Lancaster Nursing & Rehabilitation

Inspectors wroteBased on observations, interviews and record review the facility failed to post a list of names, address and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency and State licensure office for one of one facility reviewed. The facility failed to update the required facility postings identifying HHSC as the pertinent state agency. This failure could affect the residents' ability to identify and contact the appropriate state agencies. Findings Included: During an observation on 03/06/26 at 09:25am, the facility posting How to File a Complaint was observed hanging on the wall. The posting stated The Texas Department of Disability Services (DADS) hopes that you are satisfied with the care and/or services provided at this facility. [...]

Inspectors wroteBased on interviews, and record review the facility failed to provide activities based on the care plan designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 (Resident #2 and Resident #20) of 5 residents on the secured unit who were reviewed for activities. The facility failed to provide posted activities to Resident #2 and Resident # 20 on the memory care unit. These failures placed residents at risk of becoming apathetic (marked indifference to the environment), having a depressed mood and a decreased quality of life.

Inspectors wroteBased on interviews and record review the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) level 1 residents with mental illness were provided with a PASRR level 2 evaluation for 1 of 3 residents (Resident #34), reviewed for resident assessment. Resident #34's PASRR level 1 screening form did not reflect mental illness, and the resident did not have a PASRR level II evaluation. This could place residents at risk of not receiving necessary specialized services to meet their individual needs.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene, for 2 (Resident #2 and Resident #20) of 10 residents reviewed for ADLs. The facility failed to provide nail care for Resident #2 and Resident #20. This failure placed residents who required assistance with ADLs at risk of a decline in their quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, for 3 of 5 Residents (Resident#12, Resident#8 and Resident#17), reviewed for respiratory care. The facility failed to ensure that Resident#8, oxygen tubing's was changed and dated per physician orders. The facility failed to ensure that Resident#12, and Resident#8's Oxygen tubing's, were bagged in a plastic bag and stored in a drawer which was consistent with professional standards. The facility failed to ensure that Resident#17's nebulizer mask was bagged in a plastic bag and stored in a drawer which was consistent with professional standards. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of 1 medication on 1 medication cart of 2 medication carts reviewed for pharmacy services. The facility failed to ensure proper storage and disposal of Resident#11's tramadol 50 hcl mg (controlled medication) by taping a narcotic medication and retaining a discontinued narcotic in medication cart. These failures could place residents at risk of medication error due to administration of medication without physician order and at risk of pills contamination due to broken seals.

Inspectors wroteBased on interviews and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C to the maximum extent practicable to avoid duplicative testing and effort for 1 (Resident #1) of 3 residents reviewed for PASARR services and assessments. The facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team Meeting for Resident #1. This failure placed residents at risk of not receiving needed specialized services that could impact their healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and received adequate supervision 2 of 9 residents (Resident's #1 and #2) reviewed for accident hazards.1. The facility failed to immediately fix a broken window in the Memory Care Unit's dayroom. Resident #1 grabbed a shard of the glass and attempted to remove it. The Surveyor intervened to get the resident to stop grabbing it. An Immediate Jeopardy (IJ) was identified on 07/17/25. The IJ template was provided to the facility on [DATE] at 4:55 PM . While the IJ was removed on 07/18/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the transfer or discharge is documented in the medical record for one (Resident #1) of four residents reviewed for clinical records. The facility (RN A) failed to complete a Transfer/Discharge Form on 03/03/25 when he sent Resident #1 for evaluation to the Emergency Room. This failure could put residents at risk of arriving at the emergency room without information regarding their medical conditions or needs.

Inspectors wroteBased on interviews and record review, the facility failed the have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population for 2 (Resident #1 and Resident #2) of 5 residents reviewed for sufficient staffing. The facility failed to ensure the facility had sufficient staffing to meet the needs of Resident #1 and Resident #2. This failure could place the residents at risk of their needs, safety, and psychosocial well-being not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (Resident #1) of five residents reviewed for ADLs. The facility failed to provide showers or bed baths consistently for Resident #1 per the facility bathing schedule in February 2025. This failure placed residents who were dependent on staff for bathing at risk for poor personal hygiene, odors, and a decline in their quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to notify residents or their representatives on how to file a grievance in an anonymous manner, and the information of who the facility named as the Grievance Official for 5 residents out of 5 residents interviewed for grievances. 1. The facility failed to notify Residents or their representatives either individually or through prominent postings throughout the facility on how to file a grievance or complaint in an anonymous manner. 2. The facility failed to follow their grievance policy by providing the correct information as to who the facility identified as the Grievance Official for 5 resident. These failures could affect resident's ability to file a grievance without the fear of discrimination, reprisal, retribution, and their right to request a written decision regarding the resolution of their grievance. [...]

