Cycle 1
Health 2024-10-10 · Fire 2024-10-10
15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Lancaster, TX
Lancaster Nursing & Rehabilitation
1-star overall rating with 1-star inspections with $55,760 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1515 N Elm St, Lancaster, TX
(972) 227-6066
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
41
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
1999-10-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
149 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.86
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.76
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.47
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.97
CMS adjusted RN staffing hours
Adjusted total hours
3.92
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 52% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · Newly certified or not enough cases to report. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 77 |
| Staff flu vaccination coverage | 21.74% |
42%
20.3 pts worse
|
Numerator 30 · Denominator 138 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
97.1%
1.6 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 95.1% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.3%
2 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 2.4% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
3.3%
0.3 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 0.0% · Q4 8.3% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.6% |
18.9%
6.3 pts better
|
19.6%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 15.2% · Q3 14.7% · Q4 13.9% · 4Q avg 12.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.0% |
10.8%
5.2 pts worse
|
16.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 9.5% · Q3 20.0% · Q4 20.0% · 4Q avg 16.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 41.3% |
15.4%
25.9 pts worse
|
16.3%
25 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 32.2% · Q4 61.3% · 4Q avg 41.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.0% |
16.1%
9.9 pts worse
|
14.9%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 50.0% · Q3 11.8% · Q4 36.1% · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
0.8%
0.5 pts worse
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.9% |
15.0%
4.9 pts worse
|
19.8%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 27.0% · Q3 4.6% · Q4 29.0% · 4Q avg 19.9% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.2%
0.7 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 5.5% · Q3 3.1% · Q4 2.4% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
89.7%
4.9 pts better
|
81.7%
12.9 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 94.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-20 · Fire 2023-09-20
7 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-07-27 · Fire 2022-07-27
14 health deficiencies
Top issue: Infection Control (3 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-10
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-10-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-05
F · Potential for more than minimal harm
2023-09-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-31
F · Potential for more than minimal harm
2023-09-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-31
F · Potential for more than minimal harm
2023-09-20
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-31
F · Potential for more than minimal harm
2022-07-27
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2022-08-17
E · Potential for more than minimal harm
2022-07-27
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-08-17
E · Potential for more than minimal harm
2022-07-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-08-17
E · Potential for more than minimal harm
2022-07-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-08-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-21
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-11-22
J · Immediate jeopardy
2025-08-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-02
D · Potential for more than minimal harm
2025-03-05
F622 · Resident Rights Deficiencies
Health
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.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-02-21
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-02-22
D · Potential for more than minimal harm
2025-02-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-22
E · Potential for more than minimal harm
2024-10-10
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-10-10
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-10-10
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-10-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-10-10
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-10-10
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-10-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-10-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-10-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-10-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-11
C · Minimal harm
2024-10-10
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-10-11
K · Immediate jeopardy
2024-05-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-24
K · Immediate jeopardy
2024-05-02
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-04-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-02-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-02-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-28
E · Potential for more than minimal harm
2024-01-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-02-16
D · Potential for more than minimal harm
2023-12-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-29
E · Potential for more than minimal harm
2023-09-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-09-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-08-31
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-31
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-10-06
E · Potential for more than minimal harm
2022-07-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-27
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-15
D · Potential for more than minimal harm
2022-07-27
F727 · Nursing and Physician Services Deficiencies
Health
Have 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.
Corrected 2022-07-28
D · Potential for more than minimal harm
2022-07-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-27
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-19
Penalties and ownership
What sits behind the stars
$35,686
2025-08-01
Fine
Fine · fine $35,686
Fine
$20,074
2024-05-02
Fine
Fine · fine $20,074
Fine
Ownership
Blake, Gary
Operational/Managerial Control · Individual
Blake, Malisa
Operational/Managerial Control · Individual
Clanton, Auston
Operational/Managerial Control · Individual
Creative Solutions In Healthcare Inc
Operational/Managerial Control · Organization
Eamiguel, Christopher
Operational/Managerial Control · Individual
Huggins, Linda
Operational/Managerial Control · Individual
Huggins, Linda
Corporate Director · Individual
Lancaster I Enterprises, LLC
Operational/Managerial Control · Organization
Willig, Zachary
Operational/Managerial Control · Individual
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