Lancaster Nursing & Rehabilitation
1515 N Elm St, Lancaster, TX 75134 · CCN 675810
Ratings
- Overall
- ★☆☆☆☆ 1
- Health inspection
- ★☆☆☆☆ 1
- Quality measures
- ★★☆☆☆ 2
- Staffing
- ★★★★☆ 4
Facility
- Ownership type
- For profit - Limited Liability company
- Certified beds
- 120
- Avg residents/day
- 41.1
- Phone
- 9722276066
Inspection history vs Texas & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Texas avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2024-10-10 | 15 | 9.1 | 9.5 | +5.9 worse |
| 2 | 2023-09-20 | 7 | 9.4 | 9.8 | -2.4 better |
| 3 | 2022-07-27 | 14 | 8.1 | 9.3 | +5.9 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 3 |
| Quality of life and care | 4 |
| Resident assessment and care planning | 1 |
| Resident rights | 3 |
| Pharmacy service | 2 |
| Administration | 1 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.47 | 60.4% |
| RN staffing (reported) | 0.86 | 20.0% |
| Total nurse staffing (adjusted) | 3.92 | — |
Fines & penalties
- Total fines
- $55,760
- Number of fines
- 2
- Number of penalties
- 2
- Payment denials
- 0
Chain
- Chain
- CREATIVE SOLUTIONS IN HEALTHCARE
- Facilities in chain
- 149
- Chain avg overall
- 2.70 / 5
Inspection citations (36)3 immediate jeopardy
- DF0644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.2025-11-21 · Health · corrected 2025-11-22
Potential for more than minimal harm
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-08-01 · Health · corrected 2025-08-02
Immediate jeopardy
- DF0622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.2025-03-05 · Health · corrected 2025-04-14
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2025-02-21 · Health · corrected 2025-02-22
Potential for more than minimal harm
- EF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2025-02-21 · Health · corrected 2025-02-22
Potential for more than minimal harm
- DF0584Honor 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.2024-10-10 · Health · corrected 2024-10-11
Potential for more than minimal harm
- EF0585Honor 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.2024-10-10 · Health · corrected 2024-10-11
Potential for more than minimal harm
- EF0603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).2024-10-10 · Health · corrected 2024-10-11
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-10-10 · Health · corrected 2024-10-11
Potential for more than minimal harm
- DF0610Respond appropriately to all alleged violations.2024-10-10 · Health · corrected 2024-10-11
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-10-10 · Health · corrected 2024-10-11
Potential for more than minimal harm
- EF0679Provide activities to meet all resident's needs.2024-10-10 · Health · corrected 2024-10-11
Potential for more than minimal harm
- EF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-10-10 · Health · corrected 2024-10-11
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-10-10 · Health · corrected 2024-10-11
Potential for more than minimal harm
- EF0758Implement 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.2024-10-10 · Health · corrected 2024-10-11
Potential for more than minimal harm
- CF0851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.2024-10-10 · Health · corrected 2024-10-11
Potential for minimal harm
- EF0880Provide and implement an infection prevention and control program.2024-10-10 · Health · corrected 2024-10-11
Potential for more than minimal harm
- KF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-05-02 · Health · corrected 2024-05-24
Immediate jeopardy
- KF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2024-05-02 · Health · corrected 2024-05-24
Immediate jeopardy
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-04-03 · Health · corrected 2024-04-26
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-02-03 · Health · corrected 2024-02-28
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2024-02-03 · Health · corrected 2024-02-28
Potential for more than minimal harm
- EF0558Reasonably accommodate the needs and preferences of each resident.2024-01-29 · Health · corrected 2024-02-16
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2023-12-06 · Health · corrected 2023-12-29
Potential for more than minimal harm
- EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2023-09-20 · Health · corrected 2023-10-20
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-09-20 · Health · corrected 2023-10-20
Potential for more than minimal harm
- DF0584Honor 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.2023-08-31 · Health · corrected 2023-10-06
Potential for more than minimal harm
- EF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2023-08-31 · Health · corrected 2023-10-06
Potential for more than minimal harm
- DF0636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.2022-07-27 · Health · corrected 2022-08-17
Potential for more than minimal harm
- DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2022-07-27 · Health · corrected 2022-08-17
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2022-07-27 · Health · corrected 2022-08-15
Potential for more than minimal harm
- DF0727Have 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.2022-07-27 · Health · corrected 2022-07-28
Potential for more than minimal harm
- DF0759Ensure medication error rates are not 5 percent or greater.2022-07-27 · Health · corrected 2022-08-17
Potential for more than minimal harm
- DF0810Provide special eating equipment and utensils for residents who need them and appropriate assistance.2022-07-27 · Health · corrected 2022-08-17
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2022-07-27 · Health · corrected 2022-08-17
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2022-07-27 · Health · corrected 2022-08-19
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| CREATIVE SOLUTIONS IN HEALTHCARE INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-07-01 |
| LANCASTER I ENTERPRISES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-07-01 |
| BLAKE, GARY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-07-01 |
| BLAKE, MALISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-07-01 |
| CLANTON, AUSTON | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-07-01 |
| EAMIGUEL, CHRISTOPHER | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-07-01 |
| HUGGINS, LINDA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-07-01 |
| WILLIG, ZACHARY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-07-01 |
| HUGGINS, LINDA | Individual | CORPORATE DIRECTOR | — | 2024-07-01 |
Other facilities in Lancaster
| Name | Overall | Beds |
|---|---|---|
| AVIR AT LANCASTER | ★★☆☆☆ | 110 |
| Millbrook Healthcare and Rehabilitation Center | ★★☆☆☆ | 124 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.