Inspectors wroteBased on interviews record reviews the facility failed to ensure residents in the locked memory care unit were free from involuntary seclusion for 1 (Resident #45) of 8 residents reviewed for involuntary seclusion. The facility failed to ensure Resident #45 was free from physical restraints. Facility staff placed Resident #45 in the secure unit for staff convenience. This failure could place residents at risk for a decreased quality of life, a decline in physical functioning, and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities based on the comprehensive assessment and care plan, designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident for 2 (Resident #11 and Resident #38) of 4 residents on the secured unit who were reviewed for activities. The facility failed to consistently provide posted activities to Resident #11 and Resident #38 that were age/cognition appropriate, and the facility did not consistently provide encouragement and assistance to participate in any provided activities. These failures placed residents at risk of becoming apathetic (marked indifference to the environment), isolated from others, having a depressed mood, boredom, loneliness, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents, as well as that residents' environment remained as free of accident hazards as was possible, for 7 (Residents #5, #9, #11, #18, #20, #38, and #40) of 16 residents reviewed for accidents and supervision. 1.) The facility failed to ensure Resident #9 disposed of his cigarette in a safe manner on 10/08/24. Resident #9 disposed of his cigarette, which was still lit, in a regular trashcan that had other waste in it. The cigarette continued to smoke for approximately 10 minutes after it had been disposed of in the regular trashcan. 2.) The facility failed to have sufficient staff available to provide resident care and supervision for the secured unit on the 6:00AM to 2:00PM shift on 10/09/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for one (Resident #13) of eight residents reviewed for unnecessary medications. The facility failed to ensure Resident #13 was not prescribed to take Clonazepam and Lorazepam which are both in the same class of medication (benzodiazepines -medications that work in the central nervous system to treat various medical conditions) This failure could affect residents by placing them at risk for possible adverse side effects, a decreased quality of life and continued use of possible unnecessary medications.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Resident #147, Resident #19, Resident #42, Resident #21, and Resident #30) of eight residents observed for infection control. 1. The facility failed to post proper signage and put out PPE for Resident #21 who was on enhanced barrier precautions. 2. LVN A failed to perform hand hygiene and clean the blood pressure cuff between uses for Resident #147 and Resident #19. 3. CNA B failed to perform hand hygiene while performing incontinence care for Resident #30. 4. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident #21) of 8 resident rooms reviewed for cleanliness. The facility failed to ensure that Resident #21's room was thoroughly cleaned. This failure could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 3 residents (Resident #1) reviewed for neglect reporting. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that an alleged violation involving neglect was thoroughly investigated for 1 (Resident #13) of 8 residents reviewed. The facility failed to have evidence of a thorough investigation as there was no documented evidence provided of an investiation, when Resident #13 went to the hospital as a result of an injury of an unknown source that occured on 08/09/24. This failure could place residents at risk of abuse, neglect, and/or exploitation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (Resident #18) of four residents reviewed for ADLs. The facility failed to provide Resident #18 with his scheduled bathing/hygienic care on 10/08/24. This failure had the potential to affect residents who were dependent on staff for bathing by placing them at risk for poor personal hygiene, odors, embarrassment, low self-worth and a decline in their quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one (Resident #18) of eight residents reviewed for pharmacy services. RN D failed to ensure Resident #18 swallowed his medication after she administered it. This failure placed residents at risk of choking on their medications.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 5 (CMS for FY Quarter 3 2023, FY Quarter 4 2023, FY Quarter 1 2024, FY Quarter 2 2024, and FY Quarter 3 2024) of 5 quarters reviewed for compliance. The facility failed to submit accurate staffing information to CMS for FY Quarter 3 2023 (April 1-June 30), FY Quarter 4 2023 (July 1-September 30), FY Quarter 1 2024 (October 1-December 31), FY Quarter 2 2024 (January 1-March 31), and FY Quarter 3 2024 (April 1-June 30). [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and that the resident's environment remained as free of accident hazards as possible for one (Resident #1) of five residents reviewed for elopement on the facility's secured unit. The facility failed to adequately supervise, monitor, and implement interventions to prevent Resident #1 (who was assessed with severe cognitive impairment and as being at risk for elopement) from eloping from the facility unsupervised on [DATE] where he remained unaccounted for overnight. The resident was located on [DATE], 2.6 miles from the facility. The facility failed to ensure the door to the secure unit was properly functioning as the door did not fully close and/or lock consistently. On [DATE] at 5:25 p.m. an Immediate Jeopardy was identified. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 11 of 11 residents (Resident #1, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12) residing on the secured unit. 1. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which were complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation. Resident #'1's electronic medical record did not reflect that an AED was used on Resident #1 when the resident coded. This failure could result in residents' records not accurately documenting life saving measure taken on the resident.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of four residents reviewed for comprehensive care plans. The facility failed to ensure Resident #1's care plan addressed Resident #1's family member measuring Resident #1's food using her own measuring cups. The facility failed to ensure Resident #1's care plan included Resident #1 received assistance by a family member without using the call button for staff assistance. This deficit practice could place residents at risk of not receiving the services they need, not having interventions in place, and a delay in response for assistance.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 (Resident #2) of 3 residents reviewed for infection control. The facility failed to ensure Resident #2's sheets and privacy curtain were free of blood stains. These failures could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for five (Residents #1, #2, #3, #4, and #5) of twelve residents reviewed for call lights. The facility failed to ensure Residents #1, #2, #3, #4, and #5's call light were placed within their reach on 01/29/2024. This failure could place dependent residents at risk of injuries and unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of five residents (Resident #1) reviewed for infection control. CNA A failed to perform hand hygiene while providing Resident #1 with incontinence care. This failures could place residents at risk for contamination and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 (200 Hall) of 2 medication rooms (refrigerators) reviewed for medication storage. The facility failed to dispose of eight single-use vials of influenza vaccines. This failure placed residents at risk of receiving an expired vaccine and not receiving the intended therapeutic dose.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1. The facility failed to ensure foods in the refrigerator and in dry storage were properly labeled and dated. These failures could place residents at risk for food borne illness.