Inspection Reports for Emerald Nursing & Rehab Lancaster LLC

Issuance of a new Skilled Nursing Facility/Nursing Facility License due to a change of ownership for Emerald Nursing & Rehab Lancaster.

The license was issued based on the request for a new license due to ownership change, with an effective date of June 16, 2025. The license certifies the facility meets statutory requirements as a SNF/NF Dual Cert.

This Notice of Disciplinary Action was issued due to violations found during a survey dated July 8, 2024, specifically related to the facility's failure to ensure interventions were implemented to prevent elopement for two residents.

The facility was found to have violated licensure regulations concerning resident safety, resulting in probation for 180 days starting August 1, 2024, and a prohibition on admitting new residents until compliance is demonstrated.

The document is a renewal application and certification for the nursing home license of Emerald Nursing & Rehab Lancaster, verifying the facility's license status and renewal through the specified date.

The document confirms that Emerald Nursing & Rehab Lancaster meets statutory requirements for licensure renewal, including certification for Alzheimer's Special Care Unit and memory care endorsement. Staffing patterns and facility capacity are detailed, with no deficiencies or violations noted.

This document is a Nursing Home Licensure Renewal Application and related certification and occupancy permit for Lancaster Rehabilitation Center, verifying the renewal of the facility's license and compliance with state requirements.

The documents confirm the facility's licensure renewal, ownership information, and maximum occupancy of 293 beds as approved by the State Fire Marshal. No deficiencies or inspection findings are noted.

The document is a Nursing Home Licensure Renewal Application and related certification for Lancaster Rehabilitation Center, LLC, indicating the renewal of the facility's license and endorsement for Alzheimer's/Special Care Unit.

The documents confirm that Lancaster Rehabilitation Center, LLC meets statutory requirements for licensure renewal as a Skilled Nursing Facility/Nursing Facility with a dual certification and Alzheimer's/Special Care Unit endorsement. The renewal application includes facility information, ownership details, and staff training plans related to dementia care.

An unannounced visit was conducted to investigate a complaint at Lancaster Rehabilitation Center, LLC on June 18, 2019, by representatives of the Department of Health and Human Services Division of Public Health. The investigation included review of resident records, observation of care and services, and interviews with residents, family members, and staff.

The investigation found no violations related to the allegations concerning response to change in condition, housekeeping, sanitation of dining equipment, medication availability, and assistance to meals. Observations and interviews confirmed compliance with regulatory requirements in all areas reviewed.

The complaint allegations included failure to respond to change in condition, maintain effective housekeeping, ensure sanitary dining equipment, maintain medication availability, and provide required assistance to meals. All allegations were found to have no violations upon investigation.

An unannounced visit was conducted to investigate a complaint at Lancaster Rehabilitation Center, Llc on May 22, 2019, by representatives of the Department of Health and Human Services Division of Public Health.

The investigation included interviews with administrative staff, care staff, and sampled residents, as well as record reviews and observations. The facility was found to be in compliance with regulations and was not cited for any of the allegations.

The complaint allegations were: 1) failure to ensure residents are free from abuse, 2) failure to provide care and treatment to prevent pressure sore development, and 3) failure to submit investigations within 5 working days. All allegations were investigated and found to be unsubstantiated with no citations.

An unannounced visit was conducted to investigate a complaint regarding the facility's failure to complete written investigations within five working days and failure to implement interventions to prevent injuries.

The facility was found to be in compliance with relevant regulations, completing and submitting investigations within five working days and implementing interventions to prevent injuries after falls, with no concerns identified.

The complaint alleged that the facility failed to complete written investigations within five working days and failed to put interventions in place to prevent injuries. Both allegations were found to be unsubstantiated as the facility was in compliance.

An unannounced visit was conducted to investigate a complaint regarding the facility's failure to follow the plan of care for residents identified at risk for falls.

The facility was found to have followed the plan of care for residents at risk for falls, with no violations or concerns identified during the inspection, and was in compliance with relevant regulatory requirements.

The complaint alleged that the facility failed to follow the plan of care for residents at risk for falls. The allegation was not substantiated as the facility was found compliant.

The document is a Nursing Home Licensure Renewal Application and related renewal certification for Lancaster Rehabilitation Center, LLC, indicating the purpose is to renew the facility's license and certify compliance with statutory requirements.

The documents show that Lancaster Rehabilitation Center, LLC meets statutory requirements for licensure renewal as a Skilled Nursing Facility/Nursing Facility dual certified. The facility has a licensed capacity of 293 beds and a census of 217 residents at the time of renewal. The Alzheimer's/Special Care Unit disclosure and related policies indicate compliance with care standards and staffing requirements.

An unannounced visit was conducted to investigate a complaint and annual survey at Lancaster Rehabilitation Center, LLC from November 26, 2018 to December 4, 2018.

