425 North Duke Street, Lancaster, PA 17602 (opens Google Maps) · Lancaster County · (717) 397-4281· 124 certified beds · avg 102 residents/day · certified since Mar 3, 1967 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
Part of chain: LME FAMILY HOLDINGS (15 facilities, chain avg rating 2.1★)
New to these records? How to read an inspection report →
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5 · how star ratings work →
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 quality measures from resident assessments and claims.
▲ Immediate jeopardy, pattern · 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): Immediate jeopardy to resident health or safety was cited. The scope was a pattern: more than a limited occurrence, without being widespread. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Jun 10, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, isolated · 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): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Jan 2, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, isolated · 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): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Oct 27, 2023 (Past Non-Compliance)
Showing the latest 3 of 47 inspection findings. Open the full record below to read every finding.
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. F-0689
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 F-0880
The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. F-0921
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 20, 2026 | ▲ K · Immediate jeopardy, pattern | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689 |
| May 20, 2026 | E · Potential for more than minimal harm, pattern | 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 · F-0880 |
| May 20, 2026 | E · Potential for more than minimal harm, pattern | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · F-0921 |
| May 20, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584 |
| May 20, 2026 | D · Potential for more than minimal harm, isolated | 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 · F-0656 |
| May 20, 2026 | D · Potential for more than minimal harm, isolated | The 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 · F-0684 |
| May 20, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint · F-0692 |
| May 20, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · F-0698 |
| May 20, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755 |
| May 20, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide timely, quality laboratory tests to meet residents' needs. · F-0770 |
| May 20, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide routine dental care and 24-hour emergency dental care for residents. · F-0790 |
| May 20, 2026 | D · Potential for more than minimal harm, isolated | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · F-0835 |
| May 20, 2026 | D · Potential for more than minimal harm, isolated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · F-0842 |
| Feb 13, 2026 | D · Potential for more than minimal harm, isolated | The 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 · F-0740 |
| Dec 18, 2025 | E · Potential for more than minimal harm, pattern | The 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 · F-0680 |
| Dec 3, 2025 | D · Potential for more than minimal harm, isolated | The 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 · F-0684 |
| Aug 6, 2025 | D · Potential for more than minimal harm, isolated | The 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 · F-0582 |
| Apr 25, 2025 | F · Potential for more than minimal harm, widespread | The facility did not observe each nurse aide's job performance or provide regular training as required. · F-0730 |
| Apr 25, 2025 | F · Potential for more than minimal harm, widespread | The 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. · F-0756 |
| Apr 25, 2025 | F · Potential for more than minimal harm, widespread | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. · F-0947 |
| Apr 25, 2025 | E · Potential for more than minimal harm, pattern | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641 |
| Apr 25, 2025 | E · Potential for more than minimal harm, pattern | 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. · F-0656 |
| Apr 25, 2025 | E · Potential for more than minimal harm, pattern | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · F-0698 |
| Apr 25, 2025 | E · Potential for more than minimal harm, pattern | 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. · F-0758 |
| Apr 25, 2025 | E · Potential for more than minimal harm, pattern | The 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. · F-0761 |
| Apr 25, 2025 | D · Potential for more than minimal harm, isolated | The 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. · F-0580 |
| Apr 25, 2025 | D · Potential for more than minimal harm, isolated | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · F-0604 |
| Apr 25, 2025 | D · Potential for more than minimal harm, isolated | 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. · F-0610 |
| Apr 25, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684 |
| Apr 25, 2025 | D · Potential for more than minimal harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689 |
| Apr 25, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · F-0692 |
| Aug 12, 2024 | D · Potential for more than minimal harm, isolated | The 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 · F-0686 |
| Aug 12, 2024 | D · Potential for more than minimal harm, isolated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint · F-0921 |
| Mar 15, 2024 | F · Potential for more than minimal harm, widespread | 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. · F-0812 |
| Mar 15, 2024 | E · Potential for more than minimal harm, pattern | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. · F-0565 |
| Mar 15, 2024 | E · Potential for more than minimal harm, pattern | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · F-0692 |
| Mar 15, 2024 | D · Potential for more than minimal harm, isolated | The 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. · F-0600 |
| Mar 15, 2024 | D · Potential for more than minimal harm, isolated | The 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. · F-0657 |
| Mar 15, 2024 | D · Potential for more than minimal harm, isolated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · F-0658 |
| Mar 15, 2024 | D · Potential for more than minimal harm, isolated | The 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. · F-0759 |
| Mar 15, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. · F-0825 |
| Jan 3, 2024 | D · Potential for more than minimal harm, isolated | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. · from a complaint · F-0801 |
| Dec 1, 2023 | ▲ J · Immediate jeopardy, isolated | 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 · F-0656 |
| Dec 1, 2023 | ▲ J · Immediate jeopardy, isolated | 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 · F-0689 |
| Dec 1, 2023 | E · Potential for more than minimal harm, pattern | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint · F-0835 |
| Dec 1, 2023 | D · Potential for more than minimal harm, isolated | The 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 · F-0684 |
| Dec 1, 2023 | D · Potential for more than minimal harm, isolated | The 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 · F-0760 |
Citations from standard inspections stayed about the same across the last two inspection cycles (14 → 13).
