Deficiency Records for Lancaster Nursing and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Lancaster Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-01 | 2023-11-21 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-07-27 | 2023-09-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-07-27 | 2023-09-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-07-27 | 2023-09-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-27 | 2023-09-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-07-27 | 2023-09-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-27 | 2023-09-06 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-07-27 | 2023-09-06 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-07-27 | 2023-09-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-07-27 | 2023-09-06 | N |
| 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. | Health | 2023-07-27 | 2023-09-06 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-27 | 2023-09-06 | N |
| Meet other general requirements. | Fire Safety | 2023-07-12 | 2023-08-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-12 | 2023-08-29 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-07-12 | 2023-08-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-12 | 2023-08-29 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-07-12 | 2023-08-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-12 | 2023-08-29 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-07-12 | 2023-08-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-12 | 2023-08-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-12 | 2023-08-29 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2023-07-12 | 2023-08-29 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-07-12 | 2023-08-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-27 | 2023-07-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-27 | 2023-07-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-07 | 2023-04-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-07 | 2023-04-07 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-11-08 | 2023-01-04 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-07-27 | 2022-09-13 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-07-27 | 2022-09-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-27 | 2022-09-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-27 | 2022-09-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-27 | 2022-09-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-27 | 2022-09-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-27 | 2022-09-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-27 | 2022-09-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-27 | 2022-09-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-27 | 2022-09-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-07-27 | 2022-09-13 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-07-27 | 2022-09-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-15 | 2022-09-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-15 | 2022-09-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-07-15 | 2022-09-01 | N |
| 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. | Health | 2022-07-15 | 2022-09-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-15 | 2022-09-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-24 | 2021-10-14 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-09-24 | 2021-10-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-08-16 | 2021-09-23 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-07 | 2021-07-14 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-06-07 | 2021-07-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-07 | 2021-07-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-07 | 2021-07-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-06-07 | 2021-07-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-07 | 2021-07-14 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-06-10 | 2021-07-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-10 | 2021-07-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-06-10 | 2021-07-09 | N |
