Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Lancaster Nursing & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain accurate postings of state agency and advocacy group contact information, including the State Survey Agency. Multiple wall postings still referenced the dissolved Texas Department of Aging and Disability Services (DADS), listed a nonfunctional DADS website, and did not identify HHSC as the current pertinent agency, although the phone number connected to HHSC complaint and incident intake. The Administrator reported she had not reviewed the postings since starting several months earlier, was unsure how to identify outdated materials, believed the outdated agency name did not matter as long as the phone number was correct, and confirmed there was no facility policy governing postings.
A resident with mental illness and intellectual disabilities did not have a care plan for PASARR services, and the facility failed to submit a required request for nursing facility specialized services (NFSS) in the LTC Online Portal after the IDT meeting. Staff interviews revealed a lack of awareness about the PASARR process and the resident's service needs, resulting in incomplete coordination and documentation as required by facility policy.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with multiple complex medical conditions was sent to the emergency room at the request of a family member, but the nurse on duty did not complete the required transfer/discharge documentation as mandated by facility policy. Staff interviews and record review confirmed that the necessary forms were not provided to EMS, resulting in the resident being transferred without essential medical information.
A long-term care facility failed to provide sufficient nursing staff, affecting two residents' care. One resident missed scheduled showers and experienced long call light response times, while another faced similar delays due to reduced staffing. The facility decreased CNA numbers for budgetary reasons, leading to complaints about care quality and timeliness.
A resident with moderate cognitive impairment and dependency on staff for bathing did not receive scheduled showers consistently, as observed in February 2025. The DON acknowledged the issue, citing potential staffing problems, and attempts to contact the responsible CNA were unsuccessful.
The facility did not inform residents or their representatives on how to file grievances anonymously and failed to identify the Grievance Official. Interviews with residents and staff revealed a lack of awareness and resources for filing grievances, contradicting the facility's grievance policy.
A resident with severe cognitive impairment was involuntarily secluded in a memory care unit for staff convenience, despite her care plan not including such a provision. The resident was moved to the unit by an RN for closer monitoring due to fall risk, but was observed seated in the same place over two days, with her family unaware of the situation. The DON confirmed this constituted a physical restraint, as there was no order for it, violating the resident's rights.
A resident with severe cognitive impairment and multiple diagnoses was inappropriately prescribed both Clonazepam and Lorazepam, two benzodiazepines, without adequate justification. The facility failed to ensure the necessity of these medications, leading to potential risks of adverse side effects and unnecessary medication use. The physician acknowledged the issue and planned to adjust the orders.
A LTC facility failed to maintain an effective infection control program, impacting five residents. A resident on enhanced barrier precautions lacked proper signage and PPE. An LVN did not perform hand hygiene or clean a blood pressure cuff between uses for two residents. A CNA failed to change gloves or perform hand hygiene during incontinence care. Another LVN did not wear appropriate PPE during wound care for a resident with a stage IV pressure ulcer.
The facility failed to provide activities based on comprehensive assessments and care plans for two residents on the secured unit, leading to a deficiency in meeting their physical, mental, and psychosocial well-being needs. Observations revealed that scheduled activities were not consistently provided, and residents were often left without engagement. Interviews indicated unclear responsibilities for activity provision, with the Activity Director creating the calendar but relying on nursing staff to implement it. This deficiency placed residents at risk of decreased quality of life.
A resident with severe cognitive impairment disposed of a lit cigarette in a regular trashcan, contrary to the facility's smoking policy. Additionally, the secured unit was left unsupervised due to a lapse in staff communication, leaving residents without adequate supervision.
A resident with dementia and diabetes was found in a room with a dirty bedside table and a torn mattress, causing discomfort. The Housekeeping Director admitted the mattress had been torn since his employment began and was not reported. The DON stated the mattress was damaged from bed baths, and a new one was ordered, but no receipt was provided. The facility's policy requires daily cleaning, which was not followed.
A resident with severe cognitive impairment sustained a head injury requiring hospital treatment, but the incident was not reported to the State Agency as required. Interviews with the DON and Administrator revealed uncertainty about the lack of reporting, despite facility policy mandating immediate reporting of such incidents.
