Lancaster Afh LLC

Penalties

• — DQA enforcement letter

Inspection findings

Nursing homes: CMS Care Compare inspections (last three cycles), penalties and ownership. Assisted living: DHS directory data and statements of deficiencies DHS has posted since October 2026; older survey documents are on the DQA Provider Search. An absence of findings here does not mean a clean record.

1. Jul 27, 2026 DQA survey · 11 findings
   • Severity not stated

     M 0204 88.03(8)(a) Monitoring of Home

     Statement of deficiencies (PDF)

   • Severity not stated

     M 0230 88.04(2)(f) Condition Which Represents

     Risk or Harm

     Statement of deficiencies (PDF)

   • Severity not stated

     M 204 88.03(8)(a) MONITORING OF HOME

     Based on record review and interview, the licensee did not comply with all Department requests for information about the operation of the home. Staff-related records provided by Licensee A were at times either not provided in requested deadlines, not provided at all, or inconsistent with Licensee A's previously provided records and reports to Surveyor, all of which limited Surveyor's ability during a complaint investigation to verify staffing of the home and the specific service providers that came into contact with the provider's residents. Findings include: On 06/29/2026, with information obtained through 07/27/2026, Surveyor conducted a complaint investigation into allegations that staff who worked in the home were misrepresenting their identities. At approximately 12:10 p.m., Surveyor conducted a phone interview with Licensee A and during this requested a staff roster that identified all current and former employees who worked at the home from 01/01/2026 through the current day. Surveyor checked in with Licensee A on 1:15 p.m. and 3:16 p.m. regarding the roster status, during which Licensee A reported s/he was still working on it. At approximately 3:53 p.m., Surveyor received t

     Statement of deficiencies (PDF)

   • Severity not stated

     M 230 88.04(2)(f) CONDITION WHICH REPRESENTS

     Based on record review and interview, the licensee permitted an existence of a condition in the home which placed the safety and welfare of residents at substantial risk of harm by staff misrepresenting either their worked shifts/caregiving tasks completed or their identities regarding worked shifts and caregiving tasks. Findings include: On 06/29/2026, with information obtained through 07/27/2026, Surveyor conducted a complaint investigation into allegations that staff who worked in the home were misrepresenting their identities. On 06/29/2026, at approximately 12:10 p.m., Surveyor interviewed Licensee A. Licensee A reported staff records were not maintained at the home, except for select records, and that s/he generally maintained them virtually. Licensee A confirmed that only s/he could access the service provider records. Surveyor requested a staff roster in order to further select service provider records for review. Surveyor specifically requested the roster to identify any current employees and former employees who worked at the home from 01/01/2026 through the current day. At approximately 1:15 p.m., Surveyor interviewed Licensee A. Licensee A reported s/he was still workin

     Statement of deficiencies (PDF)

   • Severity not stated

     M 276 88.05(3)(a) Homelike Environment

     Based on observation and interview, the provider did not ensure that the adult family home was safe and provided a homelike environment when the temperatures in the home's living room and Resident 1's bedroom ranged from 76.8°F to 81.7°F. Findings include: On 06/29/2026, at approximately 11:30 a.m., Surveyor entered the home to conduct a survey. At approximately 11:38 a.m., Surveyor entered Resident 1's bedroom. One of Resident 1's windows was open. Surveyor took a temperature of Resident 1's bedroom, which was 79.3°F. Caregiver B stated, "It's kind of hot." At approximately 11:40 a.m., Surveyor observed the home's thermostat on the main level, located near the living room. The thermostat indicated a temperature of 79°F. The thermostat displayed a notice to "Clean filter," (Photo 1). It was unclear based on the display if the temperature indicator was a current indoor temperature reading or the temperature the thermostat was set to. At approximately 12:32 p.m., Surveyor viewed weather information from the National Weather Service (NWS). Based approximately on Surveyor's location at the home, the outdoor temperature was approximately 88°F at that time and projected to reach a high o

     Statement of deficiencies (PDF)

   • Severity not stated

     M 354 88.05(5) TELEPHONE

     Based on observation and interview, the provider did not ensure that a non-pay telephone was provided for residents to make and receive telephone calls. Findings include: On 06/29/2026, Surveyor reviewed Department records for the provider and observed that the home's listed phone number was the same as the licensee's contact phone number. On 06/29/2026, at approximately 11:30 a.m., Surveyor interviewed Caregiver B. Caregiver B reported there was no house phone. Surveyor reviewed the listed phone number provided for the home with Caregiver B, who confirmed that it was not the house number since there was no house phone. Caregiver B reported s/he believed the identified phone number was Licensee A's direct contact number. On 06/29/2026, while observing the home's common areas at approximately 12:45 p.m., Surveyor did not observe a house phone. On 07/21/2026, at approximately 1:55 p.m., Surveyor interviewed Consultant K, who reported s/he functionally served as the case manager for Resident 2 from his/her managed care organization. When discussing Consultant K's ability to get in contact with Resident 2, Consultant K reported s/he had to typically call either his/her relative (who di

     Statement of deficiencies (PDF)

