Home / Pennsylvania / Lancaster
425 North Duke Street, Lancaster, PA 17602 · Lancaster County · (717) 397-4281
124 certified beds, about 102 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1967
CMS Care Compare ratings, data as of September 1, 2026 · CCN 395177 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on May 20, 2026, inspectors cited 13 health deficiencies (the Pennsylvania average is 10, the national average 9.2).
Of 47 health citations since December 2023, 3 were rated as actual harm or immediate jeopardy to residents (3 immediate jeopardy).
CMS lists 2 fines totaling $128,792 in the last three years; the largest was $85,790, and the latest is dated May 20, 2026.
Nurses and nurse aides worked 3.35 hours per resident per day, against 3.89 across Pennsylvania and 3.86 nationally. Registered nurses accounted for 0.70 of those hours.
49.4% of nursing staff left within the year CMS measured (Pennsylvania average 44.5%).
CMS links it to Lme Family Holdings, an affiliated group of 15 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 47 health citations on file.
Inspectors wroteBased on observations, facility record review, as well as resident and staff interviews, it was determined the facility failed to ensure resident smoking materials were stored securely and monitored for four residents (Residents 18, 74, 92, 93) on two units, posing a risk for fire, resulting in immediate jeopardy to the residents (first and third floor units).
Inspectors wroteBased upon review of facility policy and procedure, observation, and clinical record review, it was determined the facility failed to ensure enhanced barrier precautions were in place for residents requiring enhanced barrier precautions for 2 of 22 (Resident 13 and Resident 14) residents reviewed and failed to practice infection control prevention and mangement during tracheostomy (A surgical procedure that creates an opening through the neck directly into the windpipe) care and Gastrostomy tube (GT- A medical device inserted directly through the abdomen into stomach) care. For one of 22 residents reviewed (Resident 5).
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure staff were provided with a safe, functional, sanitary, and comfortable environment for three of the three medication rooms observed (Second, Third, and Fourth Medication Rooms).
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure safe, clean and homelike environment was provided for one of four units observed (Second Floor Unit).
Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to create a comprehensive care plan with interventions for one of 22 residents reviewed (Resident 1).
Inspectors wroteBased on clinical records review and staff interview, it was determined that the facility failed to ensure that the ordered medication to promote comfort was administered to a resident with a terminal diagnosis for one of eight residents reviewed (Resident 71).
Inspectors wroteBased on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for two of three residents reviewed for nutrition (Resident 10 and Resident 106).
Inspectors wroteBased on a clinical records review and interview with residents and staff, it was determined that the facility failed to ensure medication orders for dialysis residents were followed for one of two residents reviewed (Residents 11).
Inspectors wroteBased on review of the facility's policy, observations, and staff interviews, it was determined that the facility failed to properly stored medications in one of three medication rooms observed (Second Floor Medication Room).
Inspectors wroteBased on clinical records review and staff interview, it was determined that the facility failed to follow laboratory orders for two of 22 residents reviewed (Resident 3 and 109).
Inspectors wroteBased on observations, interview, and review of facility documentation, the facility failed to provide dentures to one out of seven residents reviewed (Resident 2).
Inspectors wroteBased on the review of job descriptions, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure the safety of residents when residents who smoke were permitted to keep smoking materials unsecured in their rooms and on their person. This failure resulted in an Immediate Jeopardy situation. Findings Include:Review of the job description for the Nursing Home Administrator (NHA) states position purpose is to manage the Facility in accordance with current applicable federal, state, and local guidelines, and regulations that govern long term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. [...]
Inspectors wroteBased on staff interview, observation, and clinical record review, it was determined that the facility failed to ensure an accurate clinical medical record for 1 of 1 resident reviewed (Resident 106).
Inspectors wroteBased on observation, clinical records review, and staff interviews, it was determined that the facility failed to provide behavioral services in a timely manner for one out of three residents reviewed (Resident 1).
Inspectors wroteBased on policy review, interviews and records reviews it was determined that the facility failed to employ an Activity Director with the appropriate certification and/or qualifications for the position.
Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure the treating hospital received the medical records necessary to provide continuity of care and appropriate treatment for one of one resident reviewed (Resident R1).
Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed refund to the resident or resident representative any and all refunds due to the resident within 30 days from the resident's date of discharge from the facility for one of three residents (Resident R1).
Inspectors wroteBased upon review of staffing records and performance reviews it was determined the facility failed to ensure performance reviews were completed for five of five staffing records reviewed, ( Employee E5,Employee E6,Employee E7,Employee E8 and Employee E9).
Inspectors wroteBased upon review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure medication regimen reviews were acted upon by a physician for five of five residents reviewed (Residents 37, 43, 59, 75, and 84).
Inspectors wroteBased on review of staff documentation, it was determined the facility failed to ensure the required 12 hours of annual training was completed by five of five staff members reviewed (Employee E5, Employee E6, Employee E7, Employee E8 and Employee E9.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflect the residents' status for three of 23 residents reviewed (Residents 32, Resident 52 and Resident 67).
Inspectors wroteBased on observation, review of the clinical record, and interview with resident and staff, it was determined that the facility failed to develop a comprehensive care plan for three of 24 residents reviewed (Residents 32, 37, and 91).
Inspectors wroteBased on observations, a review of the facility's policy and clinical records, and interview with resident and staff, it was determined that the facility failed to ensure medications and fluid restriction orders for dialysis residents were followed for two of three residents reviewed (Residents 37 and 56).
Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure residents receiving psychotropic medications (any medication that affects brain activity associated with mental processed and behavior) were monitored for their side effects for three of five residents reviewed (Residents 37, 43, and 59).
Inspectors wroteBased on observations, a review of the medication manufacturer's guidelines, and staff interviews, it was determined that the facility failed to ensure that medications were properly stored and labeled on one of two medication carts (Fourth Floor Medication cart) and one of two Medication Rooms (Second Floor Medication Room). Findings Include: A review of the manufacturer's storage guidelines for Novolog Insulin (fast-acting insulin), revealed that the medication must be stored at room temperature and discarded within 28 days after opening. A review of manufacturers' storage guidelines for Lantus Insulin Pen (long-acting insulin) revealed that the medication may be stored at room temperature and discarded within 28 days after opening. [...]
Inspectors wroteBased upon review of clinical records, it was determined the facility failed to notify the physician of a significant weight loss for one of 21 residents reviewed (Resident 34).
Inspectors wroteBased on observations, facility policy and procedure review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free from the use of restraints for one of the eight residents reviewed. (Residents 74).
Inspectors wroteBased on review of facility policy, review of clinical record, review of facility documentation and staff interview, it was determined that the facility failed to conduct a comprehensive investigation for an injury of unknown origin for one of 19 residents reviewed (Resident 47).
Inspectors wroteBased on clinical records review, and resident and staff interview, it was determined that the facility failed to follow the physician's order for a diabetic wound order for one of three residents reviewed (Resident 37).
Inspectors wroteBased upon review of clinical records and interview, it was determined the facility failed to ensure that a current smoking assessment for one of one resident reviewed (Resident 24).
Inspectors wroteBased upon review of facility policy and procedure and review of clinical records, it was determined the facility failed to ensure weight loss and weight gain was adequately monitored for two of 23 residents reviewed (Resident 34 and Resident 79).
Inspectors wroteBased upon clinical record review and staff interview, it was determined the facility failed to comprehensively assess a resident who developed a pressure ulcer for one of four residents reviewed (Resident 4).
Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to maintain a safe environment for one of four resident bathrooms on the second floor.
Inspectors wroteBased on review of facility policy, observations and interview with staff, it was determined that the facility failed to maintain appropriate temperatures during dishwashing.
Inspectors wroteBased on a review of the minutes from Residents' Council meetings and grievances lodged with the facility and staff and resident interviews it was determined that the facility failed to demonstrate efforts to respond and resolve resident complaints raised at resident group meetings including those voiced by four Residents (Residents 20, 65, 57, and Resident 24).
