Pennsylvania ›Lancaster

Rose City Nursing and Rehab at Lancaster

425 North Duke Street, Lancaster, PA 17602 · Lancaster County · 124 certified beds · avg 102 residents/day · certified since Mar 3, 1967

Part of chain: LME FAMILY HOLDINGS (15 facilities, chain avg rating 2.1★)

1/5
Health inspection rating (on-site)
3
Serious findings on record
$128,792
Fines, last 3 years
3.84
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5

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, repeated · May 20, 2026 · F-0689

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: Jun 10, 2026 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Dec 1, 2023 · F-0656 · triggered by a complaint

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.

Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.

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: Jan 2, 2024 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Dec 1, 2023 · 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: Oct 27, 2023 (Past Non-Compliance)

All citations in the current public record (47)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
May 20, 2026▲ K · Immediate jeopardy, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
May 20, 2026E · Potential for harm, repeatedThe 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
May 20, 2026E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
May 20, 2026D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
May 20, 2026D · Potential for harm, one-offThe 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
May 20, 2026D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
May 20, 2026D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint
May 20, 2026D · Potential for harm, one-offThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
May 20, 2026D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
May 20, 2026D · Potential for harm, one-offThe facility did not provide timely, quality laboratory tests to meet residents' needs.
May 20, 2026D · Potential for harm, one-offThe facility did not provide routine dental care and 24-hour emergency dental care for residents.
May 20, 2026D · Potential for harm, one-offThe facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents.
May 20, 2026D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Feb 13, 2026D · Potential for harm, one-offThe facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint
Dec 18, 2025E · Potential for harm, repeatedThe facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials. · from a complaint
Dec 3, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Aug 6, 2025D · Potential for harm, one-offThe facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. · from a complaint
Apr 25, 2025F · Potential for harm, facility-wideThe facility did not observe each nurse aide's job performance or provide regular training as required.
Apr 25, 2025F · Potential for harm, facility-wideThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Apr 25, 2025F · Potential for harm, facility-wideThe facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention.
Apr 25, 2025E · Potential for harm, repeatedThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Apr 25, 2025E · Potential for harm, repeatedThe 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.
Apr 25, 2025E · Potential for harm, repeatedThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Apr 25, 2025E · Potential for harm, repeatedThe 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.
Apr 25, 2025E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Apr 25, 2025D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Apr 25, 2025D · Potential for harm, one-offThe facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Apr 25, 2025D · Potential for harm, one-offThe 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.
Apr 25, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Apr 25, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Apr 25, 2025D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Aug 12, 2024D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Aug 12, 2024D · Potential for harm, one-offThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Mar 15, 2024F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 15, 2024E · Potential for harm, repeatedThe facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
Mar 15, 2024E · Potential for harm, repeatedThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Mar 15, 2024D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Mar 15, 2024D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Mar 15, 2024D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Mar 15, 2024D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Mar 15, 2024D · Potential for harm, one-offThe facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them.
Jan 3, 2024D · Potential for harm, one-offThe facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. · from a complaint
Dec 1, 2023▲ J · Immediate jeopardy, one-offThe 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
Dec 1, 2023▲ J · Immediate jeopardy, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Dec 1, 2023E · Potential for harm, repeatedThe facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint
Dec 1, 2023D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Dec 1, 2023D · Potential for harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (14 → 13).

YearCitationsSerious (G–L)Worst severity that year
202352J ▲
2024110F
2025170F
2026141K ▲

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 $128,792.

DateTypeAmount / length
May 20, 2026Fine$43,002
Dec 1, 2023Fine$85,790

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityPennsylvania avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.843.943.95top 43% in Pennsylvania; top 46% in the U.S.
Registered Nurse hours0.800.800.69top 34% in Pennsylvania; top 27% in the U.S.
Weekend total nurse staffing3.613.583.50top 39% in Pennsylvania; top 37% in the U.S.
Weekend RN hours (not acuity-adjusted)0.620.560.48top 28% in Pennsylvania; top 21% in the U.S.
Total nursing staff turnover (%)49.444.545.8bottom 35% in Pennsylvania; bottom 38% in the U.S.
RN turnover (%)57.139.942.9bottom 20% in Pennsylvania; bottom 26% 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 3.35, RN 0.70, weekend 3.15. Staffing rating: 3/5.

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: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Samara Holdings Company LLCOrganization5% or Greater Indirect Ownership Interest32%01/28/2020
Strawberry Hill Holdings LLCOrganization5% or Greater Indirect Ownership Interest32%01/28/2020
Underscore Holdings LLCOrganization5% or Greater Direct Ownership Interest100%05/14/2018
Clinical Consulting Services LLCOrganizationOperational/Managerial ControlNOT APPLICABLE01/01/2019
GPH Lancaster LPOrganizationADP of the SNFNOT APPLICABLE05/14/2018
Pearlstein, RobertIndividualOperational/Managerial ControlNOT APPLICABLE01/01/2022
Pearlstein, RobertIndividualADP of the SNFNOT APPLICABLE01/01/2022
Priority Care Group LLCOrganizationOperational/Managerial ControlNOT APPLICABLE01/01/2019
Shank, ChristineIndividualOperational/Managerial ControlNOT APPLICABLE05/26/2023
Shank, ChristineIndividualADP of the SNFNOT APPLICABLE05/26/2023
Summation Financial Services LLCOrganizationOperational/Managerial ControlNOT APPLICABLE01/01/2019

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Lancaster Nursing and Rehabilitation Center1.1 miLancaster, PA★★☆☆☆3/5
Hamilton Arms Center1.2 miLancaster, PA★★★☆☆3/5
Abbeyville Skilled Nursing and Rehabilitation Cent1.8 miLancaster, PA★★★☆☆3/5
Homestead Village, INC2.4 miLancaster, PA★★★★★5/5
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Glen at Willow Valley3.4 miLancaster, PA★★★★★5/5
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Brethren Village4.3 miLancaster, PA★★★☆☆2/5abuse
Rehabilitation Center at Brethren Village LLC4.3 miLancaster, PA★★★★★5/5
Lakeside at Willow Valley4.6 miWillow Street, PA★★★★★5/5
Landis Homes5.1 miLititz, PA★★★★★4/5
Luther Acres Manor7.4 miLititz, PA★☆☆☆☆2/5abuse

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Facility data as of CMS processing date 2026-08-01. CCN 395177.