A resident with severe cognitive impairment sustained a head injury of unknown origin, and the facility failed to conduct a thorough investigation. Despite evidence suggesting the resident hit their head on a dresser, no formal investigation was documented, and the incident was not reported until prompted by a surveyor. This failure to follow protocol could place residents at risk.
A resident with Alzheimer's and coordination issues did not receive scheduled bathing care due to a misunderstanding by a CNA, who took the resident's request to "wait a minute" as a refusal. The resident was observed in soiled clothing and expressed a desire for a shower. The DON stated staff should encourage participation in ADLs and not consider such requests as refusals.
A resident with severe cognitive impairment and dysphagia was found with intact pills in his mouth, unable to swallow them, due to a nurse's failure to observe the medication administration process. This oversight posed a choking risk, as the facility's policy requires ensuring medications are swallowed.
The facility failed to submit complete and accurate staffing information to CMS for five consecutive quarters, missing RN coverage data for specific dates. The current Administrator, who took over after a management change, lacked access to prior submission evidence. A policy on PBJ submissions was requested but not provided.
A resident with severe cognitive impairment eloped from a secured unit due to inadequate supervision and a malfunctioning door that did not consistently close and lock. Staff were aware of the door issue but failed to ensure it was addressed, and the charge nurse did not respond to the door alarm. The resident was found 2.6 miles away the next day.
The facility failed to provide adequate staffing on the secured unit, resulting in a resident with severe cognitive impairment eloping from the facility. The staffing pattern assigned one nurse and one CNA to both the secured unit and other areas, leading to periods when no staff were present on the secured unit. This deficiency placed residents at risk of harm.
A resident with a full code status was found unresponsive, and CPR along with an AED was used. However, the use of the AED was not documented in the resident's medical record, contrary to the facility's policy. Staff interviews confirmed the AED's use, but the LVN forgot to document it due to the emergency's urgency.
The facility failed to update a resident's comprehensive care plan to include the family member's involvement in measuring food portions and assisting with ADLs without staff assistance. This oversight could place residents at risk of not receiving necessary services and delayed response for assistance.
The facility failed to maintain an infection prevention and control program, as evidenced by blood stains on a resident's sheets and privacy curtain. Despite the resident's need for daily bed sheet changes due to her condition and dialysis treatment, the blood stains were not addressed by the facility staff or communicated by the dialysis nurse, leading to potential cross-contamination and infection risks.
Outdated State Agency Complaint and Posting Information
Penalty
Summary
The facility failed to post an accurate and updated list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, including the State Survey Agency and State licensure office, as required. Surveyors observed multiple postings in public areas that still referenced the Texas Department of Aging and Disability Services (DADS), an agency that dissolved in 2017, instead of the current Health and Human Services Commission (HHSC). One posting titled "How to File a Complaint" stated that DADS hoped individuals were satisfied with care and directed complaints to DADS at a listed phone number and website, and was dated July 2007. Another posting titled "Notice" stated that inspection and survey information by representatives of DADS must be posted for public inspection, listed the DADS website, and was dated June 2006. A third posting regarding "Reporting Reasonable Suspicion of a Crime" listed a contact number for the local police department and a DADS phone number, with no date indicated. A review of the DADS website by surveyors showed that the site was not in service and confirmed that DADS had dissolved in 2017. The phone number listed on the outdated postings was found to be the current complaint and incident intake number for HHSC, but the postings themselves had not been updated to identify HHSC as the pertinent state agency. During interviews, the Administrator stated she had been in the role for four months and had not reviewed the postings since starting. She indicated she was unsure how she would know the postings were outdated and later stated she did not think having outdated postings would affect residents because the phone number was the same and the difference between agencies did not matter. When asked via email, the Administrator confirmed the facility did not have a policy regarding postings.
