Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Lancashire Post Acute during CMS and state inspections, most recent first.
Failure to Prevent and Treat Pressure Ulcers: A resident admitted without pressure injuries and with significant mobility impairment developed multiple pressure ulcers during the stay, including a stage 4 heel ulcer, a stage 3 ankle ulcer, and several unstageable wounds. The record showed pressure-injury prevention measures, nutrition recommendations, and wound care orders were not consistently documented as implemented, and staff interviews confirmed the resident required extensive assistance with turning/repositioning and developed wounds while in the facility.
Failure to Provide Scheduled Showers: Four residents with significant ADL needs, including stroke, paralysis, cerebral palsy, and other chronic conditions, did not receive showers according to their assigned schedules. One resident reported having to yell to get a shower, another said she had received at most two showers since admission, and two others stated they had gone weeks without showers. Records showed missed, refused, or absent shower documentation despite care plans and task schedules calling for bathing assistance.
Insufficient staffing affected resident care and daily services. The facility’s staffing sheets did not show any shift fully staffed per the facility’s own staffing pattern, and residents reported long waits for help, missed showers, and delayed response to call lights. A CNA was observed leaving a resident with food on bedding after lunch, and multiple CNAs, the Staff Coordinator, and the DON acknowledged frequent call-offs and not having enough aides to complete care tasks.
Staff failed to perform hand hygiene between resident contacts while passing lunch trays and assisting residents with eating. CNA4, CNA18, and the ADON touched residents during meal service without sanitizing hands between residents, and one CNA gave bites to two residents without hand hygiene in between. A CNA also handled dirty linen with a gloved hand in the hall and touched the gate and soiled utility door code before removing gloves and cleaning hands.
Failure to Inform Family Member of Psychiatric Visits: A resident with Alzheimer’s disease, dementia, and severe cognitive impairment received bi-weekly psychiatric NP visits, but the record showed no documentation that the FM was informed or consulted. The FM stated she was not aware of the visits and would not have agreed to them, and both the DON and Administrator stated the FM should have been notified.
A resident with cerebral palsy, paraplegia, and malignant colon cancer was verbally abused by a CNA during shower care when the resident had a bowel movement on the shower floor. The resident, who had a BIMS of 15 and was always incontinent of bowel, stated the CNA called him an "A-hole," and a roommate confirmed the abuse. The DON was notified, and the facility later documented that the CNA could not be reached for a statement.
Failure to thoroughly investigate an allegation of verbal abuse involving a cognitively intact resident who was incontinent and required extensive care. A CNA reported that another CNA allegedly used profanity during shower care after the resident had a bowel movement, but the facility had no documentation of interviews with other residents or staff, and the Administrator could not identify or interview the reporting CNA. The facility policy required immediate reporting and a thorough written investigation of alleged abuse.
The facility failed to transmit MDS assessments to CMS within the required timeframe for two residents. One resident’s quarterly MDS was overdue by 15 days and the other resident’s admission MDS was overdue by 9 days; the MDSC confirmed both were late. The residents had diagnoses including COPD, CKD, heart disease, and pressure ulcers.
Failure to refer two residents for PASARR Level II review after new MH diagnoses were identified. One resident had diagnoses including bipolar disorder, psychotic disorder, schizophrenia, MDD, and dementia, while another had depression, anxiety, and later PTSD listed on MDS. The RDSW stated documentation could not be found showing either resident was referred for Level II PASARR evaluation, despite facility policy requiring referral when Level I screening indicates possible MD, ID, or related disorder.
A resident with diabetes and CHF sustained a fall while transferring from wheelchair to bed and was diagnosed with a closed R wrist fracture after ER evaluation. The Fall Care Plan included pain control, sling use, therapy, and ortho follow-up, but it was not updated to reflect that the resident was independent in applying and removing the wrist brace; staff later observed the resident removing the splint and RN confirmed this independence.
