KADIMA REHABILITATION & NURSING AT LITITZ

125 SOUTH BROAD STREET, LITITZ, PA 17543 (717) 626-0211
For profit - Limited Liability company 42 Beds KADIMA HEALTHCARE GROUP Data: November 2025
Trust Grade
35/100
#588 of 653 in PA
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Last Inspection: July 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Kadima Rehabilitation & Nursing at Lititz has received a Trust Grade of F, indicating significant concerns about the quality of care provided at this facility. Ranked #588 out of 653 in Pennsylvania, they fall in the bottom half of nursing homes in the state, and #29 out of 31 in Lancaster County, meaning there are very few local options that are worse. The facility is worsening, with issues increasing from 4 in 2024 to 21 in 2025, which raises serious red flags for potential residents and their families. Despite having a staffing rating of 3 out of 5, which is average, the turnover rate is reported at 0%, indicating that staff members tend to stay long-term, which can contribute to better care. Notably, the facility has had no fines, which is a positive aspect, and it offers more RN coverage than 80% of similar facilities, ensuring that registered nurses are available to catch potential problems. However, specific incidents reported include a failure to provide proper care following a resident's fall, resulting in severe pain and injury, and a lack of communication regarding transfers and dietary oversight, which could compromise resident welfare. Overall, while there are strengths in staffing and RN coverage, the serious deficiencies and poor overall ratings are concerning for families considering this home.

Trust Score
F
35/100
In Pennsylvania
#588/653
Bottom 10%
Safety Record
Moderate
Needs review
Inspections
Getting Worse
4 → 21 violations
Staff Stability
○ Average
Turnover data not reported for this facility.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Pennsylvania facilities.
Skilled Nurses
✓ Good
Each resident gets 52 minutes of Registered Nurse (RN) attention daily — more than average for Pennsylvania. RNs are trained to catch health problems early.
Violations
⚠ Watch
31 deficiencies on record. Higher than average. Multiple issues found across inspections.
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 4 issues
2025: 21 issues

The Good

  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Pennsylvania average (3.0)

Significant quality concerns identified by CMS

Chain: KADIMA HEALTHCARE GROUP

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 31 deficiencies on record

1 actual harm
Jul 2025 17 deficiencies 1 Harm
SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0697 (Tag F0697)

A resident was harmed · This affected 1 resident

Number of residents sampled: Number of residents cited: Based upon clinical record review, review of facility documentation, and staff interview it was determined the facility failed to ensure proper...

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Number of residents sampled: Number of residents cited: Based upon clinical record review, review of facility documentation, and staff interview it was determined the facility failed to ensure proper care and treatment after a fall resulting in actual harm when a resident experienced severe pain after a fall and subsequent fracture due to the facility not providing interventions or monitoring the resident's pain for one of one resident reviewed (Resident 52).Findings include:Review of Resident 52's diagnosis list revealed diagnoses including Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Peripheral Vascular Disease (PVD - poor circulation of the extremities) and osteoarthritis (degenerative joint disease).Review of Resident 52's care plan revealed Resident 52 was at risk for falls and has acute and chronic pain.Review of Resident 52's progress notes dated May 8, 2025, revealed [At] 4:30 a.m. resident screamed out from room and found lying flat on the floor rolled in blankets. Last observed resident in bed five minutes prior to the incident. On assessment [resident] was alert, no obvious bruising and swelling noted on head, all extremities were moving, no shortening or obvious deformity noted. Skin assessment, open area on the left leg below the knee seen, slight bleeding noted, cleaned, dressed. Helped in bed with three (person) assist. Neuro checks started and vitals were WNL [within normal limits]. Notified hospice, notified MD, and DON [director of nursing]. New order for x-ray of femur [long bone in upper leg] stat [immediately]. Hospice suggested to give Tylenol PRN but resident declined. Tried to notify the family but left message as to directed to voicemail.Further review of Resident 52's progress notes dated May 8, 2025, at 10:19 a.m., approximately six hours post fall, revealed notified [mobile x-ray company] to obtain a STAT (immediately or at once) x-ray today. Xray tech will be in sometime today. ASAP (As Soon As Possible).Further review of Resident 52's progress note dated May 8, 2025, at 1:09 p.m., approximately nine hours post fall, revealed entered residents room to attempt administration of PRN [as needed] Tylenol for visible pain noted, upon entering resident holding right leg grimacing, pale in color with golf size ball above the knee and swelling to left side of right knee, resident would not allow writer or aide to get close to the right leg. RN sup [supervisor] and DON [Director of Nursing] notified for further assessment.Further review of Resident 52's progress notes dated May 8, 2025, at 2:20 p.m., approximately ten hours post fall, revealed Nurse placed call to hospice to notify of visible injury to right knee/femur told they were already aware no further instructions call placed to daughter voicemail left for a call back regarding sending resident out, resident appears in distress holding right leg grimacing stating please do something PRN Tylenol given, BP [blood pressure] 70/44, HR [heart rate] 76, R [respirations] 22.Further review of Resident 52's progress notes dated May 8, 2025, at 6:30 p.m., 14 hours post fall, revealed right leg x-ray completed showing acute fracture of the distal femoral metaphysis comminuted and displaced. [Resident's] right leg is swollen and hard upon palpation above right knee. Unable to move resident due to pain. Resident on hospice and morphine needed to be signed to take out of emergency cart. Resident in pain and cannot be moved at this time. Daughter is present and would like [resident] evaluated in ER [emergency room].Review of facility documentation revealed all responsible parties, including the Director of Nursing and Nursing Home Administrator, were informed of Resident 52's ongoing severe pain with documentation or signs of intervention.Further review of facility documentation revealed facility was aware of the delay in services regarding obtaining an x-ray of Resident 52's leg, but no additional assessments, treatments or emergency services were initiated until an x-ray was completed 14 hours post fall.Further review of facility documentation revealed Despite being informed throughout the day of the resident's condition, the DON did not assess the resident nor follow up on the x-ray order.Interview with Nursing Home Administrator and Director of Nursing on July 18, 2025, at 2:30 p.m. confirmed that no appropriate action was taken regarding Resident 52's severe pain for 14 hours post fall.The facility failed to ensure appropriate and timely treatment was provided for a resident in severe pain for 14 hours, causing prolonged and unmanaged pain and actual harm to Resident 52. 28 Pa. Code 201.18(e)(1) ManagementPreviously cited 8/31/202328 Pa. Code 211.12(d)(1)(3) Nursing ServicesPreviously cited8/31/2023, 6/7/2024, 6/3/2025
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0567 (Tag F0567)

