Lancaster Nursing & Rehabilitation
1515 N Elm St, Lancaster, TX 75134 · Dallas County · 120 certified beds · avg 54 residents/day · certified since Oct 12, 1999
Part of chain: CREATIVE SOLUTIONS IN HEALTHCARE (149 facilities, chain avg rating 2.1★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Aug 1, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 2, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · May 2, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: May 24, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · May 2, 2024 · F-0725 · triggered by a complaint
The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Why it matters: Understaffing means longer waits for help, missed care, and higher risk of falls and other harm.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: May 24, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (34)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 6, 2026 | C · Minimal risk, facility-wide | The facility did not post the names, addresses, and phone numbers of state agencies and advocacy groups, along with a notice that residents may file complaints with the state survey agency. · from a complaint |
| Jan 8, 2026 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Jan 8, 2026 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Jan 8, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jan 8, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jan 8, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Nov 21, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · from a complaint |
| Aug 1, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 5, 2025 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint |
| Feb 21, 2025 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Feb 21, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Oct 10, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Oct 10, 2024 | E · Potential for harm, repeated | The facility did not protect residents from being involuntarily separated — kept apart from other residents, kept out of their own room, or confined to their room. Isolating a resident this way is a form of mistreatment. · from a complaint |
| Oct 10, 2024 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Oct 10, 2024 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Oct 10, 2024 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint |
| Oct 10, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Oct 10, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Oct 10, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 10, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Oct 10, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Oct 10, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Oct 10, 2024 | C · Minimal risk, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. |
| May 2, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 2, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Apr 3, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Feb 3, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Feb 3, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jan 29, 2024 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Sep 20, 2023 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Sep 20, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 31, 2023 | E · Potential for harm, repeated | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| Aug 31, 2023 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (12 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 0 | E |
| 2024 | 18 | 2 | K ▲ |
| 2025 | 5 | 1 | J ▲ |
| 2026 | 6 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $56,554.
| Date | Type | Amount / length |
|---|---|---|
| Aug 1, 2025 | Fine | $36,480 |
| May 2, 2024 | Fine | $20,074 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.19 | 3.46 | 3.95 | bottom 38% in Texas; bottom 21% in the U.S. |
| Registered Nurse hours | 0.49 | 0.44 | 0.69 | top 28% in Texas; bottom 36% in the U.S. |
| Weekend total nurse staffing | 2.74 | 3.04 | 3.50 | bottom 34% in Texas; bottom 18% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.32 | 0.34 | 0.48 | top 41% in Texas; bottom 37% in the U.S. |
| Total nursing staff turnover (%) | 92.5 | 55.3 | 45.8 | bottom 9% in Texas; bottom 1% in the U.S. |
| RN turnover (%) | 100.0 | 54.6 | 42.9 | bottom 8% in Texas; bottom 1% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.30, RN 0.50, weekend 2.84. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Blake, Gary | Individual | Indirect Ownership Interest | NOT APPLICABLE | 07/01/2024 |
| Blake, Malisa | Individual | Indirect Ownership Interest | NOT APPLICABLE | 07/01/2024 |
| Honor X Enterprises, LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 07/01/2024 |
| Blake, Gary | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Blake, Gary | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Blake, Malisa | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Blake, Malisa | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Clanton, Auston | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Clanton, Auston | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Creative Solutions in Healthcare INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Creative Solutions in Healthcare INC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Eamiguel, Christopher | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Eamiguel, Christopher | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Huggins, Linda | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| Huggins, Linda | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Huggins, Linda | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Lancaster I Enterprises, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Silva, Phillip | Individual | ADP of the SNF | NOT APPLICABLE | 04/09/2025 |
| Stapleton, Lillian | Individual | ADP of the SNF | NOT APPLICABLE | 04/09/2025 |
| Willig, Zachary | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "Where do you post the contact information for the state agency and the ombudsman, in case we ever need to file a complaint?"
- "Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
- "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avir at Lancaster | 0.3 mi | Lancaster, TX | ★★☆☆☆ | 2/5 | |
| Millbrook Healthcare and Rehabilitation Center | 2.0 mi | Lancaster, TX | ★☆☆☆☆ | 2/5 | |
| Windsor Gardens | 2.7 mi | Lancaster, TX | ★★☆☆☆ | 2/5 | |
| Desoto Nursing & Rehabilitation Center | 5.4 mi | Desoto, TX | ★★★☆☆ | 3/5 | |
| Five Points Nursing and Rehabilitation | 5.6 mi | Desoto, TX | ★★☆☆☆ | 3/5 | |
| Park Village Healthcare and Rehabilitation | 5.7 mi | Desoto, TX | ★★☆☆☆ | 1/5 | abuse |
| Methodist Transitional Care Center-Desoto LLC | 6.0 mi | Desoto, TX | ★★★☆☆ | 2/5 | |
| Red Oak Health and Rehabilitation Center | 6.0 mi | Red Oak, TX | ★★★☆☆ | 4/5 | |
| The Villages of Dallas | 6.5 mi | Dallas, TX | ★★★☆☆ | 2/5 | |
| Williamsburg Village Healthcare Campus | 7.2 mi | Desoto, TX | ★★☆☆☆ | 1/5 | SFF |
| The Lennwood Nursing and Rehabilitation | 7.2 mi | Dallas, TX | ★☆☆☆☆ | 2/5 | |
| Southern Oaks Therapy and Living Center | 7.8 mi | Dallas, TX | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 675810.