was disbursed from the resident trust fund. Multiple withdrawals were made for one resident, each signed only by the resident and lacking the required witness signature. The facility's policy specifically mandates that when a resident cannot sign to approve a withdrawal, a witness signature is required, and the witness must not be the person responsible for accounting for the funds, their supervisor, or the individual accepting the withdrawn funds. However, review of the trust fund petty cash logs revealed several instances where cash was withdrawn and only the business office manager's (BOM) signature was present, with no witness signature documented. The resident involved had a history of schizoaffective disorder, bipolar disorder, cataracts, choroidal atrophy, transient visual loss, and major depressive disorder. The resident was assessed as having impaired vision and a BIMS score indicating moderate cognitive impairment. Interviews with the resident confirmed that she regularly requested and received varying amounts of cash, which she kept in her possession and used for personal purchases. The resident was able to account for her money and provided receipts for some purchases, but discrepancies in the amounts withdrawn and the amounts reportedly received were noted during the investigation. Interviews with facility and corporate staff confirmed that the BOM did not consistently follow the required procedure for cash disbursement, as some transactions had witnesses while others did not. The issue was identified during a corporate audit, which led to further review of the records. Although the facility and corporate staff did not find evidence of missing funds, the lack of adherence to the required process for safeguarding resident funds constituted a deficiency in the facility's management of resident trust funds.
Failure to Provide Resident with Timely Personal Fund Statements
Penalty
Summary
The facility failed to provide a resident with timely and requested statements of personal funds held in trust by the facility. Specifically, a male resident with end stage renal disease and an anxiety disorder, who was cognitively intact as indicated by a BIMS score of 14, had not received account statements from July through September, despite requesting them. The resident reported not receiving a statement since July until the new Business Office Manager (BOM) provided one in late October. The BOM confirmed that the resident had requested a printout of his account statements and acknowledged the importance of providing monthly and quarterly statements to residents with trust funds, but could not provide evidence that the requested statements had been given for the months in question. Interviews with the BOM and the Administrator (ADM) revealed that both were recently hired and, upon learning of the deficiency, ensured that residents received their most recent statements. However, prior to their employment, the facility did not provide the required monthly statements or respond to the resident's requests for account information. The facility's failure to provide these statements as required by policy and upon resident request resulted in the resident lacking knowledge of his account balance for several months.
Failure to Prevent Resident-to-Resident Abuse Resulting in Physical and Alleged Sexual Assault
Penalty
Summary
The facility failed to protect a resident from abuse, neglect, and exploitation when another resident physically and allegedly sexually assaulted her. The incident involved a female resident with a history of non-Alzheimer's dementia, anxiety disorder, depression, and schizophrenia, who was found with multiple bruises and red marks on her neck. She reported that a male resident had entered her room, attempted to touch her inappropriately, and later, in a common area, choked and sucked on her neck. The male resident, who also had non-Alzheimer's dementia and a prior history of inappropriate sexual behavior, denied any involvement and was unable to provide details due to cognitive impairment. The male resident's care plan had previously identified a risk for inappropriate sexual behaviors, including an incident months earlier where he kissed another female resident. Despite this, there was no evidence of ongoing enhanced supervision or interventions to prevent further incidents, and staff did not observe or anticipate any further behaviors from him. On the day of the incident, staff discovered the injuries after dinner when the female resident was in the TV room with the male resident and another resident. Upon questioning, the female resident identified the male resident as the perpetrator, and her account was consistent with her injuries. Staff interviews confirmed that the residents were often together in common areas and that the male resident had not previously exhibited such behaviors since the earlier incident. The deficiency was identified because the facility did not ensure all residents were free from abuse, as required. The staff had not been fully trained on resident-to-resident abuse prevention at the time of the incident, and the male resident's prior behavioral risks were not adequately addressed to prevent recurrence. The failure to implement sufficient preventive measures and staff training placed residents at risk for abuse.
Failure to Ensure Timely Mail Delivery to Residents
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods, specifically regarding the delivery of mail. Observations, interviews, and record reviews revealed that 7 out of 55 residents did not receive their mail in a timely manner, as per the facility's policy. During a confidential group interview, all 7 residents reported that mail was not distributed regularly, with 6 stating they never received mail. The facility's policy required mail to be delivered within twenty-four hours of arrival, but this was not adhered to. Interviews with the Assistant Director (AD) and Business Office Manager (BOM) revealed inconsistencies in mail distribution practices. The AD stated that mail was delivered once a week without a specific schedule, while the BOM confirmed that mail was typically delivered on Wednesdays. Mail delivered on weekends was not sorted until Monday, leading to delays. An observation of a storage tote revealed undelivered mail from the previous Friday. The Administrator (ADM) expressed expectations for more frequent mail delivery but was unsure of the current policy. The facility's failure to deliver mail promptly could impact residents' psychosocial well-being and quality of life.