Failure to Submit PASARR Specialized Services Request in Timely Manner
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program as required, specifically by not submitting a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days after the Interdisciplinary Team (IDT) meeting for one resident. The resident, who was cognitively intact and had diagnoses including seizure disorder, schizophrenia, post-traumatic stress disorder, and mild intellectual disabilities, had a positive PASARR Level 1 screening for mental illness and intellectual disabilities. However, there was no care plan for PASARR services in the resident's comprehensive care plan, and the required NFSS request was not submitted following the IDT meeting. Interviews with facility staff revealed a lack of knowledge regarding the PASARR process and the resident's status. The MDS Nurse was unaware of the required submission timeline and the services the resident should be receiving, while the DON believed the resident was receiving PASARR services but could not explain the failure to submit the necessary documentation. The Regional Reimbursement Nurse confirmed that the NFSS request form had not been submitted and indicated that this omission could prevent the resident from receiving appropriate services. Facility policy required submission of IDT meeting information in the LTC Online Portal, which was not followed in this case.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Complete Required Transfer Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to ensure that a required transfer/discharge form was completed and documented in the medical record when a resident was sent to the emergency room. The resident, an older adult with multiple complex diagnoses including anemia, hypotension, end stage renal disease, malignant neoplasm of the kidney, ulcerative colitis, cerebral infarction, and type 2 diabetes, required extensive assistance with activities of daily living and was on oxygen therapy as needed. On the day of the incident, the resident's family member requested that he be sent to the hospital, and the nurse on duty (RN A) called 911, notified the physician and the DON, but did not complete the required eTransfer form or SBAR form as per facility policy. Interviews with facility staff, including the DON and the administrator, confirmed that the nurse was expected to complete the eTransfer form and provide it, along with other relevant documents, to EMS when a resident is transferred to the hospital. The facility's policies require that a transfer form be completed whenever a resident is sent to the hospital and that all documentation be comprehensive, timely, and properly signed. However, in this instance, the nurse failed to adhere to these policies, resulting in the absence of a completed transfer/discharge form in the resident's medical record. The lack of proper documentation meant that the resident was transferred to the emergency room without the necessary information regarding his medical conditions, medications, and care needs. This omission was identified during record review and confirmed through staff interviews, which acknowledged the failure to follow established procedures for documenting and communicating resident transfers.
Insufficient Staffing Leads to Delayed Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, specifically affecting two residents. One resident, a female with moderate cognitive impairment and hemiplegia, was dependent on staff for activities of daily living (ADL) such as toileting and bathing. Her care plan required extensive assistance for bathing three times a week, but records showed she missed scheduled showers on two occasions. She also reported long wait times for call light responses, which was corroborated by her grievance form. Another resident, a male with central pain syndrome and lack of coordination, required supervision or assistance for ADLs. He reported that the facility had reduced staff, leading to delays in call light responses, sometimes taking up to an hour. He had also filed a grievance about this issue, which remained unresolved. The facility's current staffing pattern showed a reduction in the number of Certified Nursing Assistants (CNAs) per shift, which was confirmed by interviews with staff and administrators. The reduction in staffing was attributed to budgetary reasons and a slight decrease in resident census. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and several CNAs revealed that the decrease in staffing led to complaints from residents, families, and staff about the timeliness and quality of care. The facility did not have a policy related to sufficient staffing, and the interim administrator acknowledged the risk of insufficient staffing, although no adverse effects were reported at the time.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received necessary services to maintain personal hygiene. Specifically, the facility did not consistently provide showers or bed baths for a resident according to the facility's bathing schedule in February 2025. This deficiency was identified through observation, interview, and record review, which revealed that the resident did not receive scheduled showers on two specific dates. The resident, who had moderate cognitive impairment and was dependent on staff for bathing, reported issues with call light response time and receiving scheduled showers. The Director of Nursing acknowledged the issue, attributing it to potential staffing problems. Attempts to contact the responsible CNA for further clarification were unsuccessful, and the facility did not provide a policy related to ADL care upon request.
Failure to Provide Grievance Filing Information
Penalty
Summary
The facility failed to notify residents or their representatives on how to file grievances anonymously and did not provide information on who the Grievance Official was. This deficiency was identified through observations, interviews, and record reviews. During a Resident Council meeting, five residents expressed that they were unaware of how to file grievances or who to contact with their concerns. Additionally, there were no visible grievance forms or containers for submitting grievances observed at the facility's entry. Interviews with staff, including an LVN and the Social Worker, revealed inconsistencies in the grievance process. The LVN mentioned providing forms to residents but was unsure about anonymous submissions, while the Social Worker indicated that grievances should be documented in the electronic medical record system. The DON was unable to identify the Grievance Official and stated that the facility did not maintain a grievance log. The facility's grievance policy, dated November 2016, emphasized the residents' right to voice grievances without fear of reprisal, but the facility did not adhere to this policy by failing to provide necessary information and resources for filing grievances.
