Nursing home in Lancaster, Texas
Lancaster Nursing & Rehabilitation
Medicare and Medicaid
1515 N Elm St, Lancaster, TX 75134
(972) 227-6066
CMS star ratings
CMS gives this nursing home an overall star rating of 1 out of 5. Each rating is compared with the mean of rated nursing homes in Texas (1,165 for the overall rating) and in the U.S. (14,565). How to read an inspection report.
Overall rating
- This nursing home1
- Texas average2.7 (1,165 rated)
- U.S. average3.0 (14,565 rated)
Health inspections
- This nursing home2
- Texas average2.8 (1,165 rated)
- U.S. average2.8 (14,565 rated)
Staffing
- This nursing home1
- Texas average1.9 (1,163 rated)
- U.S. average2.9 (14,494 rated)
Quality measures
- This nursing home2
- Texas average3.7 (1,162 rated)
- U.S. average3.6 (14,495 rated)
Health inspections
Most recent standard health inspection (rating cycle 1): Jan 8, 2026. CMS counts 7 health deficiencies in rating cycle 1.
- This nursing home7
- Texas average9.4 (1,171 with data)
- U.S. average9.2 (14,652 with data)
Rating cycle 1 health deficiencies. Averages include every nursing home with a count in the CMS file; fewer is better.
Deficiencies since Sep 30, 2023
Inspectors cited 30 health deficiencies on 12 inspection dates since Sep 30, 2023. By level of harm: 3 immediate jeopardy, 25 potential for harm, 2 minimal harm potential.
- 3 Immediate jeopardy to resident health or safety
- 0 Actual harm
- 25 No actual harm, potential for more than minimal harm
- 2 No actual harm, potential for minimal harm
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Mar 6, 2026 | F0575 | 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.Resident Rights Deficiencies | C Minimal harm potential, widespread | Complaint | Deficient, Provider has no plan of correction |
| Jan 8, 2026 | F0679 | Provide activities to meet all resident's needs.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Feb 3, 2026 |
| Jan 8, 2026 | F0645 | PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Feb 3, 2026 |
| Jan 8, 2026 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Feb 3, 2026 |
| Jan 8, 2026 | F0695 | Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Feb 3, 2026 |
| Jan 8, 2026 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Feb 3, 2026 |
| Nov 21, 2025 | F0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Nov 22, 2025 |
| Aug 1, 2025 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | J Immediate jeopardy, isolated | Complaint | Deficient, Provider has date of correction Aug 2, 2025 |
| Mar 5, 2025 | F0622 | 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.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Apr 14, 2025 |
| Feb 21, 2025 | F0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician Services Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Feb 22, 2025 |
Show the other 20 deficiencies
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Feb 21, 2025 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Feb 22, 2025 |
| Oct 10, 2024 | F0585 | 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.Resident Rights Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Oct 11, 2024 |
| Oct 10, 2024 | F0603 | Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).Freedom from Abuse, Neglect, and Exploitation Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Oct 11, 2024 |
| Oct 10, 2024 | F0679 | Provide activities to meet all resident's needs.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Oct 11, 2024 |
| Oct 10, 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Oct 11, 2024 |
| Oct 10, 2024 | F0758 | 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.Pharmacy Service Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Oct 11, 2024 |
| Oct 10, 2024 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Oct 11, 2024 |
| Oct 10, 2024 | F0584 | 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.Resident Rights Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Oct 11, 2024 |
| Oct 10, 2024 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and Exploitation Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Oct 11, 2024 |
| Oct 10, 2024 | F0610 | Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and Exploitation Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Oct 11, 2024 |
| Oct 10, 2024 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Oct 11, 2024 |
| Oct 10, 2024 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Oct 11, 2024 |
| Oct 10, 2024 | F0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Administration Deficiencies | C Minimal harm potential, widespread | Standard | Deficient, Provider has date of correction Oct 11, 2024 |
| May 2, 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | K Immediate jeopardy, pattern | Complaint | Deficient, Provider has date of correction May 24, 2024 |
| May 2, 2024 | F0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician Services Deficiencies | K Immediate jeopardy, pattern | Complaint | Deficient, Provider has date of correction May 24, 2024 |
| Apr 3, 2024 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Apr 26, 2024 |
| Feb 3, 2024 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Feb 28, 2024 |
| Feb 3, 2024 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Feb 28, 2024 |
| Jan 29, 2024 | F0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies | E Potential for harm, pattern | Complaint, Infection control | Deficient, Provider has date of correction Feb 16, 2024 |
| Dec 6, 2023 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Complaint, Infection control | Deficient, Provider has date of correction Dec 29, 2023 |
Staffing
Total nurse staffing
Reported hours per resident per day.
- This nursing home3.30 hours
- Texas average3.39 hours (1,148 with data)
- U.S. average3.86 hours (14,351 with data)
Registered nurse staffing
Reported hours per resident per day.
- This nursing home0.50 hours
- Texas average0.43 hours (1,148 with data)
- U.S. average0.69 hours (14,351 with data)
Nursing staff turnover
Share of nursing staff who left during the year, as reported to CMS.
- This nursing home92.5%
- Texas average55.3% (1,051 with data)
- U.S. average45.8% (13,538 with data)
Penalties
CMS lists 2 penalties for this nursing home: 2 fines totaling $56,554, and 0 payment denials. CMS counts penalties from the last 3 years.
Facility details
| Certified beds | 120 |
|---|---|
| Average residents per day | 53.6 |
| Ownership | For profit - Limited Liability company |
| Provider type | Medicare and Medicaid |
| Inside a hospital | No |
| Continuing care retirement community | No |
| Resident and family council | Resident |
| Automatic sprinklers in all required areas | Yes |
| Chain | Creative Solutions in Healthcare (149 facilities) |
| Legal business name | LANCASTER I ENTERPRISES, LLC |
| First approved for Medicare and Medicaid | Oct 12, 1999 |
| County | Dallas |
| CMS certification number | 675810 |
Also in Lancaster
| Nursing home | CMS overall rating | Health inspection rating | Certified beds | Ownership |
|---|---|---|---|---|
| Windsor Gardens | 150 | For profit - Corporation | ||
| Avir at Lancaster | 110 | Government - Federal | ||
| Millbrook Healthcare and Rehabilitation Center | 124 | For profit - Limited Liability company |
| Hospital | CMS overall rating | Type | Emergency services |
|---|---|---|---|
| Crescent Medical Center Lancaster | Acute Care Hospitals | Yes |