All bars start at zero. Exact values and supporting details remain below.
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 2 | J ▲ |
| 2024 | 11 | 0 | F |
| 2025 | 17 | 0 | F |
| 2026 | 14 | 1 | K ▲ |
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.
How to file a complaint about care →
2 fines totaling $128,792.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
| Date | Type | Amount / length |
|---|---|---|
| May 20, 2026 | Fine | $43,002 |
| Dec 1, 2023 | Fine | $85,790 |
What these staffing numbers mean →
All bars start at zero. Exact values and supporting details remain below.
| Measure | This facility | Pennsylvania avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.84 | 3.94 | 3.95 | top 43% in Pennsylvania; top 46% in the U.S. |
| Registered Nurse hours | 0.80 | 0.80 | 0.69 | top 34% in Pennsylvania; top 27% in the U.S. |
| Weekend total nurse staffing | 3.61 | 3.58 | 3.50 | top 39% in Pennsylvania; top 37% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.62 | 0.56 | 0.48 | top 28% in Pennsylvania; top 21% in the U.S. |
| Total nursing staff turnover (%) | 49.4 | 44.5 | 45.8 | bottom 35% in Pennsylvania; bottom 38% in the U.S. |
| RN turnover (%) | 57.1 | 39.9 | 42.9 | bottom 20% in Pennsylvania; bottom 26% in the U.S. |
Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.35 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 3/5.
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Price evidence · separate from quality
No verified facility-specific private-pay price is available in our data for Rose City Nursing and Rehab at Lancaster. CMS inspection and staffing records do not tell us what this home will charge you.
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Understand who pays for care · How we handle price evidence · Report an incorrect price
How to read ownership records →
Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Samara Holdings Company LLC | Organization | 5% or Greater Indirect Ownership Interest | 32% | 01/28/2020 |
| Strawberry Hill Holdings LLC | Organization | 5% or Greater Indirect Ownership Interest | 32% | 01/28/2020 |
| Underscore Holdings LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 05/14/2018 |
| Clinical Consulting Services LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2019 |
| GPH Lancaster LP | Organization | ADP of the SNF | NOT APPLICABLE | 05/14/2018 |
| Pearlstein, Robert | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2022 |
| Pearlstein, Robert | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| Priority Care Group LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2019 |
| Shank, Christine | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/26/2023 |
| Shank, Christine | Individual | ADP of the SNF | NOT APPLICABLE | 05/26/2023 |
| Summation Financial Services LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2019 |
All 11 owning or managing parties CMS has on file are shown — none excluded.
CMS lists this facility under the chain Lme Family Holdings — 15 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.
Listed by state, then facility name — not a ranking. Showing 8 of the 14 others, continuing from this facility's own place in that list.
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Lancaster Nursing and Rehabilitation Center | 1.1 mi | Lancaster, PA | ★★☆☆☆ | 3/5 | |
| Hamilton Arms Center | 1.2 mi | Lancaster, PA | ★★★☆☆ | 3/5 | |
| Abbeyville Skilled Nursing and Rehabilitation Cent | 1.8 mi | Lancaster, PA | ★★★☆☆ | 3/5 | |
| Homestead Village, INC | 2.4 mi | Lancaster, PA | ★★★★★ | 5/5 | |
| Trillium Place | 2.5 mi | Lancaster, PA | ★★★★★ | 5/5 | |
| Glen at Willow Valley | 3.4 mi | Lancaster, PA | ★★★★★ | 5/5 | |
| Neffsville Nursing and Rehabilitation | 4.2 mi | Lancaster, PA | ★☆☆☆☆ | 1/5 | |
| Brethren Village | 4.3 mi | Lancaster, PA | ★★★☆☆ | 2/5 | abuse |
| Rehabilitation Center at Brethren Village LLC | 4.3 mi | Lancaster, PA | ★★★★★ | 5/5 | |
| Lakeside at Willow Valley | 4.6 mi | Willow Street, PA | ★★★★★ | 5/5 | |
| Landis Homes | 5.1 mi | Lititz, PA | ★★★★★ | 4/5 | |
| Luther Acres Manor | 7.4 mi | Lititz, PA | ★☆☆☆☆ | 2/5 | abuse |
Compare this facility with the 3 closest →
CMS records place this facility in Lancaster, PA — 31 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.
Listed by facility name — not a ranking. Homes already in the table above are not repeated here.
Facility data as of CMS processing date 2026-08-01. CCN 395177.
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