Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Lancaster Health Services during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, cognitive impairment, and a history of aggression was started on Risperidone for agitation and physical/verbal behaviors. After the antipsychotic was initiated, the resident became lethargic, somnolent, less interactive, had decreased ADL participation, and ate and drank less, yet the facility continued the medication without adequate monitoring or dose reduction to assess whether the drug was causing the decline. Surveyors observed the resident as somnolent and non-interactive, and the deficiency was cited as IJ.
Food service safety standards were not followed when several frozen vegetables were found in the freezer removed from original packaging and left without a use-by, expiration, or open date. The surveyor observed opened bags of mixed vegetables, diced carrots, peas, and yellow beans, and DM C confirmed the items were not labeled and should have been dated.
Food and drink were not consistently served at a palatable temperature or in an appetizing condition. A resident reported cold food was not cold enough, another resident complained that vegetables looked mushy, and a surveyor’s test tray from the dining room found warm milk and very soft green beans. The DM stated milk should be 40 degrees Fahrenheit or lower and acknowledged the vegetables should not have been mushy.
A facility failed to ensure advance directive/POAHC documentation was available and current for two residents. One resident’s chart lacked a copy of the advance directive even though the care plan indicated one existed, and the SSD said the document had been missed. Another resident had an invalid POAHC form in a file cabinet but not in the EHR; after the wife listed on the form died, the SSD said the resident had not completed valid updated paperwork and no documentation showed follow-up discussions.
A resident on hospice did not have a hospice care plan available in the hospice binder or included in the facility care plan, and staff gave inconsistent accounts of how hospice plans were incorporated. Another resident with a diagnosis of major depressive disorder and orders for Paxil had no depression focus, goal, or interventions in the comprehensive care plan, even though staff described mood-related concerns and the DON stated depression should have been included.
Medication error rates exceeded 5% after surveyors identified 2 errors in 29 opportunities during an observed med pass. An LPN administered insulin from a pen that had not been primed and gave a resident only one Vitamin D3 tablet instead of the ordered two tablets. The DON stated staff were expected to prime insulin pens each time and administer medications according to physician orders.
The facility failed to follow its antibiotic stewardship policy by not ensuring antibiotic therapy was reviewed and adjusted after culture and susceptibility results showed a resident’s UTI organism was resistant to Bactrim DS. The resident, who had CHF, weakness, and type 2 DM, was treated for urinary symptoms, and the ADON confirmed the culture showed E. coli resistance to the ordered antibiotic, with no documentation of discussion with the ordering physician about changing treatment.
A facility failed to ensure timely reporting of alleged abuse involving two residents. In one case, a CNA reported an incident five days late, allowing the alleged perpetrator to continue working. In another case, two CNAs and a housekeeper witnessed verbal abuse but did not report it, assuming management was aware. This lack of reporting delayed investigation and intervention, compromising resident safety.
The facility failed to investigate alleged abuse incidents involving two residents. A CNA reported verbal abuse by another CNA, but the investigation was incomplete, missing interviews with all knowledgeable staff. Another incident involved a resident hearing inappropriate yelling, but it was not reported due to assumptions that nearby staff were aware. Additionally, a housekeeper witnessed swearing by a CNA but did not report it, assuming the DON heard it. These failures highlight deficiencies in the facility's response to abuse allegations.
A resident with chronic pain and a recent fracture experienced inadequate pain management at the facility. Despite frequent reports of severe pain, the staff failed to re-evaluate pain medication effectiveness within the required timeframe, did not offer non-pharmacological interventions, and did not consult with the resident's doctor. The facility lacked a policy for pain assessment, contributing to the deficiency.
The facility failed to submit accurate staffing data to CMS through the PBJ for three quarters, due to issues with a new time punch system and agency staff not punching in properly. Discrepancies were found between timecard punches and schedules, leading to unrecognized work hours and inaccurate reporting of RN coverage.
A resident was prescribed a prophylactic antibiotic, Cephalexin, without adequate indications for its use, violating the facility's Antibiotic Stewardship Program policy. The resident, with severe cognitive impairment and multiple health conditions, continued to receive the medication without a specified stop date or clear rationale, as confirmed by the ADON.
