For profit - Limited Liability company · 120 certified beds · CMS number 675810
Lancaster Nursing & Rehabilitation, Lancaster, TX
CMS records 32 health deficiencies at Lancaster Nursing & Rehabilitation in Lancaster, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on Jan 8, 2026. The highest severity cited is K (immediate jeopardy to resident health or safety). 3 citations were at the immediate jeopardy level. CMS lists 2 fines totaling $56,554 in the last three years.
- 32deficiencies, 3 cycles (TX median 25)
- 7in the latest cycle (TX median 8)
- Khighest severity · Immediate jeopardy
- $56,554fines, last 3 years
- 1CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for Lancaster Nursing & Rehabilitation as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and Lancaster Nursing & Rehabilitation may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (7 deficiencies)
Standard inspection Jan 8, 2026. CMS counts 7 health deficiencies and 4 fire safety deficiencies in this cycle.
Mar 6, 2026 · Complaint inspection
1 deficiency, highest C
F575 · Posting agency and advocate contacts
Requirement cited (CMS): Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
- Severity
- C No actual harm, potential for minimal harm, widespread
- Status
- No plan of correction on file
Jan 8, 2026 · Standard inspection
5 deficiencies, highest E
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 3, 2026
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 3, 2026
F679 · Activities program
Requirement cited (CMS): Provide activities to meet all resident's needs.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 3, 2026
F677 · Help with daily care
Requirement cited (CMS): Provide care and assistance to perform activities of daily living for any resident who is unable.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 3, 2026
F645 · Pre-admission screening for mental disorder or intellectual disability
Requirement cited (CMS): PASARR screening for Mental disorders or Intellectual Disabilities
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 3, 2026
Nov 21, 2025 · Complaint inspection
1 deficiency, highest D
F644 · Coordinating with PASARR screening
Requirement cited (CMS): Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Nov 22, 2025
Previous cycle: 16 deficiencies (standard inspection Oct 10, 2024)
Standard inspection Oct 10, 2024. CMS counts 16 health deficiencies and 2 fire safety deficiencies in this cycle.
Aug 1, 2025 · Complaint inspection
1 deficiency, highest J
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Aug 2, 2025
Mar 5, 2025 · Complaint inspection
1 deficiency, highest D
F622 · Permitted reasons for transfer or discharge
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 14, 2025
Feb 21, 2025 · Complaint inspection
2 deficiencies, highest E
F725 · Enough nursing staff every shift
Requirement cited (CMS): Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 22, 2025
F677 · Help with daily care
Requirement cited (CMS): Provide care and assistance to perform activities of daily living for any resident who is unable.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 22, 2025
Oct 10, 2024 · Standard + complaint inspection
12 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 11, 2024
F851 · Reporting staffing data to CMS
Requirement cited (CMS): Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
- Severity
- C No actual harm, potential for minimal harm, widespread
- Status
- Correction date Oct 11, 2024
F758 · Psychotropic drug safeguards
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 11, 2024
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 11, 2024
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 11, 2024
F679 · Activities program
Requirement cited (CMS): Provide activities to meet all resident's needs.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 11, 2024
F677 · Help with daily care
Requirement cited (CMS): Provide care and assistance to perform activities of daily living for any resident who is unable.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 11, 2024
F610 · Investigating and responding to allegations
Requirement cited (CMS): Respond appropriately to all alleged violations.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 11, 2024
F609 · Reporting suspected abuse and crimes
Requirement cited (CMS): Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 11, 2024
F603 · Freedom from involuntary seclusion
Requirement cited (CMS): Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 11, 2024
F585 · Grievances and how they are handled
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 11, 2024
F584 · Safe, clean, homelike surroundings
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 11, 2024
Earlier cycle: 9 deficiencies (standard inspection Sep 20, 2023)
Standard inspection Sep 20, 2023. CMS counts 9 health deficiencies and 5 fire safety deficiencies in this cycle.
