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Lancaster Nursing & Rehabilitation
1515 N Elm St, Lancaster, TX 75134 · CMS Certification Number (CCN) 675810
At a glance
- CMS overall rating
- ★☆☆☆☆ 1 of 5
- Health inspection citations
- 32 in the last 3 inspection cycles (3 immediate jeopardy, 0 actual harm, 22 from complaints)
- Fire safety citations
- 11
- Fines (last 3 years)
- 2 fines, total $56,554
- Payment denials
- 0
- Most recent standard inspection
- January 8, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★☆☆☆☆ 1 of 5 | 2.7 | 3 |
| Health inspections | ★★☆☆☆ 2 of 5 | 2.8 | 2.8 |
| Staffing | ★☆☆☆☆ 1 of 5 | 1.9 | 2.9 |
| Quality measures | ★★☆☆☆ 2 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★☆☆☆ 2 of 5 | Not published | Not published |
| Short-stay quality | Not published Not enough data available to calculate a star rating. | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | January 8, 2026 | 7 | 5 | 2 |
| Cycle 2 | October 10, 2024 | 23 | 12 | 20 |
CMS weighted health inspection score: 123 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: 2. How to read these citations
32 health citations across 13 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
March 6, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| C | F-0575 | 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 | Complaint | Deficient, Provider has no plan of correction |
January 8, 2026: 5 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/03/2026 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/03/2026 |
| E | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/03/2026 |
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/03/2026 |
| D | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/03/2026 |
November 21, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/22/2025 |
August 1, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 08/02/2025 |
March 5, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0622 | 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 | Complaint | Deficient, Provider has date of correction Corrected 04/14/2025 |
February 21, 2025: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0725 | 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 | Complaint | Deficient, Provider has date of correction Corrected 02/22/2025 |
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/22/2025 |
October 10, 2024: 12 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 10/11/2024 |
| C | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/11/2024 |
| E | F-0758 | 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 | Standard + Complaint | Deficient, Provider has date of correction Corrected 10/11/2024 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 10/11/2024 |
| E | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/11/2024 |
| E | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/11/2024 |
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 10/11/2024 |
| D | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 10/11/2024 |
| D | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 10/11/2024 |
| E | F-0603 | Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 10/11/2024 |
| E | F-0585 | 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 | Standard + Complaint | Deficient, Provider has date of correction Corrected 10/11/2024 |
| D | F-0584 | 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 | Standard + Complaint | Deficient, Provider has date of correction Corrected 10/11/2024 |
May 2, 2024: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| K | F-0725 | 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 | Complaint | Deficient, Provider has date of correction Corrected 05/24/2024 |
| K | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 05/24/2024 |
April 3, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0842 | 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 | Complaint | Deficient, Provider has date of correction Corrected 04/26/2024 |
February 3, 2024: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/28/2024 |
| D | F-0656 | 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 | Complaint | Deficient, Provider has date of correction Corrected 02/28/2024 |
January 29, 2024: 1 citation (Complaint + Infection control)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Complaint + Infection control | Deficient, Provider has date of correction Corrected 02/16/2024 |
December 6, 2023: 1 citation (Complaint + Infection control)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Complaint + Infection control | Deficient, Provider has date of correction Corrected 12/29/2023 |
September 20, 2023: 2 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/20/2023 |
| E | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/20/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
11 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 01/08/2026 | E | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 02/16/2026 |
| 01/08/2026 | F | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 02/16/2026 |
| 01/08/2026 | E | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 02/16/2026 |
| 01/08/2026 | D | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies | Deficient, Provider has date of correction Corrected 02/16/2026 |
| 10/10/2024 | E | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 11/05/2024 |
| 10/10/2024 | E | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies | Deficient, Provider has date of correction Corrected 10/10/2024 |
| 09/20/2023 | F | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 10/20/2023 |
| 09/20/2023 | D | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 10/31/2023 |
| 09/20/2023 | D | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/31/2023 |
| 09/20/2023 | F | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/31/2023 |
| 09/20/2023 | F | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/31/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| August 1, 2025 | Fine | $36,480 | — |
| May 2, 2024 | Fine | $20,074 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.3 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.5 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.89 | Not published | Not published |
| Nurse aide hours per resident per day | 1.91 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.84 | Not published | Not published |
| RN hours per resident per day, weekends | 0.32 | Not published | Not published |
| Total nursing staff turnover (%) | 92.5 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 100 | Not published | Not published |
| Administrators who have left | 2 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Lancaster I Enterprises, LLC
- Ownership type
- For profit - Limited Liability company
- Chain
- Creative Solutions in Healthcare (149 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 120
- Average residents per day
- 53.6
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- October 12, 1999
- County/parish
- Dallas
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
21 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| HONOR X ENTERPRISES, LLC | DIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BLAKE, GARY | INDIRECT OWNERSHIP INTEREST | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BLAKE, MALISA | INDIRECT OWNERSHIP INTEREST | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HUGGINS, LINDA | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CREATIVE SOLUTIONS IN HEALTHCARE INC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LANCASTER I ENTERPRISES, LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BLAKE, GARY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BLAKE, MALISA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CLANTON, AUSTON | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| EAMIGUEL, CHRISTOPHER | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HUGGINS, LINDA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WILLIG, ZACHARY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CREATIVE SOLUTIONS IN HEALTHCARE INC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BLAKE, GARY | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BLAKE, MALISA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CLANTON, AUSTON | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| EAMIGUEL, CHRISTOPHER | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HUGGINS, LINDA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SILVA, PHILLIP | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STAPLETON, LILLIAN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WILLIG, ZACHARY | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Lancaster Nursing & Rehabilitation. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.