The facility failed to maintain an effective infection prevention and control program, with staff not performing proper hand hygiene and not sanitizing mechanical lifts between residents. CNAs were observed using contaminated gloves during incontinence care for three residents, and a mechanical lift was used for two residents without sanitization. The facility lacked a policy for lift sanitization, and the DON and ADON acknowledged these lapses.
The facility failed to report two incidents of suspected abuse and theft to the State Agency and local law enforcement. One resident reported missing cash, and another resident's daughter reported a missing wedding ring. Both incidents were not reported as required, despite the facility's policy mandating such actions.
Unnecessary Psychotropic Medication and Inadequate Monitoring
Penalty
Summary
The facility did not ensure that one resident’s drug regimen was free from unnecessary drugs. The resident had diagnoses including Parkinson’s disease, weakness, type 2 diabetes, mild cognitive impairment, congestive heart failure, and adult failure to thrive. The resident’s care plan identified a history of verbal and physical aggression, inappropriate sexual behavior, limited physical mobility, and risk for adverse effects from antipsychotic medication. After a period of intermittent verbal and physical aggression, the resident was started on Risperidone for agitation and aggression. Following initiation of Risperidone, the resident was documented as becoming lethargic, somnolent, less interactive, and less able to participate in activities and ADLs. The record also described decreased oral intake and a decline in functional status, including increased assistance needs with ADLs. The facility continued the Risperidone without evidence in the report of adequate monitoring for adverse consequences or side effects related to the antipsychotic, and the medication was not reduced to determine whether it was contributing to the resident’s acute decline. Survey observations noted the resident multiple times as somnolent, lethargic, and non-interactive with staff. The report states the facility failed to adequately monitor the resident’s response to Risperidone and failed to recognize adverse consequences of therapy, including lethargy, decreased ADL function, and decreased oral intake. The deficiency was cited as Immediate Jeopardy beginning on 7/10/25, and the report states the NHA and DON were informed on 8/7/25.
Undated Frozen Foods in Kitchen Freezer
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial kitchen tour on 8/4/25 at 9:35 AM, the surveyor observed several frozen food items in the freezer that had been removed from their original packaging and were not labeled with a use-by, expiration, or open date, including an opened package of mixed vegetables, diced carrots, peas, and yellow beans. The facility policy on Food Storage, revised 8/16/2022, states that frozen foods should be covered, labeled, and dated and that foods should be checked to ensure they are consumed by their safe use-by dates or discarded. At 1:59 PM the same day, the surveyor interviewed DM C and showed him the unlabeled and undated bags of frozen vegetables, and DM C verified that the opened bags were not labeled and should have been labeled and dated.
Food and Drink Not Served at Palatable Temperature
Penalty
Summary
The facility did not ensure that residents received food and drink that were palatable and at a safe and appetizing temperature. The deficiency involved residents who ate in the main dining room, including R4 and R22. R4, who was admitted to the facility and had a most recent MDS with a BIMS score of 11 out of 15 indicating moderately impaired cognition, stated during Resident Council that cold food was not cold enough when he received it. R22 stated during interview that the vegetables looked like they had been run through a washing machine. During a test tray observation from the main dining room, the surveyor measured beef tips in gravy at 152.3 degrees Fahrenheit, noodles at 134.1 degrees Fahrenheit, vegetable blend at 136.8 degrees Fahrenheit, and milk at 53.3 degrees Fahrenheit. The surveyor tasted the tray and found the hot food hot enough, but the milk was warm rather than cold, and the green beans in the vegetable blend were very soft and mushy and could not be picked up with a fork. While waiting in the dining room, the surveyor also observed glasses of milk and juice poured ahead of time sitting on a tray on the counter without ice. The dietary manager stated milk should be 40 degrees Fahrenheit or lower and acknowledged that the milk from the test tray should have been 40 degrees or lower and that the green beans should not have been mushy.