Could have caused harm · This affected 1 resident

Number of residents sampled: Number of residents cited: Based upon interview, it was determined the facility failed to ensure residents received personal funds upon request in a timely manner for one ...

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Number of residents sampled: Number of residents cited: Based upon interview, it was determined the facility failed to ensure residents received personal funds upon request in a timely manner for one resident reviewed (Resident 13).Findings include:Interview conducted with Resident 13 on July 15, 2025 at 11:30 a.m. revealed that on June 24, 2025 Resident 13 requested $700.00 from resident's personal funds.This interview further revealed that the facility's Business Office Manager had no access to residents' personal funds due to not being able to write checks or access the funds.This interview further revealed the facility provided Resident 13 with a check for $700.00 on July 15, 2025, at approximately 11:15 a.m., 14 days after Resident 13 made the request for funds.Interview with Employee E3 on July 15, 2025, at 12:00 p.m. confirmed Resident 13 requested $700.00 of resident's personal funds on June 24, 2025.This interview also confirmed that Employee E3 had no access to residents' personal funds and had to request access from the facility's corporate office. This interview also confirmed Resident 13 was provided with a check in the amount of $700.00 on July 15, 2025.The above information was conveyed to the Nursing Home Administrator on July 16, 2025, at approximately 1:00 p.m. 28 Pa. Code 201.18(e)(1) Management
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Number of residents sampled: Number of residents cited: Based on observations and interviews with residents and staff, it was determined that the facility failed to maintain a safe, clean, comfortable...

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Number of residents sampled: Number of residents cited: Based on observations and interviews with residents and staff, it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment for two of 12 residents reviewed (Residents 7 and 36). Findings include: Observation on July 15, 2025, at 1:31 p.m. revealed Resident 7's bedside table's locked drawer was unable to be closed and therefore could not be locked. Additionally, the bottom door of the bedside table was falling off the hinges. Observation on July 15, 2025, at 10:22 a.m. of the floor in Resident 36's room and bathroom revealed large areas that appeared dull and faded. Interview with Resident 36 at that time revealed that staff had attempted to scrape the floor, removing some of the wax. Interview with Employee E4 on July 18, 2025, at 10:30 a.m. confirmed that staff had attempted to remove something from the floor in Resident 36's room and removed the wax. Employee E4 indicated that the floor needed to be stripped, but Employee E4 has not had the time to do it. The above information was presented to the Nursing Home Administrator on July 18, 2025, at 1:00 p.m. 28 Pa. Code 204.5(f) resident rooms
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

Number of residents sampled: Number of residents cited: Based on a review of facility policy and interviews with resident and staff, it was determined that the facility failed to ensure residents were...