Failure to Monitor Fractured Wrist: A resident with a closed R wrist fracture after a fall had a soft splint in place, but later removed it independently. The wrist was observed with bruising and swelling, and the MAR/TAR contained no documentation that nursing staff monitored the wrist for changes in swelling or bruising. The RN confirmed there was no EMR monitoring, and the DON stated the wrist should have been monitored.
A resident with COPD, ESRD, and Type 2 DM was observed using a nasal cannula with the oxygen concentrator set at 4 LPM even though the EMR showed no current physician order for oxygen. The care plan did not address oxygen, and an LPN, RN, and DON all confirmed the resident should not have been receiving oxygen without an active order; the DON stated it had been overlooked.
Failure to document vaccine refusal education was cited after staff did not record that residents or representatives were informed of the risks and benefits of influenza and pneumococcal vaccines when the vaccines were declined. Three residents with varying cognitive status had MDS records showing the vaccines were offered and refused, but the IP stated they were unaware documentation was required. The facility policy stated that when vaccines are refused, the date and stated reason for refusal must be documented in the medical record.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to implement pressure ulcer prevention interventions and wound care for a resident admitted with Alzheimer's disease, urinary and fecal incontinence, autonomic nervous system degeneration, osteoarthritis of the hip, right hip pain, and generalized muscle weakness. On admission, the resident had no pressure injuries, but the MDS showed substantial to maximal assistance was needed for bed mobility and the Braden assessment identified the resident as at risk for pressure sores. The care plan included interventions such as assistance with positioning, encouragement to reposition, skin barrier cream, an air mattress or air overlay, use of pillows, pads, or wedges, turning and repositioning, and pressure-reducing surfaces. During the stay, skin checks initially documented no new areas, but later notes described discoloration to both heels and feet, very poor bed mobility, and frequent resting of the feet on the footboard. The resident then developed multiple wounds after admission, including wounds to the left heel, right heel, right ankle, and left lateral foot. The wounds progressed from discoloration and intact skin to unstageable pressure injuries and deep tissue injuries, with later documentation showing a stage 4 pressure ulcer of the left heel and a stage 3 pressure ulcer of the right ankle. A right buttock wound also developed and was documented as unstageable with deep tissue injury. The record also showed that ordered interventions and recommendations were not documented as implemented. Nutrition recommendations from the dietary assessment, including vitamin C, zinc, double protein portions, and LiquaCel, were not documented as carried out. The specialty wound physician’s recommendations on 02/18/25, including specific dressing regimens, off-loading boots, protein supplementation, thyroid testing, vitamin C, zinc, and an upgraded Roho chair cushion, were also not documented as implemented in the MAR or TAR. Interviews with the WCN, an LPN, and the DON confirmed that the resident developed pressure wounds during the stay, required two staff for turning and repositioning, and that the DON stated there was no reason the dietitian’s recommendations were not implemented.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide assistance with ADLs by not ensuring showers were given according to the residents’ shower schedules and preferences for four residents. R4, who had a history of stroke with left-sided paralysis and was dependent on staff for bathing, reported that she did not receive showers on her scheduled days and stated she had to yell to get a shower. The record showed she was scheduled for two showers per week, but documentation reflected only one shower in the prior 30 days. R18, who had diagnoses including seizures, diabetes, and an irregular heart rhythm, had a BIMS score of 10 and required moderate assistance with bathing. She stated she had received at most two showers since admission. Her task record showed she was scheduled for two showers per week, but the documentation showed one shower marked no and another documented as refused, with no further shower documentation after that. R59, who had cerebral palsy and paraplegia and was totally dependent on staff for bathing, stated it had been over a month since her last shower. Her task record showed she was scheduled for two showers weekly, but after one refusal there was no further shower documentation. R56, who had hemiplegia, osteoarthritis, and type 2 diabetes and required moderate assistance with bathing, stated she had not had a shower in weeks and that staff told her they did not have time or that it was not her shower day. The facility policy stated staff were to assist residents as necessary and provide assistance to improve quality of life.