Involuntary Seclusion and Restraint of Resident in Memory Care Unit
Penalty
Summary
The facility failed to ensure that a resident in the locked memory care unit was free from involuntary seclusion and physical restraints. The resident, a female with severe cognitive impairment and diagnoses including Alzheimer's disease and heart failure, was moved from Hall 200 to the memory care unit by RN D for closer monitoring due to a risk of falls. However, the resident's care plan did not include a provision for her to be in the secure unit, and she was observed seated in the same place in the memory care unit over two days, not eating at times. Interviews revealed that the resident expressed a preference to stay in her room on Hall 200, and her family was unaware of her being kept in the memory care unit. The Director of Nursing (DON) confirmed that the resident was only supposed to go to the secure unit for meals and that keeping her there constituted a physical restraint, as there was no order for restraints. The facility's policy emphasized the resident's right to be free from involuntary seclusion and physical restraints not required to treat medical symptoms.
Inappropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident who had not previously used psychotropic drugs was not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. The resident, a male with severe cognitive impairment and multiple diagnoses including Alzheimer's Disease, Traumatic Brain Injury, and Schizoaffective Disorder, was prescribed both Clonazepam and Lorazepam, which are benzodiazepines used to treat anxiety. This prescription was made without adequate justification for the use of both medications, leading to a potential risk of adverse side effects and unnecessary medication use. The resident's medication regimen included Clonazepam 0.5 mg three times a day and Lorazepam 1 mg twice a day, with an additional PRN order for Lorazepam 0.5 mg every six hours as needed. The facility's policy requires a monthly medication regimen review by a pharmacist to identify irregularities, but the resident's use of duplicate therapy with benzodiazepines was not adequately addressed. An interview with the physician revealed that the resident was taking both medications for anxiety and aggression, but the physician acknowledged that the resident did not need both and planned to adjust the orders.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, impacting five residents observed for infection control. For one resident on enhanced barrier precautions due to a Foley catheter, the facility did not post proper signage or provide personal protective equipment (PPE) outside the resident's door. This oversight was noted during an observation when the resident was asleep with an open door, and no PPE or signage was present. In another instance, an LVN failed to perform hand hygiene and clean a blood pressure cuff between uses for two residents. The LVN used the same blood pressure cuff on both residents without cleaning it and did not perform hand hygiene before and after administering medications. The LVN acknowledged the importance of these practices in preventing infection but did not adhere to them during the observations. Additionally, a CNA did not perform hand hygiene while providing incontinence care to a resident. The CNA used the same gloves throughout the procedure without changing them or performing hand hygiene after cleaning the resident's soiled areas. Furthermore, an LVN did not don appropriate PPE before providing wound care to a resident with a stage IV pressure ulcer, initially entering the room without a gown despite signage indicating PPE was required. The LVN later acknowledged the need for a gown to protect the resident from potential contamination.
Failure to Provide Appropriate Activities for Residents
Penalty
Summary
The facility failed to provide activities based on the comprehensive assessment and care plan for two residents on the secured unit, leading to a deficiency in meeting their physical, mental, and psychosocial well-being needs. Resident #11, a female with dementia, major depressive disorder, and anxiety, was observed sitting quietly without participating in any activities, despite her care plan indicating a need for activity involvement. She expressed a preference for activities like Bingo, but was not provided with such opportunities. Similarly, Resident #38, a male with a history of traumatic brain injury and severe cognitive impairment, was observed attempting to engage with a coloring activity inappropriately, with no alternative activities offered. The facility's activity calendar listed structured activities for the secured unit, but observations revealed that these activities were not consistently provided. On multiple occasions, residents were found sitting quietly without engagement, and the only activity offered was coloring, which was not suitable for all residents. Interviews with staff, including a CNA and the Activity Director, indicated that the responsibility for providing activities was unclear, with the Activity Director creating the calendar but relying on nursing staff to implement it. The Activity Director acknowledged that structured activities were not consistently provided, and the Director of Nursing was unaware of these issues prior to the survey. The facility's policy on activity program variety emphasized the need for a range of activities to meet residents' needs and interests, including physical, cognitive, creative, social, spiritual, and hobby interests. However, the lack of structured and individualized activities for residents on the secured unit, as observed and reported, demonstrated a failure to adhere to this policy. This deficiency placed residents at risk of decreased quality of life due to isolation, boredom, and lack of engagement.