Environmental Deficiencies in Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in resident bathrooms on two of the four halls reviewed. Observations revealed significant issues in the bathrooms of several residents, including discolored floors with grime buildup, missing baseboards, gaps between the floor and toilet, and the presence of live roaches. Additionally, a sticky brown substance was found seeping between tiles in one bathroom, and residents reported seeing insects and having holes in their bathroom walls. These conditions were confirmed through interviews with residents and staff, who acknowledged the cleanliness and repair issues. The facility's administration and staff were aware of the environmental deficiencies, as indicated by interviews with the Administrator, Housekeeping Manager, and Maintenance Supervisor. The Administrator acknowledged the importance of maintaining a clean facility and mentioned ongoing refurbishment efforts. The Housekeeping Manager and Maintenance Supervisor both noted that they were informed of repair needs through staff reports and a maintenance log book. However, the Maintenance Supervisor admitted to being aware of some issues but had not yet addressed them, citing time constraints. The facility's policy on providing a homelike environment was not adhered to, as evidenced by the observations and resident complaints.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their only kitchen. Several deficiencies were noted, including improper thawing of food, inadequate labeling of food items, and improper storage of raw meat. Specifically, lunch meat was found thawing at room temperature in the kitchen sink, which is against the recommended practice of thawing under cold running water or in a cooler. Additionally, food items in the refrigerators were not labeled with necessary information such as item description, preparation date, open date, or expiration date. Raw meat was stored on the top shelf above dairy products, increasing the risk of cross-contamination. Further observations revealed that open items in the refrigerators and freezers were not sealed properly, exposing them to air. This included a large bag of sliced ham, grated parmesan cheese, pork hotdogs, breadsticks, peanut butter cookie dough, churros, cheese and garlic biscuit dough, and pie dough. The facility also failed to store dented cans in a designated area, with dented cans of pinto beans and cheddar cheese sauce found in the dry storage area. These practices could potentially lead to food-borne illnesses and cross-contamination among residents. The facility's ice machine was found to be unclean, with pink and black buildup along the inner guard, indicating a lack of regular maintenance. Interviews with staff members revealed a lack of adherence to the facility's Nutrition & Foodservice Policy, which outlines proper food storage, labeling, and sanitation practices. The staff acknowledged the importance of these practices in preventing illnesses but admitted to lapses in following them, such as not cleaning the ice machine weekly as required.
Deficient Pest Control Program Leads to Roach and Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live roaches and flies in various areas, including two shower rooms and two resident rooms. Observations revealed live roaches in the South Shower Room and a resident's bathroom, as well as a significant number of live flies in the North Shower Room. Residents reported seeing roaches and flies in their rooms and bathrooms, and some had informed staff about these sightings. However, there was no consistent documentation or reporting of these pest sightings in the maintenance log, which was supposed to be used for such purposes. Interviews with staff, including the Assistant Director of Nursing (ADON), Licensed Vocational Nurse (LVN), Certified Nursing Assistant (CNA), and the Maintenance Supervisor, revealed a lack of awareness and use of a pest sighting log. The Maintenance Supervisor stated that the pest control company was contracted to visit the facility monthly, but there were no recent entries in the maintenance log regarding pest sightings, and receipts for pest control visits were only available up to July 2024. The facility's policy on pest control, revised in July 2013, indicated an ongoing pest control program, but the lack of documentation and communication among staff suggests deficiencies in its implementation.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment for Resident #22, who required substantial assistance for transfers due to multiple medical conditions, including a cerebral infarction and a displaced fracture of the right humerus. The resident's care plan specified the need for a mechanical lift with two-person assistance for transfers. However, CNA O attempted to transfer the resident without the necessary equipment or assistance, resulting in a fracture of the resident's right humerus. CNA O was not assigned to the hallway where Resident #22 resided and was unaware of the resident's transfer requirements. Despite the availability of resident profiles and lists indicating the need for mechanical lifts, CNA O proceeded with a manual transfer, which led to the resident's injury. The incident was reported to the charge nurse, and an x-ray confirmed the fracture. Interviews with staff revealed that CNA O was asked to assist with changing the resident but was not supposed to perform the transfer. The facility had policies in place for safe handling and transfer practices, but these were not followed in this instance, leading to the deficiency. The incident highlighted a lack of communication and adherence to established protocols for resident safety.
