Lancaster Nursing and Rehab: Restraint Used 12 Years Without Order - PA
The resident, identified in inspection records only as Resident 1, has a gastrostomy tube, known as a PEG tube, used for feeding. At some point before November 24, 2014, staff began using an abdominal binder to keep the resident from pulling the tube out. The binder was wrapped around the resident's midsection, positioned directly over the PEG tube site. The care plan noted it had to be loose enough to allow air to reach the skin but tight enough to stop the resident from dislodging the tube. If the tube did come out, the plan instructed staff to insert a foley catheter to keep the opening from closing and send the resident to the emergency room.
That care plan intervention was dated November 24, 2014.
There was no physician's order for any of it. Not in 2014. Not in 2015. Not in any of the years that followed. When inspectors arrived at the facility on May 28, 2026, they observed the binder still in place on the resident at 10:00 in the morning. They reviewed clinical documentation going back through the years. They found nothing.
The Director of Nursing confirmed it the next morning. Through an internal audit of physician orders, the director told inspectors, the facility had discovered that no order existed for the abdominal binder restraint from the time it was initiated in November 2014 until May 27, 2026, one day before inspectors observed the resident wearing it. A physician's order was written on that date.
The facility's own policy defines a physical restraint as any device attached or adjacent to a resident's body that the person cannot remove easily and that restricts their freedom of movement or normal access to their body. The policy is explicit that the definition turns not on the device itself but on what the resident can actually do. If a resident cannot remove something the way staff applied it, given that resident's physical condition, it is a restraint.
The policy also states that restraints may only be used when a resident has a specific medical symptom that cannot be addressed by a less restrictive intervention, and that a physician's written order is required before use begins. That order must include the reason for the restraint, the type of restraint, and when it should be released.
None of that documentation existed for Resident 1 for twelve and a half years.
The inspection was classified as causing minimal harm or potential for actual harm, and the deficiency affected only this one resident among the thirty-five charts inspectors reviewed. The regulatory citation was for nursing services under Pennsylvania code.
What the classification does not capture is the duration. Restraint use is among the more closely watched practices in nursing home care precisely because of the risks: pressure injuries, muscle deterioration, restricted circulation, and the basic matter of a person's physical autonomy being limited without proper review. The facility's own policy requires a restraint evaluation upon initiation and then every quarter. Quarterly evaluations over twelve years would have meant roughly fifty separate reviews of whether this restraint was still necessary, whether less restrictive alternatives had been tried, whether the resident's condition had changed.
The records show none of those evaluations were tied to a valid physician's order.
The abdominal binder was still on Resident 1 when inspectors walked in. It had been there, by the care plan's own account, since late 2014. The order that should have preceded all of it was written the day before inspectors arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lancaster Nursing and Rehabilitation Center from 2026-05-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
LANCASTER NURSING AND REHABILITATION CENTER in LANCASTER, PA was cited for violations during a health inspection on May 29, 2026.
The resident, identified in inspection records only as Resident 1, has a gastrostomy tube, known as a PEG tube, used for feeding.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.