Inadequate Supervision and Unsafe Smoking Practices
Penalty
Summary
The facility failed to ensure that a resident disposed of his cigarette in a safe manner. On the specified date, a resident with severe cognitive impairment and nicotine dependence was observed smoking a cigarette in the designated smoking area. After finishing, he disposed of the lit cigarette butt in a regular plastic trashcan containing other waste, including paper and plastic, which continued to smoke for approximately 10 minutes. The RN supervising the resident stated that the plastic trashcan was an acceptable place for cigarette disposal, despite the facility's smoking policy requiring the use of designated smoking receptacles made of noncombustible materials. Additionally, the facility did not maintain adequate staffing levels to provide supervision on the secured unit during a specific shift. An observation revealed that no staff members were present on the secured unit, leaving five residents unsupervised in the common area. A CNA assigned to the secured unit left her station to assist a resident elsewhere, assuming coverage would be provided in her absence. The lapse in communication among staff resulted in the secured unit being temporarily without supervision. The facility's administrator acknowledged the expectation for continuous staff presence on the secured unit and identified the communication lapse as the cause of the staffing deficiency. Despite a request, the facility did not provide a policy related to staffing on the secured unit at the time of the survey exit.
Failure to Maintain Clean and Safe Environment for Resident
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for Resident #21, as observed during a survey. Resident #21, a male with dementia and diabetes, was found in a room with a dirty bedside table and a torn mattress. The bedside table had spilled food and drink, and the resident expressed discomfort due to the torn mattress, which he said caused his skin to itch, although he did not have any skin irritations. The resident also mentioned that the staff did not clean the bedside table, and he had not requested them to do so. Interviews with facility staff revealed further issues. The Housekeeping Director, who had been employed since August 2024, acknowledged the mattress had been torn since his employment began but had not reported it. He also stated that the staff were supposed to clean the resident's lap tray table daily, and failure to do so could pose an infection control issue. The DON explained that the mattress was torn due to water damage from bed baths and mentioned that a new mattress had been ordered, although no receipt was provided to confirm this. The facility's housekeeping policy requires daily cleaning of resident rooms, which was not adhered to in this case.
Failure to Report Resident Injury
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident who sustained a serious injury. The resident, a male with severe cognitive impairment due to Alzheimer's Disease and Traumatic Brain Injury, was found with a head injury and bleeding. The incident was documented in the nurse's notes, and the resident was transferred to the hospital for treatment. Despite the seriousness of the injury, which required staples, the incident was not reported to the State Agency as required by regulations. Interviews with the Director of Nursing (DON) and the Administrator revealed that the incident was not self-reported, and there was uncertainty about why the reporting did not occur. The facility's policy mandates that all hospitalizations resulting from an injury or unusual occurrence be reported immediately to the appropriate authorities. However, this protocol was not followed in the case of the resident's head injury, which could potentially place other residents at risk if similar incidents are not reported and addressed.
Failure to Investigate Resident Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged incident of neglect involving a resident who sustained a head injury of unknown origin. The resident, who had severe cognitive impairment due to Alzheimer's Disease and Traumatic Brain Injury, was found with a head laceration and was unsure how the injury occurred. The resident was transferred to the hospital for treatment and returned with staples in the scalp. Despite the presence of blood on a dresser, which suggested the resident may have hit their head there, the facility did not document a comprehensive investigation into the incident. Interviews with the Director of Nursing (DON) and the Administrator revealed that no formal investigation was conducted, and the incident was not self-reported until prompted by a surveyor. The facility's policy requires a thorough investigation and immediate reporting of such incidents to various administrative and risk management personnel, but this protocol was not followed. The lack of documented investigation and delayed reporting could place residents at risk of abuse, neglect, and/or exploitation.