Inspectors wroteBased on clinical record review, facility policy and procedure review, and staff interview it was determined the facility failed to monitor the nutritional status for three of nine residents reviewed. (Residents 53, 69, and Resident 87) Findings Include: Review of facility policy and procedure titled Weight Assessment and Intervention, revised March 2019, revealed the nursing staff will measure the resident weight on admission then weekly for four weeks. If no weight concerns are noted at this point, weights will be monitored monthly thereafter or as per Dietitian or MD. Weights will be recorded in each individual's medical record. Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Physician and Dietitian. [...]
Inspectors wroteBased upon clinical record review and review of facility documentation, it was determined the facility failed to protect a resident from abuse for one of 24 residents reviewed (Resident 91).
Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to review and revise the resident care plan quarterly for one of 24 residents reviewed. (Resident 53) Findings Include: Review of Resident 53's care plan revealed a target date of December 29, 2023. Review of Resident 53's clinical record revealed no documented evidence of a care plan conference in the past year. Interview with Social Worker E3 on December 15, 2024 at 11:30 a.m. confirmed Resident 53 has not had a care plan conference in the past year and the care plan was out of date. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.11(d) Resident Care Plan 28 Pa.
Inspectors wroteBased on review of the Pennsylvania Professional Nursing Practice Act, facility policy and procedure review, observations and staff interview it was determined the facility failed to ensure staff met the professional standards for a Registered nurse during medications administration for one of three residents reviewed. (Resident 69) Findings Include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and on going data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals. [...]
Inspectors wroteBased on observations, staff interview, clinical record review and facility policy and procedure review it was determined the facility failed to administer medications accurately to one of three residents reviewed resulting in a medications administration error rate of 25%. (Resident 70) Findings Include: Review of Facility policy and procedure titled Enteral Tube Medications Administration undated, revealed crushed medications are not mixed together. The powder from each medication is mixed with water, or other suitable dilutant if water is unacceptable, before administration. Each medication is administered separately to avoid interaction and clumping. Review of Resident 70's diagnosis list revealed a diagnosis of Gastrostomy (gastrostomy is the creation of an artificial external opening into the stomach for nutritional support). [...]
Inspectors wroteBased upon clinical record review, it was determined the facility failed to ensure a Speech Therapy Evaluation was completed as ordered for one of 24 residents reviewed (Resident 91).
Inspectors wroteBased on staff interview it was determined that the facility failed to ensure that the facility had a full-time qualified dietary services manager for the month of December 2023.
Inspectors wroteBased on clinical record, facility documentation, and staff interviews, it was determined that the facility failed to ensure and implement a comprehensive care plan for residents CL1 and R4 with history of seeking and aggressive behaviors which resulted in Resident CL1 ingesting a sandwich subsequently choking and expiring. Resident R4 exhibited physical aggressive behaviors which resulted in an involuntary psychiatric hospitalization. This failure placed residents in Immediate Jeopardy for two of two residents identified as being at risk.
Inspectors wroteBased on facility documentation, clinical record review and staff interviews it was determined the facility failed to implement appropriate monitoring, supervision, and safety measures to prevent Resident CL1, with known seeking behaviors and receiving a specialty diet, from obtaining a sandwich from an unsupervised cart. Resident CL1 ingested the sandwich which caused resident to choke on the food and expire. This failure placed residents at the facility in an Immediate Jeopardy situation for one of one resident identified as being at risk. This incident has been identified as past non-compliance. Findings Include: [...]
Inspectors wroteBased on job description reviews, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility by implementing monitoring, supervision, and effective safety measures to for a resident who demonstrated food seeking behavior, which resulted in harm to Resident CL1 as evidenced by the death of Resident CL1. The Administration failure resulted in an immediate jeopardy situation for Resident CL1.
Inspectors wroteBased on clinical records and interviews with staff it was determined that the facility failed to ensure physician orders were followed for one resident out of five residents reviewed (Resident R2)
Inspectors wroteBased on clinical record review, staff interview and facility documentation it was determined that the facility failed to ensure residents were free from significant medication errors for one of three residents reviewed. (Resident R1).