Missing Advance Directive and POAHC Documentation
Penalty
Summary
The facility did not ensure that residents’ rights to request, refuse, and/or discontinue treatment and to formulate an advance directive were honored for 2 of 12 residents reviewed. During the survey, the Assistant Director of Nursing stated the facility did not have an advance directive policy. The facility admission agreement stated that it was the center’s policy to recognize and implement residents’ rights under state law to make decisions concerning medical care, including the right to accept or refuse medical treatment and to formulate advance directives. For one resident, the surveyor could not locate a copy of the resident’s advance directive or Power of Attorney for Health Care (POAHC) in the electronic medical record. The care plan indicated an advance directive was in place, and the admission agreement contained a section showing that the facility had been informed a POAHC document existed, but the document itself was not in the chart. The resident stated he recalled someone asking about an advance directive when he came to the facility, and his mother said he had one because it had been discussed at the hospital, but he could not remember whether a copy was ever provided to the facility. The Social Services Director stated her process was to obtain advance directives from the hospital or family and scan them into the file, but she had not gone back to check for this resident’s document and acknowledged the resident’s advance directive had been missed. For the second resident, the surveyor also could not locate a copy of the POAHC in the electronic record. The Social Services Director stated she had a copy in a file cabinet, but it had not been scanned into the electronic health record. She reported the resident’s wife had been listed as POAHC, but she had died, and the daughter wanted to be the POAHC; however, the paperwork was invalid because family members served as witnesses. The Social Services Director stated she had tried to talk with the resident about updating the POAHC after his wife’s death, but he initially declined to discuss it and said his daughter had it under control. No documentation was provided of those discussions, and the resident remained without a valid POAHC designee after his wife’s death.
Care plans not updated for hospice status and depression
Penalty
Summary
The facility did not ensure comprehensive care plans were reviewed and revised for 2 of 16 residents reviewed. For one resident, the record showed hospice involvement in the profile tab and the resident had been on hospice prior to 7/7/25, but surveyors could not locate a hospice plan of care in the hospice binder or in the facility’s comprehensive care plan. The only hospice-related reference found in the facility care plan was under a nutrition-at-risk focus that mentioned reduced oral intake and hospice care. Staff interviews showed inconsistent understanding of whether hospice care plans were kept separate or combined with the facility care plan, and the MDS Coordinator stated the resident should have had a separate hospice care plan and that it had been missed. For the second resident, the comprehensive care plan did not include a focus, goal, or interventions for depression, even though the resident had diagnoses including Major Depressive Disorder, Recurrent, Moderate and Mild Cognitive Impairment of Uncertain or Unknown Etiology. The resident’s physician orders included Paxil for depression and risperidone for behavioral symptoms. The care plan instead focused on behavior symptoms, with goals related to accepting care and medications and reducing behavioral symptoms, but it did not identify depression as a care-plan focus or include resident-specific goals or interventions for that diagnosis. Interviews with the resident and staff reflected mixed observations about the resident’s mood and behaviors. The resident stated she sometimes felt sad or depressed. CNA and RN interviews described that the resident preferred to stay in her room, sometimes refused meals or care, and staff used redirection, snacks, or attempts to encourage participation in activities and meals. The DON stated depression should have been on the resident’s care plan, and the ADON provided a care plan history showing the depression focus, goals, and interventions had been resolved/cancelled. The Social Services Director stated she did not know why that had been deleted and was not aware that she had removed the depression care plan.
Medication Error Rate Exceeded 5% During Observed Pass
Penalty
Summary
The facility did not ensure that medication error rates remained below 5%, as survey observation, interview, and record review identified 2 medication errors in 29 opportunities for an error rate of 6.9%. The errors involved 2 of 7 supplemental residents observed during the medication pass task: one resident received insulin from an insulin pen that had not been primed before use, and another resident did not receive the correct dose of Vitamin D3. One resident had diagnoses including Type 2 diabetes mellitus with diabetic chronic kidney disease, long-term insulin use, and weakness, and had an order for Humalog insulin 3 units subcutaneously three times daily before meals. During observation, an LPN administered the insulin without priming the pen first. The LPN stated she had been taught to prime the pen only when it was first opened, while the DON stated staff were expected to prime insulin pens at least 2 units each time. A second resident had diagnoses including multiple sclerosis, primary osteoarthritis, and weakness, and had an order for Vitamin D3 1000 units, 2 tablets by mouth daily. During observation, the LPN administered only one tablet, and later confirmed that giving the wrong dose would be a medication error. The DON stated medications were expected to be administered according to physician orders.