Failure to Protect Residents' Personal Property
Penalty
Summary
The facility failed to protect the personal property of two residents, leading to the loss of clothing items. Resident #13, who had a history of depression and mild intellectual disabilities, was missing several items of clothing, including Dickies pants and coveralls, socks, and a gray pant suit. The resident's care plan indicated a need for assistance with dressing, and the admission packet stated the facility's responsibility to safeguard personal property. Despite these measures, the resident's closet was found empty except for one unnamed T-shirt, and attempts to contact the family were unsuccessful. Resident #87, diagnosed with schizophrenia and dementia, also experienced a loss of personal clothing, including shoes, a jacket, and shorts. The resident's care plan emphasized the need for proper fitting and appropriate foot attire. Observations revealed a lack of labeled clothing in the resident's closet, and the family had previously complained about missing items. Interviews with staff indicated that clothing was often misplaced or delivered to the wrong rooms, and there was a lack of consistent labeling of clothing items. The facility's policies required nursing staff to label residents' clothing upon admission, but this was not consistently enforced. Interviews with various staff members, including housekeepers, CNAs, and the DON, highlighted a lack of clear responsibility for labeling and returning clothing to the correct residents. The ADM was unaware of a grievance regarding missing clothing until much later, and there was no grievance log for the relevant period. This lack of coordination and communication contributed to the ongoing issue of missing personal property for residents.
Failure to Resolve Resident Grievance Regarding Missing Clothing
Penalty
Summary
The facility failed to resolve a grievance for a resident, as documented in a report based on interviews and record reviews. The grievance, filed by the resident's responsible party, stated that the resident was missing several items of clothing, including pants, overalls, a sweat pant suit, and socks. Despite the facility's policy requiring grievances to be addressed within three working days, there was no documentation of efforts to resolve this grievance, and the grievance log for the month in question was incomplete. The resident in question was not available for interview or observation during the survey, and attempts to contact the family were unsuccessful. The newly appointed administrator, who had been in the position for only two weeks, was unaware of the grievance until the surveyor's inquiry. The administrator acknowledged the oversight and noted that some of the resident's clothing had been found, but the family member who filed the grievance had not yet been contacted. The facility's grievance policy mandates prompt resolution of grievances, which was not adhered to in this case.
Incomplete Medical Records and Inventory Form
Penalty
Summary
The facility failed to ensure that the medical records for a resident were complete and accurately documented according to accepted professional standards. Specifically, the facility did not complete the inventory form for a resident who was admitted with diagnoses of depression and mild intellectual disabilities. The resident's medical records, including the face sheet and care plan, indicated that the resident had moderately impaired cognition and required assistance with dressing. However, during a review, it was found that the inventory form, which should have been completed upon admission and updated with any new items, was missing from the resident's electronic medical record (EMR). Interviews with facility staff, including an LVN, the ADON, and the DON, revealed that the inventory form was a mandatory document to be completed upon admission and updated as needed. The staff acknowledged that the inventory form was not located in the EMR for the resident in question. The facility's policy required nursing assistants to assist with inventorying residents' personal effects, but the process was not followed, leading to the potential risk of residents' personal items being misplaced or lost.
Facility Fails to Maintain Proper Food Storage Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During an inspection, it was noted that the facility's refrigerator contained withered tomatoes with white spots, red bell peppers with a brownish-black spot, and an open bag of turkey exposed to air. In the dry storage area, an open bag of macaroni pasta and an open box of fish fry product were found exposed to air. Additionally, the prep table had a box of quick minute grits open and exposed to air. Further observations in the facility's outside freezer revealed a roll and an ice cream cup on the floor, along with several open and exposed food items, including boxes of frozen dough sheets, sweet roll dough, beef patties, a bag of veggie blend, and a box of fries. The Dietary Manager confirmed that she and the dietary cooks were responsible for ensuring proper food storage and acknowledged the importance of preventing food spoilage and exposure to air to avoid food-borne illnesses. The facility's policy on food storage, dated 2018, and the FDA Food Code, dated 2017, emphasize the need for food to be stored in a clean, dry location, protected from contamination.
Failure to Document Resident's Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was honored, specifically for a resident with multiple medical diagnoses including dementia, pruritus, local infection, pain, and other conditions. The resident's care plan indicated a Do Not Resuscitate (DNR) status, but the physician's orders reflected a Full Code status, indicating a discrepancy in the documentation of the resident's end-of-life wishes. This inconsistency placed the resident at risk of not having their end-of-life preferences respected. Interviews with the Director of Nursing (DON) and the facility Medical Director revealed that the facility had procedures in place to ensure code status was documented accurately, including reviewing code status during Standard of Care meetings and maintaining an Advanced Directive binder at the nurse's station. However, the failure to update and document the resident's code status in the physician's orders demonstrated a lapse in these procedures. The resident's Out of Hospital Do Not Resuscitate (OOH-DNR) Order form was completed by the resident's Power of Attorney and signed by a notary and the resident's physician, yet this was not reflected in the electronic medical record.