2 fire safety citations on file: 1 on April 25, 2025, 1 on March 15, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| May 20, 2026 | Fine | $43,002 |
| December 1, 2023 | Fine | $85,790 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Pennsylvania | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.35 | 3.89 | 3.86 |
| Registered nurses | 0.70 | 0.79 | 0.69 |
| All nursing staff on weekends | 3.15 | 3.53 | 3.42 |
| Nurse aides | 2.12 | ||
| Licensed practical nurses | 0.52 | ||
| Nursing staff turnover (share who left in a year) | 49.4% | 44.5% | 45.8% |
| Registered nurse turnover | 57.1% | 39.9% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.34 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.43 on weekdays and 3.15 on weekends, 8% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 12.4% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.20 in April to June 2025 to 3.35 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.35 | 0.70 | 3.43 | 3.15 | 12.4% | 0 of 90 | 102 |
| Oct to Dec 2025 | 2.77 | 0.62 | 2.85 | 2.57 | 6.2% | 0 of 92 | 106 |
| Jul to Sep 2025 | 3.25 | 0.61 | 3.37 | 2.93 | 22.3% | 0 of 92 | 107 |
| Apr to Jun 2025 | 3.20 | 0.60 | 3.31 | 2.92 | 19.1% | 0 of 91 | 103 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Pennsylvania, Jan to Mar 2026 | 3.69 | 0.65 | 3.82 | 3.34 | 11.3% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Pennsylvania, all employers | |||
| CNAs (nursing assistants) | $21.44 | $18.88 to $22.52 | 67,740 |
| LPNs and LVNs | $30.74 | $29.02 to $35.01 | 38,260 |
| Registered nurses | $46.36 | $38.75 to $50.35 | 146,520 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Pennsylvania | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 25.1 | 16.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.5 | 0.7 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.3 | 1.4 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.7 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 15.7 | 17.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 1.4 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 22.0 | 17.7 | 15.4 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.0 | 1.6 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.5 | 1.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Rose City Nursing and Rehab at Lancaster's Medicare short-stay residents. How to read these, and what Medicare pays for.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 51.5% · Pennsylvania: 100 better, 108 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 10 eligible stays.
9.5% this home
No different from the national rate
US median of homes 10.7% · Pennsylvania: 3 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 36 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 7.1% · Pennsylvania: 7 better, 5 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 13 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Pennsylvania54.4% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 16 residents counted.
0.0% this home
Median of homes: Pennsylvania0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 20 residents counted.
5.2% this home
Median of homes: Pennsylvania2.0% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 20 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Pennsylvania100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 4 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: KEYSTONE NURSING AND REHAB OF LANCASTER LLC. CMS links this home to Lme Family Holdings, a group of 15 nursing homes averaging 2.1 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Underscore Holdings LLC | 5% or greater direct ownership interest | Organization | 100% | 05/14/2018 |
| Samara Holdings Company LLC | 5% or greater indirect ownership interest | Organization | 32% | 01/28/2020 |
| Strawberry Hill Holdings LLC | 5% or greater indirect ownership interest | Organization | 32% | 01/28/2020 |
| Clinical Consulting Services LLC | Operational/managerial control | Organization | 01/01/2019 | |
| Priority Care Group LLC | Operational/managerial control | Organization | 01/01/2019 | |
| Summation Financial Services LLC | Operational/managerial control | Organization | 01/01/2019 | |
| Pearlstein, Robert | Operational/managerial control | Individual | 01/01/2022 | |
| Shank, Christine | Operational/managerial control | Individual | 05/26/2023 | |
| Gph Lancaster LP | Adp of the SNF | Organization | 05/14/2018 | |
| Pearlstein, Robert | Adp of the SNF | Individual | 01/01/2022 | |
| Shank, Christine | Adp of the SNF | Individual | 05/26/2023 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
Licensed assisted living residences and personal care homes in the same town or within 5 miles, each with its Pennsylvania licence record.
These are the official offices in Pennsylvania. NursingHomeClear cannot take or act on complaints.