D+
50/100Lancaster Nursing & Rehabilitation Inspection Report, Violations & Safety Grade (Lancaster, Texas)
1515 N Elm St, Lancaster, Texas 75134
Phone: 9722276066
CMS Overall:1/5
Overview & Bed Count
Certified Beds
120
Avg Residents/Day
56.5
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Dallas
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health2/5
Staffing1/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | Texas Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.48 | 0.44 | +0.04 |
| Total Nurse Hours per Resident per Day | 3.48 | 3.42 | +0.06 |
| CMS Staffing Rating | 1/5 | 1.9/5 | - |
| Nursing Staff Turnover | 52.3% | 50.8% | - |
Health Citation History
32 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-03-06 | 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. | C – Minimal Harm Potential |
| 2026-01-08 | Quality of Life and Care Deficiencies | Provide activities to meet all resident's needs. | E – Moderate Harm Potential |
| 2026-01-08 | Resident Assessment and Care Planning Deficiencies | PASARR screening for Mental disorders or Intellectual Disabilities | D – Moderate Harm Potential |
| 2026-01-08 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2026-01-08 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2026-01-08 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2025-11-21 | Resident Assessment and Care Planning Deficiencies | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D – Moderate Harm Potential |
| 2025-08-01 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2025-03-05 | 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. | D – Moderate Harm Potential |
| 2025-02-21 | 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. | E – Moderate Harm Potential |
| 2025-02-21 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-10-10 | 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. | E – Moderate Harm Potential |
| 2024-10-10 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | E – Moderate Harm Potential |
| 2024-10-10 | Quality of Life and Care Deficiencies | Provide activities to meet all resident's needs. | E – Moderate Harm Potential |
| 2024-10-10 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E – Moderate Harm Potential |
| 2024-10-10 | 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. | E – Moderate Harm Potential |
| 2024-10-10 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2024-10-10 | 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. | D – Moderate Harm Potential |
| 2024-10-10 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2024-10-10 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2024-10-10 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-10-10 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2024-10-10 | Administration Deficiencies | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | C – Minimal Harm Potential |
| 2024-05-02 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | K – Immediate Jeopardy |
| 2024-05-02 | 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. | K – Immediate Jeopardy |
| 2024-04-03 | 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. | D – Moderate Harm Potential |
| 2024-02-03 | 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. | D – Moderate Harm Potential |
| 2024-02-03 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2024-01-29 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | E – Moderate Harm Potential |
| 2023-12-06 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2023-09-20 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E – Moderate Harm Potential |
| 2023-09-20 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
Fire Safety Citation History
11 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-01-08 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2026-01-08 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2026-01-08 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2026-01-08 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D – Moderate Harm Potential |
| 2024-10-10 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | E – Moderate Harm Potential |
| 2024-10-10 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2023-09-20 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | F – Moderate Harm Potential |
| 2023-09-20 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | F – Moderate Harm Potential |
| 2023-09-20 | Miscellaneous Deficiencies | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | F – Moderate Harm Potential |
| 2023-09-20 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | D – Moderate Harm Potential |
| 2023-09-20 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | D – Moderate Harm Potential |
Total Penalties & Fines
$56,554
Total Fine Amount (CMS)
2
Number of Fines
2
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-08-01 | Fine | $36,480 | - |
| 2024-05-02 | Fine | $20,074 | - |
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3-Year Complete Report ($19)
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Lancaster area at no cost.
Find Safe, Vetted Facilities Near Lancaster
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.