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Number of residents sampled: Number of residents cited: Based on a review of facility policy and interviews with resident and staff, it was determined that the facility failed to ensure residents were free from misappropriation of property for one of 12 residents reviewed (Resident 7). Findings include: Review of facility policy, Abuse Protection, effective August 28, 2018, indicated that the resident has the right to be free from misappropriation of property. Interview with Resident 7 on July 15, 2025, at 12:09 p.m. indicated that the resident was missing approximately $65 which was in a wallet that was to have been locked in the supervisor's office while the resident was hospitalized . Resident 7 indicated that the missing money was reported to the staff, but Resident 7 was not aware of any investigation. Interview with the Nursing Home Administrator (NHA) on July 18, 2025, at 12:46 p.m. revealed that the NHA was aware of the allegation of missing money, but no investigation had been done. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition28 Pa. Code 201.18(b)(1) Management
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Number of residents sampled: Number of residents cited: Based upon review of facility policy and procedure and facility documentation, it was determined the facility failed to ensure a thorough invest...

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Number of residents sampled: Number of residents cited: Based upon review of facility policy and procedure and facility documentation, it was determined the facility failed to ensure a thorough investigation was completed for an allegation of abuse for one of one resident reviewed (Resident 43).Findings include:Review of facility policy and procedure titled Abuse Protection, effective 2018, revealed Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment.Further review of this policy revealed Investigation - timely and thorough investigations of all reports and allegations of abuse to include injuries of unknown origin.Further review of this policy revealed Regardless of how minor an accident or incident may be, including injuries of unknown source, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned. Injuries of unknown origin will be evaluated for potential or suspected abuse. An investigation is implemented and witness statements are obtained.Review of facility documentation revealed that Resident 43 made an allegation of physical abuse on May 27, 2025. The allegation stated that Resident 43 was hit in the mouth on May 26, 2025, by a facility employee.Further review of facility documentation revealed two statements were obtained of nurses working in the facility at the time of the alleged occurrence. Further review of facility documentation failed to reveal evidence that any statements were obtained from Resident 43 or other staff members working at the time of the alleged occurrence.A perpetrator was identified; however, no statement was obtained from the alleged perpetrator.Further review of facility documentation failed to reveal evidence as to a conclusion to the investigation and no PB 22 was filed for the alleged perpetrator.Interview with the Nursing Home Administrator on July 16, 2025, at 11:00 a.m. revealed that no PB 22 had been completed or filed for the alleged perpetrator and further revealed that the investigation was not thoroughly completed. 28 Pa. Code 201.18(e)(1) Management
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Number of residents sampled: Number of residents cited: Based upon clinical record review, it was determined the facility failed to follow physician's order for weights and pain medication for one of ...

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Number of residents sampled: Number of residents cited: Based upon clinical record review, it was determined the facility failed to follow physician's order for weights and pain medication for one of 12 residents reviewed (Resident 4).Findings include:Review of Resident 4's diagnosis list revealed diagnoses including left femur [long bone in upper leg] fracture, shoulder dislocation and obesity.Review of Resident 4's care plan revealed resident is at risk for pain related to left femur fracture and shoulder dislocation.Further review of Resident 4's care plan revealed Resident 4 will adhere to prescribed diet with interventions including weight resident as ordered.Review of Resident 4's physician orders revealed an order for weekly weights for four weeks.Review of Resident 4's Weight Summary revealed Resident 4 was weighed on June 30, 2025. Further review of documentation failed to reveal evidence that Resident 4 was weighed weekly for four weeks as ordered by Resident 4's physician.Further review of Resident 4's physician orders revealed an order for Hydrocodone (pain medication) 7.5 milligrams (mg) to be administered every four hours as needed for severe pain.Review of Resident 4's July 2025 Medication Administration Record revealed Resident 4 received Hydrocodone 7.5 mg on July 9, 2025, for a pain level of 0.Interview with Nursing Home Administrator and Director of Nursing on July 18, 2025, at 2:00 p.m. confirmed that Resident 4 was not weighed weekly for four weeks as ordered by Resident 4's physician and further confirmed Resident 4 should not have received Hydrocodone 7.5 mg for a pain level of 0. 28 Pa. Code 211.12(d)(1)(3) Nursing ServicesPreviously cited 6/7/2024, 6/3/2025
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Number of residents sampled: Number of residents cited: Based on review of clinical records and interview with staff, it was determined that the facility failed to ensure that a resident with a pressu...