The facility was found non-compliant with several regulations including failure to assist residents in maintaining their highest level of mobility, failure to develop complete baseline and comprehensive care plans, failure to maintain proper food safety and medication storage, and multiple life safety code violations including fire safety and electrical system deficiencies.

The complaint investigation included allegations that the facility failed to ensure residents were treated with respect and dignity, failed to change interventions to protect residents from abuse, failed to assist residents in maintaining their highest level of mobility, failed to ensure staff had appropriate credentials, and failed to ensure food was prepared and served according to food code guidelines. The facility was found non-compliant with the mobility and food preparation allegations but compliant with respect, abuse interventions, and staff credentials.

An unannounced visit was conducted to investigate a complaint at Lancaster Rehabilitation Center, Llc on April 4, 2018, by representatives of the Department of Health and Human Services Division of Public Health.

The investigation found no violations related to the allegations that the facility failed to identify changes in condition, provide wound care according to practitioner's orders, or submit investigations within 5 working days. Records, observations, and interviews indicated compliance with all these requirements.

The complaint alleged failure to identify changes in condition, failure to provide wound care according to practitioner's orders, and failure to submit investigations within 5 working days. All allegations were found to have no violations.

An unannounced visit was conducted to investigate a complaint alleging the facility fails to ensure residents are free from abuse.

The investigation found that the facility responds and follows policies and regulatory requirements regarding allegations of abuse and neglect. The facility was found to be in compliance with regulatory requirements after review of records, observations, and interviews.

The complaint alleged failure to ensure residents are free from abuse. The investigation included observation, record reviews, and interviews, and found the facility in compliance.

An unannounced visit was conducted to investigate a complaint at Lancaster Rehabilitation Center, Llc on January 16-17, 2018, triggered by allegations including failure to report neglect, identify change of condition, maintain effective infection control, account for residents' property, and protect residents from others with behaviors.

The investigation found the facility was in compliance with reporting incidents, identifying changes in condition, accounting for residents' property, and protecting residents from others with behaviors. No violations were found related to infection control for mites or other allegations due to lack of evidence.

The complaint included five allegations: failure to immediately report neglect, failure to identify change of condition, ineffective infection control program to prevent spread of mites, failure to account for residents' property, and failure to protect residents from residents with behaviors. The facility was found compliant in all areas with no violations substantiated.

The document is related to the renewal of the nursing home license for Lancaster Rehabilitation Center, LLC, including certification renewal for the Alzheimer's Special Care Unit and memory care endorsement.

The documents confirm that Lancaster Rehabilitation Center, LLC meets statutory requirements for licensure renewal as a Skilled Nursing Facility with a total licensed capacity of 293 beds. The Alzheimer's Special Care Unit is endorsed with detailed policies on admission, discharge, staff training, physical environment, and resident care.

An unannounced visit was conducted to investigate a complaint and annual survey at Lancaster Rehabilitation Center from October 15 to October 19, 2017.

The investigation found no violations related to the complaint allegations regarding resident placement, care planning participation, call system response, bladder elimination care, medication administration, plan of care adherence, and resident hygiene. However, the facility was cited for several deficiencies including dignity issues with visible lift slings, improper food handling practices risking contamination, life safety code violations including unreadable keypad at locked doors, fire alarm system deficiencies, sprinkler system policy gaps, corridor door latch failures, and unsecured oxygen cylinders.

The complaint allegations included concerns about resident placement on locked units, participation in care planning, call system responsiveness, bladder elimination care, medication administration, plan of care adherence, and residents being left in soiled clothing. All allegations were investigated and found to be without violation.

An unannounced visit was conducted to investigate a complaint at Lancaster Rehabilitation Center, LLC regarding failure to identify change in condition and failure to ensure residents are free from abuse.

The investigation found no violations related to change in condition or abuse. However, the facility failed to ensure the safety of one resident on the dementia unit to self-administer medications, specifically two Ventolin HFA inhalers without proper physician orders or pharmacy labels.

The complaint alleged the facility failed to identify change in condition and failed to ensure residents are free from abuse. The investigation found the facility in compliance with no violations for these allegations.

An unannounced visit was conducted to investigate a complaint regarding the facility's failure to implement interventions to prevent injuries and to provide care and treatment to prevent skin breakdown.

The investigation found no concerns regarding injury prevention or skin breakdown care; the facility was in compliance with regulatory requirements for both allegations.

The complaint alleged failure to put interventions in place to prevent injuries and failure to provide care and treatment to prevent skin breakdown. The investigation found the facility in compliance with these allegations.

An unannounced visit was conducted to investigate a complaint that the facility fails to allow resident choice of when to get up in the morning.

