Lancaster Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Lancaster Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Sep 24, 2021

  Based on review of facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure residents were free from neglect when they failed to respond in an appropriate and timely manner to a missing resident for one of 44 residents approved for leave of absences (Resident 1). Additionally, the facility failed to develop and implement guidelines for staff, including time frames for responding to missing residents. This failure placed the residents at high risk of potential for accidents, injury, or serious harm and placed the facility in an Immediate Jeopardy situation. […]

• Actual harm, isolatedF760Aug 16, 2021

  Based upon facility policy and procedures, clinical record, and facility reported incident review, it was determined the facility failed to ensure residents were free from significant medication errors for one of six residents reviewed, which resulted in actual harm to one resident (Resident R1). Findings include: Review of facility policy and procedure titled Administering Medications revealed If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the… […]

• No harm, potential for more than minimal, patternF584Jan 9, 2026

  Based on observation, staff interview, and facility documentation review revealed the facility failed to maintain a sanitary environment for 3 of 7 units. (4th, 5th, and 6th floors)Findings include:Observation on January 9, 2026 at 10:45 a.m. of the 6th floor west side shower room revealed 1 live roach in a supply cabinet, 5 dead roaches in the same supply cabinet, and 1 dead roach in the sink. 1 dying roach (approximately 3 inches in length) was observed in the 6th floor lobby in front of the elevators.Observation on January 9, 2026 at 11:30 a.m. of the 5th floor east side shower room revealed multiple dead roaches in the toilet and shower rooms and 1 live roach on the shower curtain.Observation on January 9, 2026 at 12:15 p.m. […]

• No harm, potential for more than minimal, patternF692Apr 11, 2025

  Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure weights were monitored and a significant weight change was promptly addressed for five out of 15 residents reviewed (Residents 27, 74, 158, 202, and 338). Findings include: A review of the facility's policy titled Weight Assessment and Interventions, last revised in March 2022, states Resident weights are monitored for undesireable or unintended weight loss or gain. Any weight change of 5% or more since the last weight assessment must be retaken the next day for confirmation. A. If the weight is verified, nursing will notify the dietitian. Review of Resident 27's physician's orders included an order to weigh monthly every day shift every four weeks. […]

• No harm, potential for more than minimal, patternF761Apr 11, 2025

  Based on a review of the facility policy, review of the medication manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to properly store and label medication on four of four medication carts reviewed (7th Floor South Side Cart, 7th Floor North Side Cart, 8th Floor North/South Cart and 8th Floor Southeast/Northeast Cart) Findings include: A review of the facility's policy titled Medication Labeling and Storage, revision date of February 2023, revealed that medications and biologicals are stored in the packaging, containers, or other dispensing systems they are received. Only the issuing pharmacy is authorized to transfer medications between containers. Medications may not be transferred between containers. […]