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Number of residents sampled: Number of residents cited: Based on review of clinical records and interview with staff, it was determined that the facility failed to ensure that a resident with a pressure ulcer received the necessary treatment and services, consistent with professional standard, to promote healing for one of two residents (Resident 17). Findings include:Review of Resident 17's wound consult of July 16, 2025, revealed resident was seen for an unstageable pressure ulcer (wound covered by eschar [hardened, dry, black or brown dead tissue] or necrotic tissue [dead tissue]) of the right medial (inner side) ankle. Treatment recommendations were made to cleanse with NSS (normal saline solution), apply medical grade honey, calcium alginate (type of wound dressing) to base of wound, secure with bordered foam, change daily and prn (as needed).Review of Resident 17's physician's orders and July 2025 Treatment Administration Record revealed that the recommendation had not been acted upon, and the treatment changed as recommended.The information that the wound recommendation had not been addressed was presented to the Director of Nursing at 11:45 a.m. on July 18, 2025.483.25 Treatment/Svcs to Prevent/Heal Pressure UlcersPreviously cited 6/7/2428 Pa. Code 211.5(f) Clinical recordsPreviously cited 6/3/25, 6/7/2428. Pa. Code 211.12(d)(1)(3)(5) Nursing servicesPreviously cited 6/7/24
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled: Number of residents cited: Based on review of facility policy, review of clinical records, and inte...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled: Number of residents cited: Based on review of facility policy, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure that acceptable parameters of nutritional status were maintained for two of five residents reviewed (Residents 1 and 47).Findings include:Review of facility policy, Weight Monitoring and Weight Loss Intervention, revised November 2025, indicated that all residents will be weighed on admission, readmission, and at least monthly.Review of Resident 1's clinical record revealed that the resident was admitted on [DATE]. An admission weight was obtained on May 29, 2025, and a mini nutritional assessment completed on that day determined that the resident was at risk for malnutrition. Further review of the clinical record revealed no other weights were obtained.Review of Resident 47's clinical record revealed that the resident was admitted on [DATE]. The only weight documented for the resident was recorded as May 19, 2025, prior to the resident's admission. Further review of the clinical record revealed no further weights were obtained.This information was presented to the Nursing Home Administrator and Director of Nursing at 1:33 p.m. on July 18, 2025.28 Pa. Code 211.12(c) Nursing services28 Pa. Code 211.12(d)(1)(3)(5) Nursing servicesPreviously cited 6/7/24
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled: Number of residents cited: Based upon review of policy and procedure and clinical record review, it...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled: Number of residents cited: Based upon review of policy and procedure and clinical record review, it was determined the facility failed to provide transportation to a dialysis center for dialysis for one of one resident reviewed (Resident 8).Findings include:Review of policy and procedure titled Dialysis Care, revised November 2024, revealed The facility will make all transportation arrangements to and from the Dialysis Center.Resident 8 was admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease.Review of Resident 8's clinical progress notes dated June 23, 2025 revealed Resident sent to [hospital emergency department] via ambulance to receive dialysis.Review of Resident 8's clinical progress notes dated July 2, 2025 revealed Patient missed dialysis due to transportation issue.Resident 8 discharged from the facility on July 15, 2025.Interview with the Nursing Home Administrator and Director of Nursing on July 18, 2025 at 2:00 p.m. confirmed the facility had issues with transportation and have since retained a transport company to transport residents to appointments. 28 Pa. Code 201.18(e)(1) Management
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected 1 resident

Number of residents sampled: Number of residents cited: Based upon facility documentation, it was determined that the facility failed to ensure nurse aides completed the annual 12-hour in servicing a...

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Number of residents sampled: Number of residents cited: Based upon facility documentation, it was determined that the facility failed to ensure nurse aides completed the annual 12-hour in servicing as required.Findings include:Review of facility documentation revealed the facility had one certified nurse aide employed for at least one year.Further review of facility documentation failed to reveal evidence that the nurse aide had completed the required 12-hour annual in servicing as required.Interview with the Nursing Home Administrator and Director of Nursing on July 18, 2025, at 1:00 p.m. confirmed that the nurse aide had not completed the required 12 hours of annual inservicing as required. 28 Pa. Code 201.18(b)(2) ManagementPreviously cited 4/29/2025
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

Number of residents sampled: Number of residents cited: Based upon clinical record review, it was determined the facility failed to ensure pharmacy consultant reviews were completed monthly as require...

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Number of residents sampled: Number of residents cited: Based upon clinical record review, it was determined the facility failed to ensure pharmacy consultant reviews were completed monthly as required for one of five records reviewed (Resident 3).Findings include:Review of Resident 3's clinical record failed to reveal evidence that Pharmacy Consultant reviews were completed for Resident 3 for the following months - July, September, October, November and December 2024 and January, February, March and June 2025.Review of Resident 7's clinical record indicated that the consultant pharmacist identified an irregularity during the drug regimen review of March 27, 2025. There was no documented evidence of the irregularity or that the physician addressed the irregularity.Review of Resident 17's clinical record indicated that the consultant pharmacist recommended Venlafaxine (antidepressant medication) be assessed for a gradual dose reduction on December 8, 2024. There was no documented evidence that the physician addressed the recommendation. Additionally, the consultant pharmacist identified an irregularity during the drug regimen review of May 30, 2025. There was no documented evidence of the irregularity or that the physician addressed the irregularity.Review of Resident 37's clinical record indicated that the consultant pharmacist identified irregularities during the drug regimen reviews of December 8, 2024, May 30, and June 29, 2025. There was no documented evidence of the irregularities or that the physician addressed the irregularities.Interview with the Nursing Home Administrator on July 18, 2025, at 1:00 p.m. confirmed that no documented evidence exists that the Pharmacy Consultant completed medication reviews for the above-mentioned months and no documented evidence that the physician addressed pharmacy recommendations. 28 Pa. Code 211.9(a)(f)(3) Pharmacy Services
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected multiple residents

Number of residents sampled: Number of residents cited: Based upon clinical record review, review of select facility policies and procedures, and facility documentation, it was determined the facility...

