Lancaster Nursing & Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF689May 2, 2024

  Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and that the resident's environment remained as free of accident hazards as possible for one (Resident #1) of five residents reviewed for elopement on the facility's secured unit. The facility failed to adequately supervise, monitor, and implement interventions to prevent Resident #1 (who was assessed with severe cognitive impairment and as being at risk for elopement) from eloping from the facility unsupervised on [DATE] where he remained unaccounted for overnight. The resident was located on [DATE], 2.6 miles from the facility. […]

• Immediate jeopardy, patternF725May 2, 2024

  Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 11 of 11 residents (Resident #1, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12) residing on the secured unit. 1. […]

• Immediate jeopardy, patternF880Oct 8, 2021

  Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for eight (Residents #1, #2, #3, #4, #5, #6, #7, & #8) of eight residents reviewed for infection control. The facility failed to isolate COVID-19 positive Residents #1, #2, #3, and #4 after they tested positive for COVID-19 and continued to cohort them in the same room with residents who had tested negative for COVID-19 . An Immediate Jeopardy (IJ) was identified on 10/07/21 at 6:05 PM. The Administrator was provided with the IJ template on 10/07/21 at 6:05 PM. […]

• Immediate jeopardy, isolatedF689Aug 1, 2025

  Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and received adequate supervision 2 of 9 residents (Resident's #1 and #2) reviewed for accident hazards.1. The facility failed to immediately fix a broken window in the Memory Care Unit's dayroom. Resident #1 grabbed a shard of the glass and attempted to remove it. The Surveyor intervened to get the resident to stop grabbing it.An Immediate Jeopardy (IJ) was identified on 07/17/25. The IJ template was provided to the facility on [DATE] at 4:55 PM . […]

• No harm, potential for more than minimal, widespreadF812May 20, 2021

  Based on observation, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1. The facility failed to ensure food was properly stored in the facility's dry storage, refrigerator, and freezer. 2. The facility failed to ensure expired foods were discarded. These failures could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on [DATE] at 9:31 AM revealed: - One molded onion stored in a box of squash; - Opened bag and box of sausage exposed to air; - Opened box of bacon exposed to air; and - 1 cracked egg in a box of eggs. […]