Pennsylvania Department of Health
LANCASTER NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LANCASTER NURSING AND REHABILITATION CENTER
Inspection Results For:

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LANCASTER NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit survey completed on February 25, 2026, it was determined that Lancaster Nursing and Rehabilitation Center, continues to be out of compliance for staffing ratios from the initial complaint survey of June 18, 2024 and subsequent follow-up surveys of September 11, 2024, October 31, 2024, January 10, 2025, April 11, 2025, July 14, 2025, September 23, 2025 and December 3, 2025, under the requirements of the Commonwealth of Pennsylvania Long Term Care Regulations for the Health portion of the survey process.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of facility staffing data, it was determined that the facility failed to ensure a minimum of one nurse aide per 10 residents on the day shift for ten days, a minimum of one nurse aide per 11 residents on the evening shift for six days and one nurse aide per 15 residents on the night shift for two days for the period from January 27 through February 5, 2026.

Findings include:

Review of facility staffing data for the period of January 27 through February 5, 2026, revealed the following dates and shifts that did not meet the requirements of one nurse aide per 10 residents on the day shift, one nurse aide per 11 residents on the evening shift and one nurse aide per 15 residents on the night shift.

Day shift
1/27/2026
1/28/2026
1/29/2026
1/30/2026
1/31/2026
2/1/2026
2/2/2026
2/3/2026
2/4/2026
2/5/2026

Evening shift
1/28/2026
1/29/2026
1/31/2026
2/1/2026
2/2/2026
2/4/2026

Night shift
1/29/2026
1/30/2026

The aforementioned data was conveyed to the Nursing Home Administrator in a telephone interview on February 25, 2026.

Plan of Correction - To be completed: 04/23/2026

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.

P 5520
Effective July 1, 2024 a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11residents during the evening and 1 nurse aide per 15 residents overnight.
1. Findings of Nurse aide care ratios cannot be retroactively corrected.
2. The facility will provide a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening and 1 nurse aide per 15 residents overnight.
3. The scheduling coordinators will be educated on the requirements of a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening and 1 nurse aide per 15 residents overnight.
4. NHA or designee will conduct random audits to verify that the requirements are met for nurse aides. Nurse aide ratios of a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening and 1 nurse aide per 15 residents overnight. Audits will be conducted daily x 7 days then weekly for 3 weeks and then monthly for 2 months. Audit results will be presented at QAPI meeting for review and recommendations.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of facility staffing data, it was determined that the facility failed to meet the required Per Patient Day (PPD) of 3.20 for ten days for the period of January 27 through February 5, 2026.

Findings include:

A review of facility staffing data from January 27 through February 5, 2026, revealed that the facility had a PPD below the required 3.20 on the following dates:

1/27/2026 - 3.05
1/28/2026 - 3.08
1/29/2026 - 2.90
1/30/2026 - 2.94
1/31/2026 - 2.93
2/1/2026 - 3.04
2/2/2026 - 2.94
2/3/2026 - 3.12
2/4/2026 - 3.09
2/5/2026 - 3.06

The aforementioned data was conveyed to the Nursing Home Administrator in a telephone interview on February 25, 2026.

Plan of Correction - To be completed: 04/23/2026

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.

P 5640
Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hr period shall, when totaled for the entire facility, be a minimum of 3.20 hours of direct resident care for each resident.
1. Findings of PPD cannot be retroactively corrected.
2. The facility will have daily staffing meetings to review staffing levels and make the necessary adjustments as possible to meet the state minimum requirements of 3.2
3. NHA or designee will provide re-education to nursing administration and scheduling that staffing levels must be 3.2 or above and have the appropriate staff to perform care in the facility.
4. Facility leadership will complete random audits weekly x 4 and then monthly x 2 months to ensure the facility had a PPD of 3.2 or above. The audits will be reviewed by the QAPI committee and the QAPI committee will determine the need for further audits.

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