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Number of residents sampled: Number of residents cited: Based upon clinical record review, review of select facility policies and procedures, and facility documentation, it was determined the facility failed to implement non-pharmaceutical interventions prior to the administration of pain medication for three residents and failed to monitor side effects of pain medication and anti-depressant medication for two residents (Resident 1, Resident 4, Resident 17). Findings include: Review of facility policy “Pain Management Guideline” effective August 2017, indicated that documentation and observation of care and treatment reflects ongoing monitoring of pain levels and interventions (pharmacological and non-pharmacological). The documentation will be reflected on the eMAR (electronic medication administration record) and progress notes. Review of Resident 1’s physician’s orders included an order for Oxycodone HCl (pain medication) 5 milligrams (mg) to be administered every six hours as needed for moderate to severe pain. Review of Resident 1’s clinical record failed to reveal evidence that non-pharmaceutical interventions were attempted prior to the administration of the as needed pain medication and failed to reveal evidence that side effects were being monitored for the use of pain medication. Review of Resident 4’s diagnosis list revealed diagnoses including left femur [long bone in upper leg] fracture and left shoulder dislocation. Review of Resident 4’s physician orders revealed an order for Hydrocodone – Acetaminophen [pain medication] 7.5-325 milligrams (mg) to be administered every 4 hours as needed for pain. Review of Resident 4’s clinical record failed to reveal evidence that non-pharmaceutical interventions were attempted prior to the administration of the as needed pain medication and failed to reveal evidence that side effects were being monitored for the use of pain medication. Review of Resident 4’s clinical record failed to reveal evidence that non-pharmaceutical interventions were attempted prior to the administration of the as needed pain medication and failed to reveal evidence that side effects were being monitored for the use of pain medication. Review of Resident 17’s physician’s orders included an order for Percocet 5-325 mg (oxycodone with acetaminophen) every six hours as needed for moderate to severe pain. Interview with the Nursing Home Administrator and Director of Nursing on July 18, 2025, at 1:00 p.m. confirmed that no non-pharmaceutical interventions were attempted prior to the administration of pain medication and no side effects were monitored during the use of the pain medication. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 6/7/2024, 6/3/2025
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Number of residents sampled: Number of residents cited: Bases on observations and interviews with staff, it was determined that the facility failed to store food in accordance with professional stand...

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Number of residents sampled: Number of residents cited: Bases on observations and interviews with staff, it was determined that the facility failed to store food in accordance with professional standards for food service safety.Findings include:Observations on July 15, 2025, at 9:40 a.m. during a tour of the kitchen with Employee E3, a large build up of ice was noted in the walk-in freezer. Boxes of food were observed to be covered in ice to the point of not being able to identify what the items were.Interview at the time with Employee E3 confirmed that the ice build up had been an on-going problem.The above information was presented to the Nursing Home Administrator at 1:30 p.m. on July 18, 2025.483.60 Food Procurement, Store/Prepare/Serve - SanitaryPreviously cited 6/7/24
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Number of residents sampled: Number of residents cited: Bases on observations and interviews with staff, it was determined that the facility failed to handle, store, and process so as to prevent the s...

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Number of residents sampled: Number of residents cited: Bases on observations and interviews with staff, it was determined that the facility failed to handle, store, and process so as to prevent the spread of infection.Findings include:Observations of the laundry area on July 18, 2025, at 11:00 a.m. revealed large trash bags on the floor containing dirty items in front of the dryer. The folding table containing clean items was located approximately four feet from the dirty items. Shelves on the walls contained various maintenance items such as tools and small hardware items. Additional observations revealed no PPE (personal protective equipment) was available for staff to use while sorting and handling contaminated items.Interview with E4 at that time revealed that PPE is used when items are from rooms that are on transmission-based precautions, but the PPE is not available in the laundry area.483.80 Infection Prevention and ControlPreviously cited 6/7/2428 Pa. Code 205.2(c)28 Pa. Code 205.26(d)
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected multiple residents

Number of residents sampled: Number of residents cited: Based upon interview and review of facility documentation, it was determined that the facility failed to ensure that a staff person was certifie...

