A list of the most recent deficiencies for Lancaster Ltc Partners Inc. 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-12-06 | 2023-12-29 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-20 | 2023-10-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-20 | 2023-10-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-09-20 | 2023-10-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-20 | 2023-10-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-20 | 2023-10-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-20 | 2023-10-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-20 | 2023-10-20 | N |
| 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. | Health | 2023-08-31 | 2023-10-06 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-08-31 | 2023-10-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-18 | 2022-12-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-27 | 2022-08-19 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-07-27 | 2022-08-17 | 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 | 2022-07-27 | 2022-08-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-27 | 2022-08-17 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-07-27 | 2022-08-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-27 | 2022-08-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-26 | 2022-08-17 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-07-26 | 2022-08-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-07-26 | 2022-08-17 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-07-26 | 2022-08-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-26 | 2022-08-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-27 | 2022-08-15 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-07-27 | 2022-07-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-07 | 2021-12-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-08 | 2021-11-03 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-10-08 | 2021-11-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-20 | 2021-07-04 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-05-20 | 2021-06-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-20 | 2021-06-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-20 | 2021-06-10 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-05-20 | 2021-05-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-20 | 2021-05-25 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-05-20 | 2021-05-25 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-05-20 | 2021-05-24 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-20 | 2021-05-24 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-05-20 | 2021-05-24 | 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 | 2021-05-20 | 2021-05-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-05-20 | 2021-05-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-20 | 2021-05-24 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-05-20 | 2021-05-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-29 | Not Fixed | N |