Failure to Monitor Antibiotic Use and Adjust Treatment for Resistant UTI Organism
Penalty
Summary
The facility failed to follow its Antibiotic Stewardship Program policy, which requires antibiotic use protocols and a system to monitor antibiotic use, including reviewing laboratory results to determine whether an antibiotic is still indicated or should be adjusted. The policy also states that antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. In this case, the facility did not ensure that the ordered antibiotic was changed after culture and susceptibility results showed the organism was resistant to the prescribed medication. A resident with diagnoses including CHF, weakness, and type 2 diabetes was evaluated for new or increased incontinence, urgency, and frequency. A urinalysis was collected and a physician ordered Bactrim DS for a UTI. The urine culture later showed greater than 100,000 CFU of E. coli, and susceptibility testing indicated the bacteria was resistant to Bactrim DS. During interview, the ADON confirmed the organism was resistant to the ordered antibiotic and stated the culture and susceptibility had been sent to the physician, but there were no notes documenting any discussion about changing the antibiotic.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required by their policy. This deficiency was identified in two cases involving residents. In the first case, a Certified Nursing Assistant (CNA) reported an incident of alleged abuse five days after it occurred. The incident involved another CNA allegedly holding down a resident and using derogatory language. The delay in reporting meant that the alleged perpetrator continued to work in the facility for several days after the incident, potentially compromising resident safety. In the second case, two CNAs and a housekeeper witnessed or had knowledge of verbal abuse by the same CNA towards another resident but failed to report it to management. One CNA assumed that a Licensed Practical Nurse (LPN) in the vicinity had heard the incident, while the other CNA and the housekeeper assumed that management was aware because they were nearby. This lack of reporting prevented timely investigation and intervention, leaving the resident exposed to potential further abuse. The facility's Director of Nursing (DON) and Nursing Home Administrator (NHA) acknowledged the expectation that staff should report any abuse immediately. However, the failure of staff to report these incidents promptly indicates a breakdown in communication and adherence to the facility's abuse prevention policy. This deficiency highlights the need for staff to understand their responsibility in reporting abuse to ensure resident safety and compliance with regulatory requirements.
Failure to Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to thoroughly investigate all alleged violations of abuse involving two residents, R1 and R2. An allegation was made by CNA G against CNA F, stating that CNA F verbally abused R1 during care. The facility's investigation was incomplete as it did not include interviews with all staff who had knowledge of the incident. Additionally, CNA F was allowed to continue working before the allegation was reported to management, and the investigation did not substantiate the abuse due to lack of physical or psychological harm to R1. Further deficiencies were noted in the handling of another incident involving R2. CNA C reported hearing CNA F yelling inappropriately at R2, but did not report it to management, assuming that LPN H, who was nearby, had heard it. However, LPN H was unaware of the incident. Similarly, CNA E witnessed CNA F verbally abusing R2 but did not report it, assuming that a nurse at the station had heard it. These incidents were not investigated by the facility, indicating a failure to follow up on potential abuse situations. Additionally, Housekeeper D observed CNA F swearing in front of residents but did not report it, assuming that the DON, who was nearby, had heard it. The DON, however, did not confirm hearing the incident. The facility's policy requires immediate reporting of suspected abuse, but this was not adhered to by the staff involved. The lack of thorough investigation and failure to interview all relevant staff members contributed to the deficiency in addressing the alleged abuse incidents.
Inadequate Pain Management for Resident
Penalty
Summary
The facility staff failed to adequately assess and manage the pain of a resident, identified as R1, who was admitted with multiple diagnoses including chronic pain and knee pain. The resident experienced a significant change in status after a fall caused by a malfunctioning Hoyer lift, resulting in a fracture of the right humerus. Despite the resident's consistent reports of severe pain, often rated at 10 out of 10, the facility did not re-evaluate the effectiveness of pain medication within one hour of administration, as required. The facility also failed to offer non-pharmacological interventions for pain management, such as ice, heat, repositioning, or distraction, despite the resident's ongoing high pain levels. The resident's medical records indicated frequent high pain ratings, yet there was no documentation of non-pharmacological interventions being attempted or their effectiveness. Additionally, the facility did not have a policy related to pain rating and assessment, which contributed to the inadequate management of the resident's pain. Furthermore, the facility did not consult with the resident's medical doctor when the pain ratings consistently exceeded the goal of 2 out of 10. Interviews with facility staff, including a Physician Assistant, LPN, RN, and the Director of Nursing, revealed that the expected protocols for managing severe pain were not followed. The staff acknowledged the need for reassessment and physician notification in cases of uncontrolled pain, but these actions were not documented or executed, leading to the deficiency in pain management for the resident.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) through the mandatory Payroll Based Journal (PBJ) for three consecutive quarters. This issue was identified during a survey when the Business Office Manager (BOM) was unable to provide the necessary documentation to verify the staffing data submitted. The surveyor noted discrepancies in the reported staffing levels, particularly on weekends and the absence of a Registered Nurse (RN) as indicated in the PBJ report. The facility had recently transitioned from Kronos to Smartlink for time punches, which required manual data input to function correctly. However, agency staff were not punching in properly, leading to unrecognized work hours. Further investigation revealed that there were inconsistencies between the timecard punches and the facility schedules, with missing data for certain dates. The Nursing Home Administrator (NHA) acknowledged that the facility was short on RN coverage for specific dates. The Vice President of Success (VPS) explained that there were issues with pulling agency hours from the system, which affected the PBJ reporting. Despite efforts to correct the system, the facility's staffing data for the specified quarters remained inaccurate, leading to the deficiency being cited as past noncompliance.