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Number of residents sampled: Number of residents cited: Based upon interview and review of facility documentation, it was determined that the facility failed to ensure that a staff person was certified as an Infection Preventionist.Findings include:Review of facility documentation failed to provide evidence that the facility had a qualified staff person certified as an Infection Preventionist.Interview with the Nursing Home Administrator on July 18, 2025, at 1:00 p.m. confirmed that the Director of Nursing was taking the required classes but had not completed the required classes and certification for Infection Prevention. The interview further revealed that the facility had no Infection Preventionist on staff. 28 Pa. Code 201.18(b)(2) ManagementPreviously cited 4/29/2025
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0628 (Tag F0628)

Could have caused harm · This affected most or all residents

Based on facility policy, clinical record review and staff interviews, it was determined that the facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman of the ...

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Based on facility policy, clinical record review and staff interviews, it was determined that the facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman of the transfer or discharge for 4 of 4 (6, 7, 41, and 47) residents reviewed. The facility also failed to provide written information about the bed-hold policy to the resident, and if applicable the resident's representative, at the time of transfer, or in cases of emergency transfer, within 24 hours for 3 of 3 residents reviewed (7, 41, and 47). Additionally, the facility failed to reconcile the medications prior to discharge for one of one resident (6).Findings include:Review of facility policy Bed Hold Policy and Procedure revised November 1, 2024, revealed that upon discharge from the facility and admission to a hospital, the social service department or the Administrator's designee will contact, by telephone and in writing, the resident/agent (responsible party) to inform them that the resident was discharged to the hospital. The bedhold letter and bedhold reservation request must be mailed on the date the resident was discharged to the hospital for all residents, regardless of payer. Documentation regarding the contact by telephone and a copy of the bedhold letter and bedhold reservation request sent to the family will be kept on file in the resident's admission folder.Review of Resident 6's clinical record revealed that the resident was discharged to home on June 28, 2025. Further review of the clinical record revealed no evidence that the resident's medications were reconciled prior to discharge. Interview with the Director of Nursing on July 18, 2025, at 11:42 a.m. confirmed that there was no evidence of the medication reconciliation or that a representative of the Office of the State Long-Term Care Ombudsman was notified of the discharge.Review of Resident 7's progress note of February 20, 2025, revealed that the resident was admitted to the hospital for a scheduled surgical procedure. Review of Resident 7's progress note of May 23, 2025, revealed that the resident was admitted to the hospital with a diagnosis of UTI (urinary tract infection) and encephalopathy (disorder or disease of the brain). Review of Resident 7's progress note of June 11, 2025, revealed that the resident was admitted to the hospital with a diagnosis of encephalopathy. Interview with the Director of Nursing on July 18, 2025, at 12:41 p.m. confirmed that there was no evidence that the bed-hold policy was provided to the resident or the resident's representative when the resident was hospitalized . Additionally, there was no evidence that a representative of the Office of the State Long-Term Care Ombudsman was notified of the hospitalizations.Review of Resident 41's clinical record revealed Resident 41 was admitted to an acute care facility on April 18, 2025, with a diagnosis of sepsis.Further review of Resident 41's clinical record failed to reveal evidence that the resident or resident's representative were provided with a copy of the facility bed-hold policy. Additionally, there was no documented evidence that the State Ombudsman was notified of the transfer and admission to the acute care facility.Interview with the Director of Nursing on July 18, 2025, at 11:43 a.m. confirmed that there was no evidence the bed hold policy was provided to Resident 41 or Resident 41's representative and further there was no evidence that the State Ombudsman was notified of Resident 41's transfer and admission to an acute care facility.Review of Resident 47's progress note of May 30, 2025, revealed that the resident was sent to the hospital for evaluation and treatment. Interview with the Nursing Home Administrator on July 18, 2025, at 9:58 a.m. confirmed that there was no evidence that the bed-hold policy was provided to the resident's representative when the resident was hospitalized . Additionally, there was no evidence that a representative of the Office of the State Long-Term Care Ombudsman was notified of the hospitalization. 28 Pa. Code 201.14(a) Responsibility of licensee
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

Number of residents sampled: Number of residents cited: Based upon interview and observation, it was determined the facility failed to employ a Licensed Dietitian.Findings include:Review of clinical r...

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Number of residents sampled: Number of residents cited: Based upon interview and observation, it was determined the facility failed to employ a Licensed Dietitian.Findings include:Review of clinical records failed to reveal evidence that a Licensed Dietitian was reviewing or monitoring the nutritional status of residents.Interview with the Nursing Home Administrator on July 18, 2025, at 1:30 p.m. confirmed that the Licensed Dietitian, supposedly employed by the facility, was unavailable. This interview further revealed that a Licensed Dietitian had not been reviewing the nutritional status or providing nutritional services to residents in the facility. 28 Pa. Code 201.18(e)(1) Management
Jun 2025 3 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on review of the Pennsylvania Nursing Practice Act, residents' clinical records, and the facility's investigative documents, as well as staff interviews, it was determined that the facility fail...