Insufficient staffing and delayed resident care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of 108 residents. The facility’s undated Facility Assessment listed a base staffing pattern of 2 RNs on the 7-3 shift, 2 LPNs on the 7-3 shift, 2 RNs on the 3-11 shift, 2 LPNs on the 3-11 shift, 3 LPNs on the 11-7 shift, and CNAs at 11 on 7-3, 8 on 3-11, and 5 on 11-7. Review of Daily Staffing Sheets and daily nursing schedules for 01/15/25 through 02/28/25 showed an average daily census of 80 residents, and no shift could be located that was fully staffed per the Facility Assessment staffing guidelines. Residents and staff described delays and missed care tied to the staffing shortages. R56 reported not having a shower in weeks and said CNAs told her they did not have time and kept changing her shower day. R46 was observed with oily hair and sloppy joe meat on her sheet and blanket after lunch, and a CNA stated she was busy and had to make rounds. R4, R18, and R59 each reported long waits for assistance and call lights not being answered, with R18 stating waits of 45 minutes to an hour and R59 stating waits of more than 30 minutes, especially on the 3-11 shift. Multiple CNAs stated the facility was short-staffed, had frequent call-offs, and that they could not complete charting or all resident care tasks, while the Staff Coordinator and DON acknowledged ongoing staffing concerns and a lack of enough aides.
Failure to Perform Hand Hygiene Between Resident Contacts and During Dirty Linen Handling
Penalty
Summary
The facility failed to perform hand hygiene between contact with residents while serving lunch trays for 28 of 108 residents. During an observation on 02/17/26 from 12:29 PM until 1:28 PM, CNA4, CNA18, and the ADON were serving lunch trays and assisting residents with sanitizing hand wipes before eating, but the three staff members were observed touching residents while helping them sit down, distracting residents until trays were served, or touching residents' arms or shoulders without performing hand hygiene between resident contacts. CNA4 was also observed giving one resident a bite to eat and then going to another resident and giving that resident a bite to eat without performing hand hygiene between residents. The facility also failed to remove gloves and perform hand hygiene prior to carrying bagged dirty linen in the hall. During an observation on 02/17/26 at 3:00 PM, CNA18 carried a plastic bag of dirty linen with a gloved hand down the hall to the dirty utility room, touched the gate to open it, and entered the code on the soiled utility room door. CNA2 was observed brushing her hair out of her face with her hands and picking up her cell phone off the floor without performing hand hygiene while assisting a resident with eating. The DON stated staff should sanitize hands between touching residents and that dirty linens should be bagged and carried to the soiled utility room with one gloved hand, followed by hand hygiene. Facility policy stated hand hygiene is indicated immediately before touching a resident, after touching a resident, after touching the resident's environment, and immediately after glove removal.
Failure to Inform Family Member of Psychiatric Visits
Penalty
Summary
The facility failed to provide information and choices to the family member of a resident regarding psychiatric visits. Resident 13 was admitted with diagnoses including Alzheimer's disease, atrial fibrillation, and dementia, and the significant change MDS showed a BIMS score of 99, indicating severe cognitive impairment. The record review found psychiatric visits dated 01/27/26 and 02/13/26 by the psychiatric NP, but there was no mention of consultation with the family member in those notes. Review of the Progress Notes showed no documentation that the family member was informed of the risks and benefits or made aware that psychiatric visits were being provided bi-weekly. During interview, the family member stated she had not been consulted and said she would not have agreed to the visits because the resident had been completely uncommunicative for months and rarely opened her eyes. The DON and Administrator both stated the family member should have been notified.
