Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Trillium Place
LANCASTER, PA · 160 certified beds · Last Life Safety survey November 26, 2024
CMS Certification Number 395559 · first certified April 1983
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within PA
8 citations — more than 39% 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 1 citation; the earlier surveys in the window averaged 3.5. 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 (October 2025 to November 2025), and past the point by which nine in ten PA facilities have been surveyed. This facility’s last Life Safety survey was November 2024. 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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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 | 8 |
| Median facility in PA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 9, 2023 | 4 |
| November 30, 2023 | 3 |
| November 26, 2024 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | 1 | 2023-11-30 |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | 1 | 2023-01-09 |
| K-0541 | Install properly constructed and protected linen or trash chutes. | 1 | 2023-11-30 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2023-01-09 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2023-01-09 |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 1 | 2024-11-26 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2023-11-30 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2023-01-09 |
What the citations cover
- Smoke Deficiencies 4
- Services Deficiencies 2
- Egress Deficiencies 1
- Gas, Vacuum, and Electrical Systems Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 4 |
| Services Deficiencies | 2 |
| Egress Deficiencies | 1 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 26, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (December 10, 2024) |
November 30, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (December 1, 2023) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (December 1, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 1, 2023) |
January 9, 2023 — 4 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 (February 10, 2023) |
| 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 (February 10, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (February 10, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (February 10, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.