Rose City Nursing and Rehab at Lancaster
425 North Duke Street, Lancaster, PA 17602
Rose City Nursing and Rehab at Lancaster is a nursing home in Lancaster, Pennsylvania. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating2 of 5
- Last standard health inspectionMay 20, 2026 (5 months ago)
- Health citations since December 1, 202347 (Pennsylvania average 31)
- Fines in the past three years2, $128,792 in total
- CMS flagsNone listed by CMS
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One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
Health inspection on May 20, 2026
13 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
67 of 656 Pennsylvania homes (10%) got a citation at the immediate jeopardy level in 2026.
CMS fine of $43,002 on May 20, 2026.
Show the 13 citations
Citation F0689. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 10, 2026.
CMS has cited this home for F0689 3 times since 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 10, 2026.
Citation F0921. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on June 10, 2026.
CMS has cited this home for F0921 2 times since 2024.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 10, 2026.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on June 10, 2026.
CMS has cited this home for F0656 3 times since 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 10, 2026.
CMS has cited this home for F0684 4 times since 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on June 10, 2026.
CMS has cited this home for F0692 3 times since 2024.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on June 10, 2026.
CMS has cited this home for F0698 2 times since 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on June 10, 2026.
Citation F0770. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely, quality laboratory services/tests to meet the needs of residents.
CMS lists it as corrected on June 10, 2026.
Citation F0790. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide routine and 24-hour emergency dental care for each resident.
CMS lists it as corrected on June 10, 2026.
Citation F0835. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
CMS lists it as corrected on June 10, 2026.
CMS has cited this home for F0835 2 times since 2023.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on June 10, 2026.
CMS update of April 29, 2026
Staffing
Total nurse staffing reported to CMS went from 3.2 to 2.8 hours per resident per day.
Health inspection on February 13, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0740. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS lists it as corrected on March 30, 2026.
Health inspection on December 18, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0680. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure the activities program is directed by a qualified professional.
CMS lists it as corrected on January 19, 2026.
Health inspection on December 3, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 8, 2025.
CMS update of November 20, 2025
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 5 of 5.
Ownership
CMS lists this home under a new chain.
Fire safety citation
CMS removed citation K0100 from the fire safety inspection on April 8, 2025.
Fire safety citation
CMS removed citation K0211 from the fire safety inspection on April 8, 2025.
Fire safety citation
CMS removed citation K0225 from the fire safety inspection on April 8, 2025.
Fire safety citation
CMS removed citation K0353 from the fire safety inspection on April 8, 2025.
Fire safety citation
CMS removed citation K0372 from the fire safety inspection on April 8, 2025.
Fire safety citation
CMS removed citation K0920 from the fire safety inspection on April 8, 2025.
Fire safety citation
CMS removed citation K0929 from the fire safety inspection on April 8, 2025.
Health inspection on August 6, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on August 20, 2025.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Health inspection on April 25, 2025
14 citationsCMS lists this as a standard inspection.
Show the 14 citations
Citation F0730. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on June 12, 2025.
Citation F0756. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on June 12, 2025.
Citation F0947. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on June 12, 2025.
Citation F0641. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on June 12, 2025.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on June 12, 2025.
Citation F0698. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on June 12, 2025.
Citation F0758. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on June 12, 2025.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on June 12, 2025.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on June 12, 2025.
Citation F0604. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
CMS lists it as corrected on June 12, 2025.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on June 12, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 12, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 12, 2025.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on June 12, 2025.
Fire safety inspection on April 25, 2025
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation E0004. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on April 29, 2025.
CMS update of March 26, 2025
CMS abuse icon
CMS removed its abuse icon from this home.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
Health inspection on August 12, 2024
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on September 3, 2024.
Citation F0921. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on September 3, 2024.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
CMS update of June 26, 2024
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of May 29, 2024
Fine
CMS changed the fine from December 1, 2023 from $131,985 to $85,790.
CMS update of March 28, 2024
Ownership
CMS lists this home under a new chain.
Health inspection on March 15, 2024
8 citationsCMS lists this as a standard inspection.
Show the 8 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on May 1, 2024.
Citation F0565. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS lists it as corrected on May 1, 2024.
Citation F0692. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on May 1, 2024.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on May 1, 2024.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on May 1, 2024.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on May 1, 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on May 1, 2024.
Citation F0825. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or get specialized rehabilitative services as required for a resident.
CMS lists it as corrected on May 1, 2024.
Fire safety inspection on March 15, 2024
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation E0006. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on May 1, 2024.
CMS update of February 29, 2024
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
Ownership
CMS lists this home under a new chain.
Health inspection on January 3, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0801. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
CMS lists it as corrected on January 15, 2024.
Health inspection on December 1, 2023
5 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
15 of 656 Pennsylvania homes (2%) got a citation at the immediate jeopardy level in 2023.
CMS fine of $85,790 on December 1, 2023.
Show the 5 citations
Citation F0656. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on January 2, 2024.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on October 27, 2023.
Citation F0835. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
CMS lists it as corrected on January 2, 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on January 2, 2024.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on January 2, 2024.
CMS star ratings
- 2 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (717) 397-4281
- Last standard health inspection
- May 20, 2026 (5 months ago)
- Certified beds
- 124
- Residents per day, on average
- 107.9
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Keystone Nursing and Rehab of Lancaster LLC
- Chain
- Lme Family Holdings
- Takes part in
- Medicare and Medicaid
More health citations than the Pennsylvania average (47 vs 31).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- UNDERSCORE HOLDINGS LLC5% or greater direct ownership interest · 100% · since 05/14/2018
- SAMARA HOLDINGS COMPANY LLC5% or greater indirect ownership interest · 32% · since 01/28/2020
- STRAWBERRY HILL HOLDINGS LLC5% or greater indirect ownership interest · 32% · since 01/28/2020
- CLINICAL CONSULTING SERVICES LLCOperational/managerial control · not applicable · since 01/01/2019
- PRIORITY CARE GROUP LLCOperational/managerial control · not applicable · since 01/01/2019
Show 3 more
- SUMMATION FINANCIAL SERVICES LLCOperational/managerial control · not applicable · since 01/01/2019
- PEARLSTEIN, ROBERTOperational/managerial control · not applicable · since 01/01/2022
- SHANK, CHRISTINEOperational/managerial control · not applicable · since 05/26/2023
Questions
When was Rose City Nursing and Rehab at Lancaster last inspected?
CMS lists May 20, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Rose City Nursing and Rehab at Lancaster have?
CMS lists 47 health citations since December 1, 2023. CMS also calls these deficiencies.
Has Rose City Nursing and Rehab at Lancaster been fined?
CMS lists 2 fines in the past three years, $128,792 in total.
What is the CMS star rating of Rose City Nursing and Rehab at Lancaster?
Its CMS overall star rating is 2 of 5.
Is Rose City Nursing and Rehab at Lancaster a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.