   • Severity not stated

     M 406 88.06(3)(b) PERSONS INVOLVED WITH ISP &

     Based on record review and interview, the provider did not ensure that Resident 1's individual service plan (ISP) and assessment was developed with his/her legal guardian. Findings include: On 06/29/2026, Surveyor reviewed Resident 1's record. Resident 1 was admitted to the provider on 03/09/2026. On 07/16/2026, at approximately 10:59 a.m., Surveyor interviewed Licensee A. Surveyor requested the 2 most recently signed ISPs for Resident 1, if more than 1 existed since his/her admission, to be e-mailed to him/her. Surveyor gave a deadline of 5:00 p.m. that day. No ISPs were received. On 07/16/2026, at approximately 7:05 p.m., Surveyor e-mailed Licensee A and confirmed that no ISPs were received. On 07/17/2026, at approximately 8:45 a.m. (approximately 12 hours after Surveyor's deadline), Surveyor received one ISP and behavioral support plan (BSP) for Resident 1. Both were dated "03/2026." Resident 1's ISP documented, "This agency-level resident packet has been developed using [Resident 1]'s individualized [electronic record platform] information, behavior support planning, crisis cycle data, service planning needs, and support goals." There was no information about either the ISP or

     Statement of deficiencies (PDF)

   • Severity not stated

     M 424 88.06(3)(f) REVIEW OF ISP

     Based on record review and interview, the provider did not ensure that the individual service plan (ISP) for 1 of 1 applicable resident reviewed, was reviewed every 6 months by the resident and the resident's service coordinator. The 2 most recent ISPs for Resident 2, dated 12/08/2025 and 05/07/2026, did not have any evidence of being reviewed by anyone other than the provider. Findings include: On 06/29/2026, Surveyor reviewed a partial record for Resident 2. Resident 2 was admitted to the provider on 12/28/2022 and was identified as being his/her own legal representative. Resident 2's record onsite did not identify his/her service coordinator information, but information provided by Licensee A via text to Caregiver B at approximately 1:03 p.m. identified his/her managed care organization as well as his/her service coordinator's e-mail contact and phone number. On 07/16/2026, at approximately 10:59 a.m., Surveyor interviewed Licensee A and requested the two most recently signed and/or reviewed ISPs for Resident 2. Surveyor gave a deadline of 5:00 p.m. that day. No ISPs were received. At approximately 7:05 p.m., Surveyor e-mailed Licensee A and confirmed that no ISPs as requested w

     Statement of deficiencies (PDF)

   • Severity not stated

     M 466 88.07(3)(e)1 MEDICATION- RECORD KEEPING

     Based on record review and interview, the provider did not ensure that the record of all prescription medications administered by staff showed either the administration of the medications or their omissions. Resident 1's medication administration record (MAR) for May 2026 contained a collective 107 blank entries across 4 medications within a period of 23.5 days. This is a repeat deficiency. See Statement of Deficiency (SOD) F3SB11, dated 09/30/2025. Findings include: On 06/29/2026, Surveyor reviewed Resident 1's partial record. Resident 1's partial record included MARs in which staff initialed off on the administration of Resident 1's medications. At approximately 12:15 p.m., Caregiver B confirmed that staff controlled and administered Resident 1's medications. In reviewing Resident 1's May MAR, Surveyor observed the following: - Entry for cetirizine 10 mg tablets, with an order start date of 03/11/2026 and instructions to, "Take 1 tablet by mouth twice daily." Subentries within this entry documented administration at 8:00 a.m. and 8:00 p.m. daily. Staff initialed off on all administrations from 05/01/2026 through the 8:00 a.m. administration on 05/08/2026, but the remainder of the

     Statement of deficiencies (PDF)

   • Severity not stated

     M 482 88.09(1)(a) RESIDENT RECORDS

     Based on record review and interview, the provider did not ensure that the name, address, and phone number of Resident 1's service coordinator as well as the name, address, and phone number of Resident 1's legal guardian were maintained within his/her record within the home. Findings include: On 06/29/2026, Surveyor reviewed Resident 1's partial record, which was located within the home. At approximately 12:15 p.m., Surveyor was reviewing Resident 1's medication administration records (MARs) and asked Caregiver B about administration initials that did not appear to match the provider's staff initials. Caregiver B reported they were the initials of Person D, who was Resident 1's family member. At approximately 12:35 p.m., Caregiver B reported s/he was unsure if Person D or another family member of Resident 1 served as his/her legal guardian. In reviewing the entirety of Resident 1's record available at the home, Surveyor did not find any records identifying any guardian information, including contact information, for Resident 1. Resident 1's record identified the agency that placed him/her but in reviewing the entirety of Resident 1's record available at the home, Surveyor did not f

     Statement of deficiencies (PDF)

   • Severity not stated

     M 540 88.09(2)(c) Location and Retention Period

     Based on record review and interview, the provider did not ensure that the records of 4 of 4 current service provider were available at the adult family home for review by the licensing agency or that the records for 2 of 2 former service providers were retained for at least 3 years after ending employment. Findings include: On 06/29/2026, at approximately 12:10 p.m., Surveyor interviewed Licensee A. Licensee A reported staff records were not maintained at the home, except for select records, and that s/he generally maintained them virtually. Licensee A confirmed that only s/he could access the service provider records. Surveyor requested a staff roster in order to further select service provider records for review. On 06/29/2026, Surveyor reviewed the only staff records available in the home, which consisted of 1 background information disclosure (BID) each for the 2 staff on shift, Caregiver B and Caregiver F. At approximately 1:15 p.m., Surveyor interviewed Licensee A. Licensee A reported s/he was still working on the staff roster to provide to Surveyor. At approximately 3:16 p.m. (approximately 3 hours after the initial request for a staff roster), Surveyor interviewed Licensee

     Statement of deficiencies (PDF)