Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
LANCASTER HEALTH SERVICES
LANCASTER, WI · 50 certified beds · Last Life Safety survey August 19, 2025
CMS Certification Number 525352 · first certified March 1984
Ownership
Operated by NORTH SHORE HEALTHCARE · For profit - Limited Liability company
- Ownership changed December 1, 2019 (change of ownership)from LANCASTER CARE CENTER LLC
Position within WI
15 citations — more than 38% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 3.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: September 2026 to November 2026. This facility’s last Life Safety survey was August 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 15 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 15 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 6, 2023 | 1 |
| July 24, 2024 | 6 |
| August 19, 2025 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2025-08-19 |
| K-0912 | Have power receptacles that are properly grounded. | 2 | 2025-08-19 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2025-08-19 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2025-08-19 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-07-24 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2025-08-19 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2025-08-19 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2024-07-24 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Smoke Deficiencies 5
- Services Deficiencies 2
- Emergency Preparedness Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Smoke Deficiencies | 5 |
| Services Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 19, 2025 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (September 18, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (September 18, 2025) |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Deficient, Provider has date of correction (September 18, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (September 18, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (September 18, 2025) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (September 18, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 18, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 18, 2025) |
July 24, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (August 23, 2024) |
April 6, 2023 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (April 17, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.