Lancaster Nursing & Rehabilitation

Penalties

• Aug 1, 2025 — Fine ($36,480)
• May 2, 2024 — Fine ($20,074)

Inspection findings

1. Mar 6, 2026 Health · 1 finding
   • Not serious Scope/severity C Complaint

     F0575 Resident Rights Deficiencies

     Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

     CMS health inspection

2. Jan 8, 2026 Health · 9 findings
   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Feb 3, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Feb 3, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected Feb 3, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Feb 3, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Feb 3, 2026 · CMS health inspection

   • Not serious Scope/severity D

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Feb 16, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Feb 16, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Feb 16, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Feb 16, 2026 · CMS fire safety

3. Nov 21, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Nov 22, 2025 · CMS health inspection

4. Aug 1, 2025 Health · 1 finding
   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Aug 2, 2025 · CMS health inspection

5. Mar 5, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0622 Resident Rights Deficiencies

     Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

     Corrected Apr 14, 2025 · CMS health inspection

6. Feb 21, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Feb 22, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0725 Nursing and Physician Services Deficiencies

     Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

     Corrected Feb 22, 2025 · CMS health inspection

7. Oct 10, 2024 Health · 14 findings
   • Not serious Scope/severity D Complaint

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Oct 11, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0585 Resident Rights Deficiencies

     Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

     Corrected Oct 11, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0603 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

     Corrected Oct 11, 2024 · CMS health inspection

   • 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 Oct 11, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Oct 11, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Oct 11, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected Oct 11, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Oct 11, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Oct 11, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected Oct 11, 2024 · CMS health inspection

   • Not serious Scope/severity C

     F0851 Administration Deficiencies

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

     Corrected Oct 11, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Oct 11, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Oct 10, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Nov 5, 2024 · CMS fire safety

8. May 2, 2024 Health · 2 findings
   • Serious Scope/severity K Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected May 24, 2024 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0725 Nursing and Physician Services Deficiencies

     Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

     Corrected May 24, 2024 · CMS health inspection

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

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Apr 26, 2024 · CMS health inspection

10. Feb 3, 2024 Health · 2 findings
    • Not serious Scope/severity D Complaint

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Feb 28, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Feb 28, 2024 · CMS health inspection

11. Jan 29, 2024 Health · 1 finding
    • Not serious Scope/severity E Complaint

      F0558 Resident Rights Deficiencies

      Reasonably accommodate the needs and preferences of each resident.

      Corrected Feb 16, 2024 · CMS health inspection

12. Dec 6, 2023 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Dec 29, 2023 · CMS health inspection

13. Sep 20, 2023 Health · 7 findings
    • Not serious Scope/severity E

      F0755 Pharmacy Service Deficiencies

      Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

      Corrected Oct 20, 2023 · CMS health inspection

    • Not serious Scope/severity E

      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 Oct 20, 2023 · CMS health inspection

    • Not serious Scope/severity F

      K0363 Smoke Deficiencies

      Install corridor and hallway doors that block smoke.

      Corrected Oct 31, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0372 Smoke Deficiencies

      Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

      Corrected Oct 31, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0374 Smoke Deficiencies

      Install smoke barrier doors that can resist smoke for at least 20 minutes.

      Corrected Oct 31, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0712 Miscellaneous Deficiencies

      Have simulated fire drills held at unexpected times.

      Corrected Oct 31, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0741 Miscellaneous Deficiencies

      Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

      Corrected Oct 20, 2023 · CMS fire safety

14. Aug 31, 2023 Health · 2 findings
    • Not serious Scope/severity D Complaint

      F0584 Resident Rights Deficiencies

      Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

      Corrected Oct 6, 2023 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0919 Environmental Deficiencies

      Make sure that a working call system is available in each resident's bathroom and bathing area.

      Corrected Oct 6, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• BLAKE, GARY — indirect ownership interest, NOT APPLICABLE, since 07/01/2024
• BLAKE, GARY — adp of the snf, NOT APPLICABLE, since 07/01/2024
• BLAKE, GARY — operational/managerial control, NOT APPLICABLE, since 07/01/2024
• BLAKE, MALISA — adp of the snf, NOT APPLICABLE, since 07/01/2024
• BLAKE, MALISA — operational/managerial control, NOT APPLICABLE, since 07/01/2024
• BLAKE, MALISA — indirect ownership interest, NOT APPLICABLE, since 07/01/2024
• CLANTON, AUSTON — operational/managerial control, NOT APPLICABLE, since 07/01/2024
• CLANTON, AUSTON — adp of the snf, NOT APPLICABLE, since 07/01/2024
• EAMIGUEL, CHRISTOPHER — operational/managerial control, NOT APPLICABLE, since 07/01/2024
• EAMIGUEL, CHRISTOPHER — adp of the snf, NOT APPLICABLE, since 07/01/2024
• HUGGINS, LINDA — adp of the snf, NOT APPLICABLE, since 07/01/2024
• HUGGINS, LINDA — operational/managerial control, NOT APPLICABLE, since 07/01/2024
• HUGGINS, LINDA — corporate director, NOT APPLICABLE, since 07/01/2024
• SILVA, PHILLIP — adp of the snf, NOT APPLICABLE, since 04/09/2025
• STAPLETON, LILLIAN — adp of the snf, NOT APPLICABLE, since 04/09/2025
• WILLIG, ZACHARY — adp of the snf, NOT APPLICABLE, since 07/01/2024
• WILLIG, ZACHARY — operational/managerial control, NOT APPLICABLE, since 07/01/2024
• CREATIVE SOLUTIONS IN HEALTHCARE INC — adp of the snf, NOT APPLICABLE, since 07/01/2024
• CREATIVE SOLUTIONS IN HEALTHCARE INC — operational/managerial control, NOT APPLICABLE, since 07/01/2024
• HONOR X ENTERPRISES, LLC — direct ownership interest, NOT APPLICABLE, since 07/01/2024
• LANCASTER I ENTERPRISES, LLC — operational/managerial control, NOT APPLICABLE, since 07/01/2024