Verbal Abuse by CNA During Resident Care
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse by staff. The resident was admitted with cerebral palsy, paraplegia, and malignant colon cancer, and the quarterly MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact and always incontinent of bowel. According to the Administrator Statement, the DON received a report that a CNA had used profanity while providing care when the resident had a bowel movement on the shower floor during a shower and the CNA called the resident an "A-hole." The resident later stated that the CNA wheeled him into the shower, he had a bowel movement that went all over the floor, and the CNA called him an "A-hole," which made him feel terrible. The resident reported the incident to the DON, and the roommate was present during the interview and confirmed that the CNA had verbally abused the resident. The Administrator stated that the CNA was not scheduled when the report was received, management had been unable to reach the CNA for a statement after multiple attempts, and the CNA was removed from the schedule and terminated. The facility policy titled Resident Abuse Policy and Procedure stated that residents are to be free from abuse, neglect, misappropriation of resident property, and exploitation.
Failure to Thoroughly Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving one resident. The resident was admitted with cerebral palsy, paraplegia, and malignant colon cancer, and the quarterly MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact and always incontinent of bowel. According to the Administrator Statement, the DON received a report from a CNA that the resident said another CNA used profanity during shower care after the resident had a bowel movement on the shower floor and the CNA allegedly called the resident an "A-hole." The staff member accused of the profanity was not scheduled when the report was received, could not be reached for a statement after multiple attempts, and was terminated. During interview, the Administrator stated there was no documentation showing that other residents on the unit were interviewed about possible verbal abuse by the CNA, and no documentation of staff interviews was available. The Administrator also stated she did not know who the unknown CNA was that reported the allegation and that person was not interviewed for the investigation. The facility policy required all alleged violations involving abuse to be reported immediately and for the facility to complete a thorough written investigation while preventing further potential abuse during the investigation.
Late Transmission of MDS Assessments
Penalty
Summary
The facility failed to electronically transmit MDS assessments to CMS within the required timeframe for two residents in a sample of 32. For one resident, the quarterly MDS with an ARD of 10/26/25 was 15 days overdue for transmission; the resident’s admission record listed diagnoses of chronic obstructive pulmonary disease, chronic kidney disease, and heart disease. For a second resident, the admission MDS with an ARD of 02/03/26 was nine days overdue for transmission; the resident’s admission record listed diagnoses that included pressure ulcers. During interviews on 02/19/26, the MDS Coordinator confirmed that both assessments were overdue for transmission to CMS.
Failure to Refer Residents for PASARR Level II Review After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer two residents, R8 and R97, for Level II PASARR evaluation and determination after each was identified with a new diagnosis of mental illness. Record review showed R8 was admitted with diagnoses including dementia, cognitive communication deficit, bipolar disease, major depressive disorder, and schizophrenia, and the facility’s screening dated 12/06/19 indicated R8 did not have a current serious mental illness. A later quarterly MDS with an ARD of 09/15/25 listed bipolar disorder, psychotic disorder, and schizophrenia. R97 was admitted with diagnoses of depression, anxiety disorder, and nightmare disorder, and the facility’s screening dated 02/28/23 indicated R97 did not have a current serious mental illness. A later MDS with an ARD of 12/05/25 listed PTSD. During interview, the Regional Director of Social Work stated documentation could not be found to support that a PASARR Level II referral was made for either resident. The facility policy stated that residents are screened for mental disorders, intellectual disabilities, or related disorders and, if the Level I screen indicates possible criteria, they are referred for Level II screening.
Fall Care Plan Not Updated for Wrist Brace Independence
Penalty
Summary
The facility failed to ensure the Fall Care Plan was updated to include interventions related to a fractured wrist for one resident, R20, in a sample of 32. R20 was admitted with diabetes and congestive heart failure. The record showed that on 01/06/26 the resident attempted to transfer from a wheelchair to bed, lost balance, and was found on the floor yelling that her wrist hurt. She was unable to complete range of motion because of extreme pain to the right arm, and the physician ordered transfer to the ER for evaluation and treatment. After returning to the facility, the resident had x-rays of the right elbow and right wrist and was diagnosed with a closed fracture of the right wrist. The resident was instructed to leave the splint in place until seeing orthopedics. The Fall Care Plan listed the right wrist fracture and included interventions such as pain management, sling use, therapy consult, and follow-up orthopedic appointment, but it did not include the resident’s independent ability to apply and remove the right wrist brace. During observations, the resident was seen with the wrist splint on but with the Velcro ties not connected, and later was observed removing the splint and stating that she removes it and puts it back on when she wants to. RN 1 confirmed the resident was independent in applying and removing the wrist brace, and the DON acknowledged the care plan should have been updated to include that information.