Failure to Provide Scheduled Bathing Care
Penalty
Summary
The facility failed to ensure that a resident, who was unable to carry out activities of daily living, received necessary services to maintain personal hygiene. The resident, an elderly male with Alzheimer's disease and lack of coordination, was identified as requiring supervision or touching assistance for bathing. Despite this, the resident did not receive his scheduled bathing care on a specific date. Observations revealed that the resident was wearing a soiled shirt and expressed a desire to take a shower, but was unable to recall the last time he had one. A Certified Nursing Assistant (CNA) attempted to assist the resident with a shower but misunderstood the resident's request to "wait a minute" as a refusal of care. The CNA did not provide encouragement or alternative approaches to assist the resident. The Director of Nursing stated that staff were expected to provide encouragement and not consider a request to wait as a refusal. The facility's policy related to activities of daily living, including showers, was requested but not provided at the time of the survey exit.
Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, specifically in ensuring the safe administration of medications. During an observation, a resident with severe cognitive impairment and a history of dysphagia was found struggling to swallow three intact pills. The resident was unable to sit up independently and had difficulty swallowing, which was not adequately monitored by the attending nurse. The nurse, identified as RN D, admitted to not observing the resident swallow the medications, which is a critical step in the medication administration process. The resident's care plan indicated a need for a mechanical soft diet and allowed for medications to be crushed or capsules opened unless contraindicated. Despite these precautions, the resident was left with intact pills in his mouth, posing a choking risk. The facility's policy requires licensed personnel to administer medications and ensure they are swallowed, which was not followed in this instance. The Director of Nursing confirmed that the nurse should have watched the resident swallow the medications to prevent the risk of choking.
Failure to Submit Accurate Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for five consecutive fiscal quarters, from FY Quarter 3 2023 to FY Quarter 3 2024. This included missing RN coverage data for specific dates within each quarter. The absence of this data submission was based on payroll and other verifiable and auditable data, as required by CMS specifications. The failure to submit this information could potentially place residents at risk for unmet personal needs, decreased quality of care, and a decline in health status. During an interview, the Administrator stated that a new company took over management of the facility on July 1, 2024, and the previous Administrator was responsible for submitting the data for the PBJ report before this date. The current Administrator did not have access to evidence that accurate staffing information was submitted to CMS prior to the acquisition. Additionally, a policy related to Payroll Based Journal submissions was requested but not provided at the time of the survey exit.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Faulty Secured Unit Door
Penalty
Summary
The facility failed to ensure adequate supervision and a safe environment for a resident with severe cognitive impairment, who was at risk for elopement. The resident, who had a history of cocaine abuse, intracerebral hemorrhage, and encephalopathy, was housed in a secured unit. Despite being assessed as at risk for elopement, the only intervention in place was to house the resident in the secured unit. On the evening of the incident, the resident eloped from the facility and was found 2.6 miles away the following day. The secured unit's door was not functioning properly, as it did not consistently close and lock. Staff interviews revealed that the door had been problematic since its installation, with multiple staff members aware of the issue but failing to ensure it was consistently reported or addressed. On the night of the elopement, the charge nurse on duty did not respond to an alarm, which was later identified as a door alarm, and the resident was not accounted for until hours later. The facility's failure to maintain a properly functioning secured unit door and to ensure continuous supervision of residents in the secured unit contributed to the resident's elopement. Staff were not adequately trained or responsive to the door alarm, and there was a lack of clear procedures to ensure the door was secured at all times. This deficiency placed residents at risk of harm due to potential elopement.