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Based on review of the Pennsylvania Nursing Practice Act, residents' clinical records, and the facility's investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that a registered nurse completed a timely assessment when changes in condition occurred for one of 5 residents reviewed (Resident 1). 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 ongoing 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 carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 16, 2025, revealed that the resident was cognitively impaired and required extensive assistance from staff for daily care. A nursing note for Resident 1, dated May 8, 2025, at 4:30 a.m. revealed that the resident was found lying on the floor. The resident was assessed by the registered nurse (RN) and there was an open area on the left leg below the knee with slight bleeding noted. The resident had no complaint of pain and vital signs were within normal limits. A nursing note for Resident 1, dated May 8, 2025, at 2:00 p.m. revealed that the resident began to complain of a new onset severe pain, and her blood pressure was 70/44 (normal 120/80) and respirations were 22 (normal 12-20 at rest) the Registered Nurse supervisor and Director of Nursing were made aware of the change in the resident's condition. There was no documented evidence that a registered nurse assessed Resident 1's change in condition when she began to complain of new onset pain or a low blood pressure of 70/44. Interview with the Director of Nursing on June 2, 2025, at 10:02 a.m. confirmed that Resident 1 should have been assessed by a registered nurse and the assessment should have been documented in the resident's medical record. 28 Pa. Code 211.12(d)(1)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that dependent residents were provided with the necessary services to maintain personal hygi...

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Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that dependent residents were provided with the necessary services to maintain personal hygiene, by failing to provide showers as scheduled for one of 5 residents reviewed (Resident 3). Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 2, 2025, revealed that the resident was cognitively intact and required maximum staff assistance with daily care needs. The facility's shower schedule, undated, indicated that Resident 3 was to receive a shower twice weekly on Mondays and Thursdays in the morning. A review of the clinical records for Resident 3 revealed that she did not receive showers in the month of May 2025 on May 1,5, 19,26, and 29th. Interview with the Director of Nursing on June 2, 2025, at 2:02 p.m. confirmed that Resident 3 had not received a shower on the above dates in May 2025 and should have. 28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Based on review clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for three o...

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Based on review clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for three of 5 residents reviewed (Resident 3,4,5). Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 2, 2025, revealed that the resident was cognitively intact and required maximum staff assistance with daily care needs. An activities of daily living care plan for Resident 3 dated, January 24, 2025, revealed that the resident was to be turned and repositioned every two hours. Review of the clinical records for Resident 3 for May 2025 revealed that there was no documented evidence the resident was repositioned every two hours during day shift on May 1, 3,4,5,6, 11, 14, 17, 18, 19,20, 21, 26, 30, and 31, 2025; during the evening shift on May 5, 7,9,10,11, 19, 24, 25, 26, and 29, 2025 and the night shift on May 6, 15, 24, 30, and 31, 2025. Interview with Resident 3 on June 2, 2025, at 8:51 a.m. revealed that she is able to self-re-position in bed she just needs some extra help sometimes. An admission MDS assessment for Resident 4, dated April 21, 2025, revealed that the resident was cognitively intact and required maximum staff assistance with daily care needs. A skin integrity care plan for Resident 4 dated, April 16, 2025, revealed that the resident was to be turned and repositioned every two hours. Review of the clinical records for Resident 4 for May 2025 revealed that there was no documented evidence the resident was repositioned every two hours for the month of May 2025. An admission diagnosis for Resident 5 for May 30, 2025, revealed that the resident had a diagnosis of femur fracture and stroke. An activities of daily living care plan for Resident 5 dated May 27, 2025, revealed that the resident was to be turned and repositioned every 2 hours as tolerated. Review of the clinical records for Resident 5 revealed no documented evidence the resident was turned and repositioned in May of 2025, June 1 or June 2, 2025. Interview with the Director of Nursing on June 2, 2025, at 12:33 p.m. revealed there is no documented evidence that the above residents were repositioned every 2 hours, and it should have been. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(5) Nursing services.
Apr 2025 1 deficiency
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0568 (Tag F0568)

Could have caused harm · This affected multiple residents

Based upon interview, it was determined the facility failed to ensure residents were provided quarterly statements in regard to their personal funds for three of three residents interviewed (Resident ...

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Based upon interview, it was determined the facility failed to ensure residents were provided quarterly statements in regard to their personal funds for three of three residents interviewed (Resident 1, Resident 2 and Resident 3). Findings include: During an interview with residents on April 29, 2025 at 11:00 a.m. it was revealed that residents do not receive quarterly statements regarding personal finances. No documented evidence was provided on April 29, 2025 to support quarterly statements sent to residents by facility staff. Interview with the Nursing Home Administrator via telephone on April 30, 2025 at 2:00 p.m. revealed that the facility and/or corporate offices have not sent quarterly statements to any residents during 2024 or 2025. 28 Pa. Code 201.18(b)2) Management
Jun 2024 4 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based upon review of the clinical record and facility documentation, it was determined the facility failed to follow physician orders for one of twelve residents reviewed (Resident 28). Findings inclu...