May 2, 2024 · Complaint inspection
2 deficiencies, highest K
F725 · Enough nursing staff every shift
Requirement cited (CMS): Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- Severity
- K Immediate jeopardy to resident health or safety, pattern
- Status
- Correction date May 24, 2024
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- K Immediate jeopardy to resident health or safety, pattern
- Status
- Correction date May 24, 2024
Apr 3, 2024 · Complaint inspection
1 deficiency, highest D
F842 · Complete, confidential medical records
Requirement cited (CMS): Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 26, 2024
Feb 3, 2024 · Complaint inspection
2 deficiencies, highest D
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 28, 2024
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 28, 2024
Jan 29, 2024 · Complaint inspection
1 deficiency, highest E
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 16, 2024
- Found in
- infection control inspection
Dec 6, 2023 · Complaint inspection
1 deficiency, highest D
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 29, 2023
- Found in
- infection control inspection
Sep 20, 2023 · Standard inspection
2 deficiencies, highest E
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 20, 2023
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Oct 20, 2023
Tags cited in more than one inspection
6 tags cited on more than one inspection date at Lancaster Nursing & Rehabilitation; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F677 Help with daily care | 3 | Jan 8, 2026; Feb 21, 2025; Oct 10, 2024 |
| F689 Accident prevention and supervision | 3 | Aug 1, 2025; Oct 10, 2024; May 2, 2024 |
| F755 Pharmacy services and a consultant pharmacist | 3 | Jan 8, 2026; Oct 10, 2024; Sep 20, 2023 |
| F880 Infection prevention and control program | 3 | Oct 10, 2024; Feb 3, 2024; Dec 6, 2023 |
| F679 Activities program | 2 | Jan 8, 2026; Oct 10, 2024 |
| F725 Enough nursing staff every shift | 2 | Feb 21, 2025; May 2, 2024 |
Fines and payment denials
| Date | Type | Amount / length |
|---|---|---|
| Aug 1, 2025 | Fine | $36,480 |
| May 2, 2024 | Fine | $20,074 |
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- 3.30 h (about the same as the Texas median of 3.27 h)
- RN hours per resident per day
- 0.50 h (above the Texas median of 0.38 h)
- Weekend nurse staff hours per resident per day
- 2.84 h
- Nursing staff turnover
- 92.5% (Texas median 52.1%)
- Administrators who left
- 2
- CMS overall rating
- 1 of 5
- Health inspection rating
- 2 of 5
- Staffing rating
- 1 of 5
- Quality measure rating
- 2 of 5
CMS figures for Lancaster Nursing & Rehabilitation, copied as published; Texas medians are ours.
Facility details
- Address
- 1515 N Elm St, Lancaster, TX 75134
- Phone
- (972) 227-6066
- County
- Dallas
- Accepts
- Medicare and Medicaid
- Ownership
- For profit - Limited Liability company
- Chain (CMS)
- Creative Solutions in Healthcare
- Certified beds
- 120
- Average residents per day
- 53.6
- In Medicare/Medicaid since
- Oct 12, 1999
- Inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- How often do residents who need help get assistance with bathing, grooming, and mouth care? (F677, cited 3 times)
- How does the home assess each resident's fall risk and plan to prevent falls? (F689, cited 3 times)
- How are new medication orders filled, and how quickly can urgent medications arrive? (F755, cited 3 times)
- How do staff track and report infections among residents? (F880, cited 3 times)
Other nursing homes in Lancaster and the same chain
- Avir at Lancaster
Lancaster · 31 deficiencies - Millbrook Healthcare and Rehabilitation Center
Lancaster · 27 deficiencies - Windsor Gardens
Lancaster · 27 deficiencies - Franklin Heights Nursing & Rehabilitation
El Paso · 76 deficiencies - St. Teresa Nursing & Rehab Center
El Paso · 75 deficiencies - Mountain View Health & Rehabilitation
El Paso · 72 deficiencies - Pleasant Springs Healthcare Center
Mount Pleasant · 66 deficiencies
Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.