Inadequate Staffing Leads to Resident Elopement
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the safety and well-being of residents on the secured unit. This deficiency was identified through observations, interviews, and record reviews, which revealed that the facility did not assign designated staff to the secured unit. As a result, residents who were cognitively impaired and at risk for elopement were frequently left unattended when staff were providing care in other parts of the building. One significant incident involved a resident who eloped from the facility. The resident, who had severe cognitive impairment and was at risk for elopement, was last seen in the secured unit dining room before the charge nurse left to pass medications and take a break. During this time, the resident managed to exit the secured unit and was found 2.6 miles away from the facility the following day. Interviews with staff revealed that the staffing pattern on the secured unit was inadequate, with one nurse and one CNA assigned to both the secured unit and other areas, leading to periods when no staff were present on the secured unit. The facility's failure to ensure adequate supervision and staffing on the secured unit placed residents at risk of harm. Interviews with staff and the facility's medical director highlighted the need for a dedicated staff member on the secured unit at all times. Despite the facility's policy stating that sufficient numbers of staff should be provided, the staffing patterns did not reflect this, contributing to the deficiency and the subsequent elopement incident.
Failure to Document AED Use in Resident's Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was reviewed for documentation. The resident, a female with a history of fluid overload, cerebral infarction, and end-stage renal disease, was admitted to the facility with a full code status. During an incident where the resident was found unresponsive, CPR was initiated, and an AED was used. However, the use of the AED was not documented in the resident's electronic medical record, which is a deviation from accepted professional standards and practices. Interviews with staff, including a CNA, an LVN, the Director of Nursing, and the Administrator, confirmed that the AED was indeed used during the code event. The LVN involved admitted to forgetting to document the use of the AED due to the fast-paced nature of the emergency. The facility's policy on the use and care of AEDs requires that a Defibrillation Event Report be completed within 24 hours and that details of the event be documented in the resident's medical record. This oversight could result in the resident's records not accurately reflecting the life-saving measures taken.
Failure to Update Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one resident. Specifically, the care plan did not address the resident's family member measuring the resident's food portions using her own measuring cups, nor did it include the family member assisting the resident without using the call button for staff assistance. This oversight could place residents at risk of not receiving the services they need and a delay in response for assistance. The resident in question was a male with Huntington's disease, cognitive communication deficit, muscle wasting and atrophy disorder, generalized muscle weakness, and dysphagia. He was severely cognitively intact and dependent on staff for activities of daily living (ADLs) such as eating, showering, personal hygiene, dressing, and transferring. Despite these needs, the care plan did not reflect the family member's involvement in measuring food portions and assisting with ADLs without staff assistance. Interviews with various staff members, including the RN Weekend Supervisor, LVN, CNA, Dietary Manager, MDS Coordinator, and the new DON, confirmed that the family member had been measuring the resident's food and assisting with ADLs without using the call button. The MDS Coordinator acknowledged that these issues should have been included in the care plan, and the DON stated that staff should notify her or the MDS Coordinator if they were aware of such practices so they could be added to the resident's care plan.
Infection Control Deficiency Due to Blood Stains on Resident's Sheets and Privacy Curtain
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by the presence of blood stains on a resident's sheets and privacy curtain. Resident #2, a severely cognitively impaired female with multiple diagnoses including cerebrovascular disease, Lupus, End Stage Renal Disease, and Heart Failure, was observed with blood stains on her bed sheet and privacy curtain. The resident required daily bed sheet changes due to her condition and dialysis treatment, which was provided in her room by a contract dialysis nurse. However, the blood stains were not addressed by the facility staff or communicated by the dialysis nurse, leading to potential cross-contamination and infection risks. Interviews with the RN Weekend Supervisor and the DON confirmed that the blood stains were an infection control issue that should have been addressed immediately. Despite the RN Weekend Supervisor's acknowledgment of the need to change the sheets and privacy curtain, the blood stains remained unaddressed for several hours. The facility's infection control policy, revised in October 2018, mandates maintaining a safe, sanitary, and comfortable environment to prevent and manage the transmission of diseases and infections, which was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 847 citations issued within 25 miles in the last 12 months — including the 44 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
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) |
|---|---|---|---|---|
| Avir At Lancaster | 0.3 mi | ★★★★★ | 15 | 1 |
| Millbrook Healthcare And Rehabilitation Center | 2 mi | ★★★★★ | 5 | 0 |
| Windsor Gardens | 2.7 mi | ★★★★★ | 14 | 0 |
| Desoto Nursing & Rehabilitation Center | 5.4 mi | ★★★★★ | 15 | 1 |
| Five Points Nursing And Rehabilitation | 5.6 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lancaster Nursing & Rehabilitation.
100% money-back within 48 hours.
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.