Lancaster Health Services

Inspection findings

1. Aug 19, 2025 Fire Safety · 15 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Sep 18, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0578 Resident Rights Deficiencies

     Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

     Corrected Sep 16, 2025 · CMS health inspection

   • Serious Scope/severity J

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected Sep 16, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Sep 16, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Sep 16, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Sep 16, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Sep 16, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected Sep 16, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Sep 18, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0343 Smoke Deficiencies

     Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

     Corrected Sep 18, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Sep 18, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Sep 18, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0912 Gas, Vacuum, and Electrical Systems Deficiencies

     Have power receptacles that are properly grounded.

     Corrected Sep 18, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Sep 18, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Sep 18, 2025 · CMS fire safety

2. Feb 19, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Mar 18, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Mar 18, 2025 · CMS health inspection

3. Aug 27, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0697 Quality of Life and Care Deficiencies

     Provide safe, appropriate pain management for a resident who requires such services.

     Corrected Sep 27, 2024 · CMS health inspection

4. Jul 24, 2024 Health · 9 findings
   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Aug 23, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0851 Administration Deficiencies

     Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

     Corrected Mar 5, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 23, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0911 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the installation and maintenance of electrical systems.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0912 Gas, Vacuum, and Electrical Systems Deficiencies

     Have power receptacles that are properly grounded.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0919 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the use of electrical equipment.

     Corrected Aug 23, 2024 · CMS fire safety

5. Apr 24, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected May 3, 2024 · CMS health inspection

6. Apr 6, 2023 Health · 5 findings
   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected May 2, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 2, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected May 2, 2023 · CMS health inspection

   • Not serious Scope/severity C

     F0888 Infection Control Deficiencies

     Ensure staff are vaccinated for COVID-19

     Corrected Apr 6, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Apr 17, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BAUMANN, TROY — adp of the snf, NOT APPLICABLE, since 12/01/2019
• BAUMANN, TROY — operational/managerial control, NOT APPLICABLE, since 12/01/2019
• BAUMANN, TROY — corporate director, NOT APPLICABLE, since 10/01/2019
• BELONGIA, CHRISTINA — adp of the snf, NOT APPLICABLE, since 12/01/2019
• BELONGIA, CHRISTINA — operational/managerial control, NOT APPLICABLE, since 12/01/2019
• GEE, DARREN — operational/managerial control, NOT APPLICABLE, since 11/30/2021
• GEE, DARREN — adp of the snf, NOT APPLICABLE, since 11/30/2021
• GREER, LAUREN — adp of the snf, NOT APPLICABLE, since 11/29/2023
• GREER, LAUREN — operational/managerial control, NOT APPLICABLE, since 11/29/2023
• HOEHN, JEFFREY — corporate director, NOT APPLICABLE, since 12/01/2019
• HOEHN, JEFFREY — adp of the snf, NOT APPLICABLE, since 12/01/2019
• HOEHN, JEFFREY — operational/managerial control, NOT APPLICABLE, since 12/01/2019
• HORSTMAN, NATALIE — operational/managerial control, NOT APPLICABLE, since 01/21/2026
• HORSTMAN, NATALIE — adp of the snf, NOT APPLICABLE, since 01/21/2026
• MILLS, DAVID — 5% or greater indirect ownership interest, 18%, since 10/01/2019
• PATZER, COLLEEN — operational/managerial control, NOT APPLICABLE, since 02/14/2023
• PATZER, COLLEEN — adp of the snf, NOT APPLICABLE, since 02/14/2023
• PURTELL, BRIAN — operational/managerial control, NOT APPLICABLE, since 12/01/2019
• PURTELL, BRIAN — adp of the snf, NOT APPLICABLE, since 12/01/2019
• SLANE, ERIC — adp of the snf, NOT APPLICABLE, since 02/01/2023
• SLANE, ERIC — operational/managerial control, NOT APPLICABLE, since 02/01/2023
• ARROWHEAD 123 LLC — 5% or greater indirect ownership interest, 10%, since 10/01/2019
• ARROWHEAD 123 LLC — adp of the snf, NOT APPLICABLE, since 12/01/2019
• CIBC BANK USA — 5% or greater mortgage interest, NOT APPLICABLE, since 12/31/2024
• CIBC BANK USA — operational/managerial control, NOT APPLICABLE, since 12/31/2024
• CIBC BANK USA — 5% or greater security interest, NOT APPLICABLE, since 12/31/2024
• CLIFTONLARSONALLEN LLP — adp of the snf, NOT APPLICABLE, since 06/06/2025
• CLIFTONLARSONALLEN LLP — operational/managerial control, NOT APPLICABLE, since 12/01/2019
• CONTINUUM THERAPY PARTNERS LLC — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• CONTINUUM THERAPY PARTNERS LLC — adp of the snf, NOT APPLICABLE, since 06/06/2025
• NORTH SHORE HEALTHCARE LLC — operational/managerial control, NOT APPLICABLE, since 12/01/2019
• NORTH SHORE HEALTHCARE LLC — adp of the snf, NOT APPLICABLE, since 06/06/2025
• NSH 1350 SOUTH MADISON STREET LLC — adp of the snf, NOT APPLICABLE, since 12/01/2019
• NSH REHAB LLC — adp of the snf, NOT APPLICABLE, since 06/06/2025
• NSH REHAB LLC — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• NSHR OPERATIONS LLC — 5% or greater direct ownership interest, 100%, since 10/01/2019
• THE LANE MORRELL BOWEN TRUST — adp of the snf, NOT APPLICABLE, since 12/01/2019
• THE LANE MORRELL BOWEN TRUST — 5% or greater indirect ownership interest, 10%, since 10/01/2019
• WIPFLI LLP — operational/managerial control, NOT APPLICABLE, since 02/01/2025
• WIPFLI LLP — adp of the snf, NOT APPLICABLE, since 06/06/2025