Lancaster Nursing And Rehabilitation Center
LANCASTER NURSING AND REHABILITATION CENTER in LANCASTER, PA — inspection on May 29, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
treatment.
determined that the facility failed to ensure appropriate items were in place for a resident with a
policy and procedure titled Use of Restraints revealed Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.Further review of the policy and procedure revealed The definition of a restraint is based on the functional status of the resident and not the device. I the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered a restraint.Further review of the policy and procedure revealed Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to : a) treat the medical symptom; b) protect the resident's safety and c) help the resident attain the highest level of his/her physical or psychological well-being.
Restraint evaluation will be completed upon initiation of a restraint and quarterly.
Restraints shall only be used upon the written order of a physician.
The order shall include the following: a) the specific reason for the restraint and b) the type of restraint and period for the release of the restraint.Review of Resident 1's diagnosis list revealed diagnoses including the presence of a gastrostomy tube to facilitate tube feeding.Review of Resident 1's current care plan revealed an intervention initiated November 24, 2014, which stated abdominal binder in place loosely enough to allow air to get to area but still close enough to prevent [resident] from pulling PEG tube out.
Check placement of binder every shift. If PEG tube comes out, insert foley tube to prevent stoma from closing and sent to ER if dislodged.Review of Resident 1's physician orders revealed an order dated May 27, 2026, which stated abdominal binder on at all times, may remove for care, release every two hours every shift.Observation of Resident 1 on May 28, 2026, at 10:00 a.m. revealed an abdominal binder in place covering Resident 1's PEG tube.Review of all clinical documentation failed to reveal evidence that a physician's order was in place for the use of an abdominal binder restraint which was initiated on November 24, 2014.Interview with the Director of Nursing on May 29, 2026, at 11:00 a.m. revealed that through an audit of physician's orders, it was discovered that no physician's order existed for Resident 1's use of the abdominal binder restraint until May 27, 2026. 28 Pa.
Code 211.12(c)(d)(1)(5) Nursing Services Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
395774 05/29/2026
Lancaster Nursing and Rehabilitation Center 900 East King Street Lancaster, PA 17602
Review of clinical orders for Resident #11
requests all possible life-saving measures be utilized in the event of a cardiac arrest).
Review of Resident #11's Comprehensive Care Plan reveals that the care plan was updated on May 28, 2026, to reflect the resident's change in code status to Full Code.
Review of Resident #11's clinical record failed to reveal evidence that Resident #11's care plan was updated to Full Code Status on June 28, 2025, when Resident #11's physician initiated the Full Code Status order. 28 Pa.
Code 211.5(f) Clinical Records 28 Pa.
Code 211.12(d)(3)(5) Nursing Services
395774 05/29/2026
Lancaster Nursing and Rehabilitation Center 900 East King Street Lancaster, PA 17602
Review of Resident 2's diagnosis list revealed diagnoses including congestive heart failure (CHF – excessive body/lung fluid caused by a weakened heart muscle).
Review of Resident 2's physician's orders revealed an order dated March 31, 2026, for 2000 milliliter (ml) fluid restriction every day – Dietary 1080 ml; nursing 920 ml (480 ml day shift, 360 ml evening shift and 80 ml night shift.
Review of Resident 2's May 2026 Medication Administration Record revealed daily documentation of fluid consumption for nursing.
Further review of Resident 2's clinical record failed to reveal any documented evidence of dietary fluid consumption and also failed to reveal any documented evidence of a total daily fluid consumption to ensure Resident 2 did not exceed the physician ordered 2000 ml daily fluid restriction.
Interview with the Nursing Home Administrator and Director of Nursing on May 29, 2026, at 11:30 a.m. confirmed that the facility was not ensuring that Resident 2 did not exceed the 2000 ml fluid restriction as ordered by Resident 2's physician.
Review of Resident 19's clinical record revealed diagnoses including congestive heart failure (excessive body/lung fluid caused by a weakened heart muscle).
Review of Resident 19's physician's orders dated February 21, 2026, revealed an order for 2L Daily Fluid Restriction – dining 1040 mL/day; Nursing - 960mL/day (400 mL 7-3, 400 mL 3-11, 160mL 11-7) every shift Review of Resident 19's Fluid Task sheet and Medication Administration Record revealed Resident 19 exceeded the daily fluid allotment as follows on: May 4, 2026; May 11, 2026, and May 20, 2026.
Interview with Nursing Home Administrator on May 20, 2026, at 10:15 a.m. confirmed the above findings. 28 Pa.
Code 211.12(c)(d)(1)(5) Nursing Services
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.