Facility Fails to Maintain Homelike Environment for Resident
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, specifically regarding the condition of the resident's room. The resident, who was severely cognitively impaired with a BIMS score of 0 out of 15, had a hole in the wall above the baseboard in her room. This hole was approximately 1 foot long and 6 inches wide. The resident appeared confused and did not respond to the surveyor's questions during the observation. The Maintenance Supervisor, responsible for facility repairs, was unaware of the hole in the wall and did not know how long it had been there. Despite making daily rounds, the Maintenance Supervisor had not identified the need for repair in the resident's room. The Administrator, who also makes rounds and relies on the Maintenance Supervisor to inform her of needed repairs, was not aware of the issue either. The facility's policy on providing a homelike environment was not adhered to in this instance, as the hole in the wall did not create a homelike environment for the resident.
Failure to Administer Prescribed Tube Feeding
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, identified as Resident #17, who was severely cognitively impaired and required tube feeding. The resident's care plan indicated a need for enteral feeding with Jevity 1.2, administered as a bolus of two cans four times a day, totaling eight cans daily. However, the resident was only receiving one can during the 6:00 AM and 12:00 PM feedings due to reported intolerance, which was not documented. This deviation from the prescribed feeding regimen was not communicated to the physician or documented, leading to a risk of increased weakness and weight loss for the resident. The resident's weight had been steadily declining from 193 lbs in April to 174 lbs in September, indicating a failure to maintain nutritional status. Interviews with the LVN and DON revealed a lack of communication and documentation regarding the resident's feeding intolerance and the deviation from the prescribed feeding schedule. The physician was unaware of the changes in the feeding regimen, and the facility's policy on reporting significant weight changes was not followed. This oversight placed the resident at risk of health complications related to nutrition and hydration.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as observed during a survey. A Certified Nursing Assistant (CNA B) was seen assisting a resident with incontinent care without performing proper hand hygiene. Specifically, CNA B did not wash her hands or change gloves while assisting the resident in the toilet. The CNA gloved without hand hygiene, assisted the resident with clothing, and cleaned the resident's bottom area without changing gloves or washing hands. Afterward, CNA B continued to touch various surfaces, including the sink and soap dispenser, with the same gloves, before finally removing the gloves and performing hand hygiene. In an interview, CNA B admitted to not completing hand hygiene due to being in a hurry, despite having received infection control training two weeks prior. The Director of Nursing (DON), who also serves as the Infection Preventionist, stated that staff are in-serviced monthly on infection control and are expected to follow the facility's policy, which requires hand hygiene before donning gloves and after providing resident care. The facility's policy emphasizes hand hygiene as the primary means to prevent the spread of infections.
Ceiling Tile Disrepair Compromises Safety and Comfort
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by the condition of ceiling tiles throughout the facility. During an observation, a ceiling tile in one of the hallways was found to be swooping and discolored with a yellowish-brown spot, while another tile in a different hallway was unsecured. Residents were observed walking beneath these compromised tiles, indicating a potential risk to their safety and quality of life. Interviews with the Maintenance Supervisor and the Administrator revealed awareness of the ceiling tile issues. The Maintenance Supervisor acknowledged responsibility for facility repairs and admitted knowledge of the swooping and discolored tile since a few days prior to the observation. However, he was unaware of the unsecured tile and cited the presence of state surveyors as a reason for not obtaining materials to make repairs. The Administrator confirmed awareness of the needed repairs and stated that both she and the Maintenance Supervisor conduct rounds to identify such issues, with an expectation for the Maintenance Supervisor to prioritize repairs. The facility's policy emphasizes providing a safe, clean, and homelike environment, which was not upheld in this instance.
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What surveyors actually found near you
We read the 831 citations issued within 25 miles in the last 12 months — including the 43 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lancaster Nursing & Rehabilitation | 0.3 mi | ★★★★★ | 2 | 0 |
| Millbrook Healthcare And Rehabilitation Center | 1.7 mi | ★★★★★ | 5 | 0 |
| Windsor Gardens | 2.5 mi | ★★★★★ | 14 | 0 |
| Desoto Nursing & Rehabilitation Center | 5.2 mi | ★★★★★ | 15 | 1 |
| Five Points Nursing And Rehabilitation | 5.4 mi | ★★★★★ | 6 | 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.