Unnecessary Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically a prophylactic antibiotic. This deficiency was identified for a resident who was prescribed Cephalexin without adequate indications for its use. The resident returned from the hospital with an order for the antibiotic, but no diagnosis or stop date was provided for this medication. The facility's Antibiotic Stewardship Program policy requires prescriptions to specify the dose, duration, and indication for use, which was not adhered to in this case. The resident involved had multiple diagnoses, including chronic respiratory failure, hypertension, congestive heart failure, chronic kidney disease, and Alzheimer's disease, and was assessed with severe cognitive impairment. Despite these conditions, the facility did not provide a clear rationale for the continued use of the antibiotic. The Assistant Director of Nursing confirmed that the resident had been hospitalized twice for pneumonia but could not provide further justification for the prophylactic antibiotic use. The pharmacy review also noted the absence of a stop date for the medication, indicating a lack of proper oversight and documentation.
Infection Control Deficiencies in Hand Hygiene and Equipment Sanitization
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not performing proper hand hygiene and not sanitizing durable medical equipment between resident uses. During observations, Certified Nursing Assistants (CNAs) were seen performing incontinence care on residents without changing gloves or conducting hand hygiene, despite handling urine-soaked products and touching clean clothing and residents. This was observed in three separate instances involving three different residents, where CNAs continued to use contaminated gloves throughout the care process, contrary to the facility's hand hygiene policy. Additionally, the facility did not have a policy for sanitizing mechanical lifts between resident uses. Observations showed that a mechanical lift was used for two residents without being sanitized before or after each use. Interviews with the CNAs involved and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the expected practice was to sanitize the lifts between residents, which was not done. This lack of adherence to infection control protocols was acknowledged by the facility's nursing leadership.
Failure to Report Suspected Abuse and Theft
Penalty
Summary
The facility did not immediately report alleged violations of abuse to the State Agency and local law enforcement for two reportable incidents involving residents. In the first incident, a resident reported on 3/21/24 that he was unable to find the cash he kept in his room, amounting to a grand. Despite the resident finding the money the next day, the Nursing Home Administrator (NHA) failed to report this suspicion of a crime to local law enforcement and the State Agency within the required timeframe. The facility's Vice President of Success (VPS) admitted that they did not maintain a timeline of when the money was reported missing and when it was found. In the second incident, another resident's daughter reported on 3/16/24 that her mother's wedding ring was missing. The NHA did not investigate the allegation or report this suspicion of a crime to local law enforcement and the State Agency. The VPS stated that the resident had a history of misplacing items and it was believed that she had thrown the ring away. However, the NHA acknowledged that the incident should have been reported regardless of this belief. The facility completed grievance forms for both incidents but failed to follow regulatory requirements for reporting these concerns.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orchard Manor | 1.4 mi | ★★★★★ | 9 | 0 |
| Dove Healthcare - Fennimore | 10.3 mi | ★★★★★ | 33 | 0 |
| Edenbrook Of Platteville | 13.8 mi | ★★★★★ | 0 | 0 |
| Care And Rehab - Boscobel | 20.4 mi | ★★★★★ | 0 | 0 |
| Guttenberg Care Center | 20.5 mi | ★★★★★ | 1 | 0 |
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