Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lancaster Health Services during CMS and state inspections, most recent first.
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.
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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.