Observations and interviews indicated that residents were allowed to get up at their choice, with some residents rising as early as 4 AM by their lifelong pattern. Night nursing staff offered to assist residents to get up according to their preferences, and no disciplinary action was taken if staff did not assist four residents as planned. No citation was issued related to this allegation.

The complaint alleged the facility failed to allow resident choice of when to get up in the morning. The investigation found no substantiated citation related to this issue.

An unannounced visit was conducted to investigate a complaint and annual survey at Lancaster Rehabilitation Center, LLC from July 19, 2016 to July 26, 2016, by representatives of the Department of Health and Human Services Division of Public Health.

The investigation included review of resident records, observations, and interviews. The facility was found to be in compliance with most allegations including safe environment, emergency care, plan of care for eating, transfers, meals, medication evaluation, skin breakdown prevention, physician orders, prompt response to calls, background checks, staff orientation, access to updated policies, and abuse prevention. No citations were issued related to these allegations.

The complaint allegations included failure to maintain a safe environment, ensure prompt emergency care, follow plan of care for eating, assist with transfers, provide three meals per day, evaluate medications to prevent over sedation, prevent skin breakdown, follow physician orders, respond promptly to calls, complete background checks, complete staff orientation, ensure access to updated policies, prevent abuse, and complete written investigations timely. The facility was found in compliance with all these allegations.

An unannounced visit was conducted to investigate a complaint alleging the facility failed to provide care and treatment to prevent skin breakdown and failed to implement or follow the plan of care.

The investigation found that the facility provided appropriate care and treatment to prevent skin breakdown and that care plans were being implemented and followed by staff. The facility was found to be in compliance with relevant regulatory requirements.

The complaint alleged failure to provide care and treatment to prevent skin breakdown and failure to implement or follow the plan of care. The allegations were not substantiated as the facility was found compliant.

An unannounced visit was conducted to investigate a complaint alleging that the facility fails to put fall interventions into place to prevent injuries.

Observations, interviews, and record reviews showed that care was provided according to residents' care plans, which were updated after falls with new interventions to prevent further falls and encourage safe mobility. No citation was issued related to this issue.

The complaint alleged failure to implement fall interventions to prevent injuries. The investigation found no substantiated citation.

The document is a Nursing Home Licensure Renewal Application and related materials for Lancaster Rehabilitation Center, LLC, indicating the facility's license renewal process and certification status.

The documents confirm that Lancaster Rehabilitation Center, LLC meets statutory requirements for licensure renewal as a Skilled Nursing Facility with a capacity of 293 beds. The materials include ownership information, facility layout, and policies related to Alzheimer's/Special Care Unit admissions and discharges.

An unannounced visit was conducted to investigate a complaint and annual survey at Lancaster Rehabilitation Center, LLC from June 10, 2015 to June 17, 2015.

The complaint investigation found no violations related to medication administration, privacy, abuse protection, transfer methods, misappropriation, care planning, meal quality, bladder elimination, fall interventions, call light response, respect and dignity, neglect reporting, and staff training. However, a federal violation was found related to inaccurate resident MDS assessments concerning dental issues for two residents.

The complaint investigation included allegations regarding failure to complete treatments according to practitioner's orders, failure to provide treatments in private, failure to protect residents from abuse, failure to provide appropriate positioning transfer, failure to ensure residents are free from misappropriation, failure to include residents in care planning, failure to ensure meals are attractive and palatable, failure to provide care for bladder elimination, failure to change fall interventions, failure to respond promptly to call notification systems, failure to treat residents with respect and dignity, failure to ensure accurate MDS assessments, failure to report allegations of neglect, and failure to ensure staff training. Most allegations were found to have no violations except for inaccurate MDS assessments related to dental issues.

An unannounced visit was conducted to investigate allegations regarding failure to recognize changes in resident condition and failure to ensure clothing are washed to meet residents' needs.

The facility was found to be in compliance with the allegations related to resident condition changes and clothing laundering. However, multiple deficiencies were identified related to life safety code violations including smoke door gaps, missing 'No Exit' signage, non-latching hazardous area doors, delayed egress signage and door malfunctions, inadequate illumination of exit paths, non-uniform fire alarm signals, unmaintained smoke detectors, sprinkler system maintenance issues, obstructed exit paths, non-flame resistant curtains, unsecured oxygen cylinders, missing oxygen signage, and non-hospital grade electrical outlets in resident rooms.

The complaint alleged failure to recognize changes in resident condition and failure to ensure clothing are washed to meet residents' needs. The investigation found no violation related to these allegations.

Annual survey inspection of Lancaster Manor to assess compliance with federal and state regulations including resident rights, life safety code, and quality of care.

The facility was found deficient in multiple areas including failure to ensure residents had private telephone access, lack of visual privacy during bathing, inadequate pain management for a resident, improper perineal care, and improper storage of medications. Life safety code violations included doors not latching properly, missing exit signage, lack of emergency lighting, obstructed egress, and staff not knowing exit door codes.

