Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
LANCASTER NURSING AND REHABILITATION CENTER
LANCASTER, PA · 446 certified beds · Last Life Safety survey April 11, 2025
CMS Certification Number 395774 · first certified January 1989
Ownership
Operated by IMPERIAL HEALTHCARE GROUP · For profit - Corporation
- Ownership changed April 30, 2021 (change of ownership)from CONESTOGA VIEW NURSING LP
Position within PA
22 citations — more than 86% of the 656 certified nursing homes in PA. Compared within PA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 4 citations; the earlier surveys in the window averaged 9. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (February 2026 to April 2026), and past the point by which nine in ten PA facilities have been surveyed. This facility’s last Life Safety survey was April 2025. Facilities in PA are typically surveyed 10–12 months after the last one (median 11), measured over 1,113 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 22 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in PA, and nationally. Surveyors differ markedly between states, so the PA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 22 |
| Median facility in PA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| July 27, 2023 | 11 |
| May 22, 2024 | 7 |
| April 11, 2025 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-05-22 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2 | 2025-04-11 |
| K-0293 | Have properly located and lighted "Exit" signs. | 2 | 2025-04-11 |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | 2 | 2024-05-22 |
| K-0908 | Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | 1 | 2023-07-27 |
| K-0311 | Have an enclosure around a vertical opening shaft. | 1 | 2023-07-27 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2023-07-27 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-05-22 |
What the citations cover
- Smoke Deficiencies 12
- Egress Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Construction Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 12 |
| Egress Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Construction Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 11, 2025 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (June 18, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 18, 2025) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (June 18, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 18, 2025) |
May 22, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (June 25, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (June 25, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 25, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 25, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (June 25, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 25, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (June 25, 2024) |
July 27, 2023 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (August 29, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (August 29, 2023) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (August 29, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (August 29, 2023) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (August 29, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 29, 2023) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (August 29, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (August 29, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (August 29, 2023) |
| K-0908 | Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Deficient, Provider has date of correction (August 29, 2023) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (August 29, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.