Lancaster, PA

Rose City Nursing And Rehab At Lancaster

2-star overall rating with 1-star inspections with $85,790 in total fines with 17 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

425 North Duke Street, Lancaster, PA

(717) 397-4281

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

124

Certified beds

Average residents

107

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Lme Family Holdings

Operator or chain grouping

Approved since

1967-03-03

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

15 facilities

Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.61

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.56

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.07

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.25

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.18

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

2.93

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.57

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.77

CMS adjusted RN staffing hours

Adjusted total hours

4.10

CMS adjusted total nurse staffing hours

Case-mix index

1.08

Higher values indicate more complex resident acuity

RN turnover

71%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

52%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,047

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

14.17

Composite VBP score used to determine payment impact.

Payment multiplier

0.9813

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

Baseline 67.39% · Performance 66.67% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

2.83

Baseline 3.18 hours · Performance 3.88 hours · Measure score 2.83 · Achievement 2.83 · Improvement 2.21

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.46%	10.72% 1.3 pts better	No Different than the National Rate · Eligible stays 36 · Observed rate 2.78% · Lower 95% interval 5.85%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	0.63	1.02 0.4 pts better
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	47.37%	8.2% 39.2 pts better	Numerator 54 · Denominator 114
Staff flu vaccination coverage	33.03%	42% 9 pts worse	Numerator 36 · Denominator 109
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.3	1.7 0.4 pts better	1.9 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 0.9 · Expected 1.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.5	1.2 0.3 pts worse	1.8 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.2 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	76.7%	86.9% 10.2 pts worse	93.4% 16.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 84.0% · Q2 81.9% · Q3 73.1% · Q4 70.2% · 4Q avg 76.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	92.0%	93.5% 1.5 pts worse	95.5% 3.5 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 92.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.6%	3.2% 2.6 pts better	3.3% 2.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.6%	6.5% 5.9 pts better	11.4% 10.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.6%
Percentage of long-stay residents who lose too much weight	6.5%	6.5% About the same	5.4% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 8.5% · Q3 5.9% · Q4 5.4% · 4Q avg 6.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	17.9%	19.9% 2 pts better	19.6% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 17.9% · Q3 20.7% · Q4 14.9% · 4Q avg 17.9%
Percentage of long-stay residents who received an antipsychotic medication	22.8%	18.7% 4.1 pts worse	16.7% 6.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 21.3% · Q3 20.3% · Q4 26.5% · 4Q avg 22.8% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	16.2%	19.6% 3.4 pts better	16.3% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 15.9% · Q3 19.4% · Q4 14.4% · 4Q avg 16.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	17.9%	18.3% 0.4 pts better	14.9% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 14.7% · Q3 17.7% · Q4 28.6% · 4Q avg 17.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.9%	0.9% About the same	1.0% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 0.0% · Q4 1.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.3%	1.7% 1.4 pts better	1.7% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.8%	26.4% 1.6 pts better	19.8% 5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.5% · Q2 30.3% · Q3 20.0% · Q4 21.4% · 4Q avg 24.8%
Percentage of long-stay residents with pressure ulcers	1.1%	5.3% 4.2 pts better	5.1% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	26.7%	68.9% 42.2 pts worse	81.7% 55 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 30.0% · Q3 31.8% · Q4 22.2% · 4Q avg 26.7%
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.5% 1.5 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	38.1%	68.7% 30.6 pts worse	79.7% 41.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 38.1%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-25 · Fire 2025-04-25

17 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 2 Health 2024-03-15 · Fire 2024-03-15

10 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 3 Health 2023-06-02 · Fire 2023-06-02

11 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

C · Minimal harm 2025-04-25

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2025-04-29

C · Minimal harm 2024-03-15

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2024-05-01

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-12-18

F680 · Quality of Life and Care Deficiencies

Health

Ensure the activities program is directed by a qualified professional.

Corrected 2026-01-19

D · Potential for more than minimal harm 2025-12-03

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-12-08

D · Potential for more than minimal harm 2025-08-06

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-08-20

F · Potential for more than minimal harm 2025-04-25

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2025-06-12

F · Potential for more than minimal harm 2025-04-25

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-06-12

F · Potential for more than minimal harm 2025-04-25

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2025-06-12

E · Potential for more than minimal harm 2025-04-25

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-06-12

E · Potential for more than minimal harm 2025-04-25

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-06-12

E · Potential for more than minimal harm 2025-04-25

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2025-06-12

E · Potential for more than minimal harm 2025-04-25

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2025-06-12

E · Potential for more than minimal harm 2025-04-25

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2025-06-12