Failure to Monitor Fractured Wrist
Penalty
Summary
The facility failed to monitor a resident’s fractured right wrist for increased swelling and bruising after the resident fell while attempting to transfer from a wheelchair to bed and reported severe pain in the right arm. The resident was found on the floor yelling that her wrist hurt, could not complete range of motion due to extreme pain, and was sent to the ER after the physician was notified. Emergency medical technicians splinted the right arm before transfer. After the resident returned to the facility, records documented a closed fracture of the right wrist and instructions to leave the splint in place until orthopedic follow-up. During a later interview and observation, the resident had removed the soft splint independently; the wrist showed bruising and swelling on the back side of the wrist/forearm, and the resident denied pain. Review of the MAR and TAR showed no documentation that nursing staff monitored the wrist for increased or decreased swelling and bruising, and the RN confirmed there was no monitoring of the wrist or brace removal in the EMR. The DON stated the wrist should have been monitored.
Oxygen Given Without Current Physician Order
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when the facility failed to ensure an active physician order for oxygen administration for one resident. The resident was admitted with chronic obstructive pulmonary disease, end stage renal disease, and Type 2 diabetes. Review of the resident’s significant change MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. The care plan dated 10/06/20 and revised on 01/08/26 did not include oxygen, and the physician orders dated 01/08/26 showed no current order for oxygen. Despite the absence of a current oxygen order, observations on 02/17/26 at 1:15 PM and 02/18/26 at 8:35 AM showed the resident lying in bed using a nasal cannula with the oxygen concentrator set at 4 LPM. During interviews, an LPN and an RN both confirmed the resident was receiving oxygen and stated a resident should not receive oxygen without a physician order. The DON also confirmed the resident should not receive oxygen without a physician order and stated the resident had been in and out of the hospital and it must have been overlooked. No oxygen policy was provided by the facility.
Failure to Document Vaccine Refusal Education
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after the facility failed to document, when vaccines were declined, that the resident and/or representative had been educated on the risks and benefits of the influenza and pneumococcal vaccines for three residents reviewed. R2 was admitted with Alzheimer’s disease and dementia; the annual MDS showed a BIMS score of 99 and that the influenza vaccine was offered and declined. R19 was admitted with anxiety disorder and major depressive disorder; the quarterly MDS showed a BIMS score of 15 out of 15 and that both the influenza and pneumococcal vaccines were offered and declined. R20 was admitted with diabetes and heart failure; the annual MDS showed a BIMS score of 10 out of 15 and that the influenza and pneumococcal vaccinations were offered and refused. During interview, the Infection Preventionist stated they were not aware that documentation was needed when a resident or representative declines the vaccines. The facility policy titled, Pneumococcal Vaccine and Influenza Vaccine, dated August 2025, stated that the resident or representative has the right to refuse vaccines and that if refused, the date of and stated reason for the refusal are documented in the resident's medical record.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kilmarnock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rappahannock Westminster Canterbury | 2.8 mi | ★★★★★ | 0 | 0 |
| Dockside Health & Rehab Center | 10 mi | ★★★★★ | 0 | 0 |
| Riverside Lifelong Health & Rehabilitation Salud | 14.1 mi | ★★★★★ | 9 | 1 |
| Riverside Lifelong Health And Rehabilitation - M | 20 mi | ★★★★★ | 0 | 0 |
| Walter Reed Post Acute | 22.1 mi | ★★★★★ | 0 | 0 |
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