The inspection was conducted to determine if Lancaster Manor was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs. A revisit was conducted due to noncompliance found in the initial survey.

The facility was found not to be in substantial compliance with Federal requirements during the March 20, 2012 survey and the May 10, 2012 revisit. As a result, payment for new Medicare and Medicaid admissions was initially denied effective May 31, 2012. However, a subsequent revisit on May 15, 2012 established that corrections had been made and the denial of payment was not effectuated.

Annual survey conducted to assess compliance with state and federal regulations including housekeeping, maintenance, care plan adherence, accident hazards, food safety, and life safety code standards.

The facility was found deficient in housekeeping and maintenance services, failure to follow care plans for nutritional supplements, accident hazards due to splintered handrails and beds, food safety violations including improper hand washing and sanitizer use, and multiple life safety code violations including inadequate fire barriers, exit signage, smoke barrier penetrations, hazardous area separations, exit lighting, oxygen storage ventilation, and electrical safety.

The inspection was conducted as a routine survey to assess compliance with regulations governing licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities.

The facility failed to maintain complete, accurate, and accessible clinical records for one of three sampled residents, specifically Resident 3, where nursing documentation did not fully capture an identified change in condition and related assessments and interventions.

The inspection was conducted based on a complaint investigation regarding failure to administer a prescribed medication to a resident and failure to notify the physician or transplant team of the omission.

The facility failed to ensure administration of a prescribed inhalation medication (Pentamidine) for one resident and failed to notify the physician or transplant team about the missed medication. There was no alternative plan to ensure administration, and discharge communication did not reflect the omission or request follow-up.

The visit was complaint-related, focusing on medication administration errors and failure to notify healthcare providers of the omission.

The inspection was conducted as an annual survey to assess compliance with regulations governing licensure of skilled nursing facilities, focusing on comprehensive care plans, discharge summaries, infection control, and other regulatory requirements.

The facility was found deficient in developing comprehensive care plans for residents, ensuring discharge summaries contained required information, and maintaining infection control practices including hand hygiene. Deficiencies were noted in care plan interventions for oxygen therapy, dialysis, hospice services, pain management, and documentation of discharge summaries and inventory of personal effects.

The inspection was conducted to evaluate medication error rates and compliance with regulations governing licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities.

The facility failed to meet the requirement of having medication error rates of five percent or less, with a 7.5% error rate observed during medication administration. Multiple medication administration errors were documented involving several residents and medication aides.

This document serves as a renewal application and certification for the Lancaster Rehabilitation Center, LLC nursing home license, verifying compliance with statutory requirements and renewal of the SNF/NF dual certification.

The document confirms the facility's licensure renewal, ownership information, accreditation status, and details about the Alzheimer's/Special Care Unit including staffing, training, environment, and resident care philosophy. No deficiencies or inspection findings are reported.

The document is a Nursing Home Licensure Renewal Application and related certification and disclosure forms for Lancaster Rehabilitation Center, indicating the purpose is to renew the facility's license and certifications.

The documents confirm that Lancaster Rehabilitation Center meets statutory requirements for licensure renewal as a Skilled Nursing Facility with various therapy services and an Alzheimer's Special Care Unit. The facility is licensed for 293 beds with a maximum capacity of 56 Alzheimer's beds.

The document serves as a renewal application for the nursing home license of Emerald Nursing & Rehab Lancaster LLC, including certification of services, occupancy permit, and Alzheimer's Special Care Unit disclosure.

The documents certify that Emerald Nursing & Rehab Lancaster LLC meets statutory requirements for licensure renewal, with a licensed capacity of 293 beds, and includes details on staffing patterns and care philosophy for the Alzheimer's Special Care Unit.

The documents serve to renew the nursing home license, verify licensure status, provide occupancy permit details, and disclose Alzheimer's Special Care Unit information for Emerald Nursing & Rehab Lancaster LLC.

No inspection findings or deficiencies are reported. The documents primarily consist of administrative and licensing information, facility capacity, floor plans, and care unit disclosures.

This Notice of Disciplinary Action was issued due to violations related to failure to provide care and services to alleviate a resident's dental pain, resulting in the facility's license being placed on probation for 90 days beginning April 24, 2013.

The Department of Health and Human Services determined that the facility violated licensure regulations pertaining to Provision of Care and Treatment, specifically failing to alleviate a resident's dental pain, as documented in the CMS-2567 Report dated April 9, 2013.

This Notice of Disciplinary Action was issued to impose probation on the facility's license for 90 days beginning November 27, 2024, due to violations related to wound care and failure to follow medical practitioners' orders.

The facility failed to follow medical practitioners' orders and ensure treatments were completed regarding wound care, as evidenced by the CMS-2567 Report dated October 29, 2024.