Lancaster Health Services

In the surveyor’s words

From the most serious findings on record at Lancaster Health Services, in the surveyor’s own words.

• Immediate jeopardy, isolatedF605Aug 19, 2025

  Based on observation, interview, and record review the facility did not ensure that 1 (R8) of 5 residents drug regimen was free from unnecessary drugs. R8 was prescribed Risperidone for verbal and physical aggression. The facility failed to adequately monitor R8's response to Risperidone and failed to recognize adverse consequences of Risperidone therapy including lethargy, decreased Activities of Daily Living (ADL) function and decreased oral intake. The facility failed to adjust R8's Risperidone when R8 presented with adverse consequences. R8 was administered Risperidone (Antipsychotic) daily starting on 6/22/25 following two days of intermittent verbal and physical aggression. […]

• Actual harm, isolatedF689Jul 20, 2021

  Based on interview and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R1). The facility was aware R1 was being transferred by family and did not provide the supervision necessary to help prevent accidents which resulted in a fall with major injury. Findings include R1 was admitted to the facility on [DATE] and had diagnoses that included dementia and coronary [CONDITION(S)]. Her most recent MDS (Minimum Data Set) shows a BIMS (Brief Interview for Mental Status) score of 3, which indicates R1 was severely cognitively impaired. […]

• No harm, potential for more than minimal, widespreadF812Aug 19, 2025

  Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 39 of 39 residents.Surveyor observed food to have been removed from the original packaging and not dated with an expiration date, an open date, or a use by date. Evidenced by: Facility policy, entitled Food Storage, date revised 8/16/2022, states in part: .13. Frozen Foods: .c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. […]

• No harm, potential for more than minimal, widespreadF851Jul 24, 2024

  Based on interview and record review, the facility failed to submit accurate data to Centers for Medicare and Medicaid Services (CMS) mandatory Payroll Based Journal (PBJ) for Quarter 4 2023, Quarter 1 2024, and Quarter 2 2024. This had the potential to affect all 38 residents. Findings: On 07/22/24 at 1:21 PM, Surveyor interviewed Business Office Manager (BOM) G about the low weekend staffing data and no Registered Nurse (RN) that was triggered in the PBJ report. Surveyor asked for the information that was submitted. On 07/23/24 at 9:46 AM, Surveyor interviewed BOM G and asked for the information submitted for the PBJ. BOM G replied, I thought that you already had that information, so I wasn't sure if I needed to print that out or not. […]

• No harm, potential for more than minimal, widespreadF812Apr 6, 2023

  Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is stored and distributed in accordance with professional standards for food service safety. This has the potential to affect all 33 residents who reside in the facility. Surveyor observed DA F (Dietary Aide) during dishwashing. Surveyor observed DA F go from working with dirty dishes to clean dishes four times without washing hands in between. Evidenced by: The facility policy titled, Cleaning Dishes Dish Machine, with a reviewed date of 7/13/22, includes, in part: Policy Explanation and Compliance Guidelines .2. […]