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Based upon review of the clinical record and facility documentation, it was determined the facility failed to follow physician orders for one of twelve residents reviewed (Resident 28). Findings include: Review of Resident 28's physician orders revealed an order dated February 29, 2024, for Dermal sleeves [worn to protect skin] to bilateral lower extremities for protection. Remove to assess skin. May remove for care/showers then reapply. Review of Resident 28's active plan of care revealed tubigrips [sleeves worn to protect skin] to bilateral legs at all times. Review of documentation dated March 1, 2024, revealed Resident acquired a skin tear to right lower leg measuring 9 cm [centimeters] x 4 cm with adipose tissue exposed. Sanguineous drainage was noted. Resident c/o [complained of] pain upon dressing change but denied pain after. The resident did not have tubigrips during transfers. Resident has an order for dermal sleeves to BLE [bilateral lower extremities] to be worn for protection. Review of [community wound specialist] wound evaluation dated March 6, 2024, revealed 9.4 cm x 3.9 cm x 0.1 cm right lower lateral leg skin tear. Interview with the Director of Nursing and Nursing Home Administrator on June 7, 2024, at 11:00 a.m. confirmed Resident 28 was not wearing tubigrips as ordered by the physician on the lower extremities during the transfer. 28 Pa. Code 211.12(d)(1)(3) Nursing Services Previously cited 8/31/2023
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that necessary servic...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that necessary services were provided for one of one residents with a pressure ulcer (Resident 20). Findings include: Review of Resident 20's clinical record revealed that the resident was admitted on [DATE], with diagnoses of but not limited to stage 4 pressure ulcer (full thickness skin loss exposing underlying muscle, tendon, cartilage, or bone) of the sacral region (portion of spine between the lower back and tailbone and an unstageable pressure ulcer (pressure ulcer not stageable due to coverage of wound bed due to slough [non-viable yellow, tan, gray, green or brown tissue] and/or eschar [dead or devitalized tissue that is hard or soft in texture]) of the right heel. Review of Resident 20's wound consult of May 15, 2024, revealed new recommendations for an x-ray of the right heel to rule out osteomyelitis (bone infection) and a wound culture of the right heel. A follow up wound consult of May 22, 2024, again recommended a wound culture of the right heel. Review of physician's order dated May 22, 2024, indicated to obtain a wound culture of the right heel. Review of the clinical record revealed no evidence that the wound culture was obtained. An additional physician's order of May 29, 2024, instructed staff to swab the right heel for a wound culture. Further review of the clinical record revealed no evidence that the wound culture was obtained. Interview with the Nursing Home Administrator on June 7, 2024, at 2:00 p.m. confirmed that the wound culture was not obtained as ordered. 28 Pa. Code 211.5(f) Clinical records Previously cited 8/31/23 28. Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based upon observation, clinical record review, and interviews with staff, it was determined the facility failed to ensure enhanced barrier precautions were in place for residents requiring enhanced b...

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Based upon observation, clinical record review, and interviews with staff, it was determined the facility failed to ensure enhanced barrier precautions were in place for residents requiring enhanced barrier precautions for one of one residents reviewed (Residents 20). Findings include: Observations of Resident 20's room on all days of the survey failed to reveal evidence of enhanced barrier precautions. Review of Resident 20's admission MDS (Minimum Data Set - periodic assessment of resident needs) dated May 15, 2024, revealed the resident had an in-dwelling catheter (flexible tube inserted into the bladder for removing fluid), ileostomy (opening in the abdominal wall for the end of the small intestine to pass out digested food into a pouch), a stage 4 pressure ulcer (full thickness skin loss exposing underlying muscle, tendon, cartilage, or bone) of the sacral region (portion of spine between the lower back and tailbone and an unstageable pressure ulcer (pressure ulcer not stageable due to coverage of wound bed due to slough [non-viable yellow, tan, gray, green or brown tissue] and/or eschar [dead or devitalized tissue that is hard or soft in texture]) of the right heel. Interview with licensed staff Employee E3 on June 6, 2024, at 1:15 p.m. revealed that he/she was not aware of enhanced barrier precautions. Interview with the Nursing Home Administrator on June 7, 2024, at 11:33 a.m. confirmed that enhanced barrier precautions were not in place for Resident 20. 28 Pa. Code 211.5(f) Clinical records Previously cited 8/31/23 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 8/31/23
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on review of facility policy, observations, and interview with staff, it was determined that the facility failed to maintain appropriate sanitation during dishwashing. Findings include: Review o...

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Based on review of facility policy, observations, and interview with staff, it was determined that the facility failed to maintain appropriate sanitation during dishwashing. Findings include: Review of facility policy Low Temperature Dish Machine Temperatures & Sanitizer Testing, undated, revealed that the sanitizer levels are to be checked at each meal cycle using a chlorine test strip. This test is to be recorded during the rinse/sanitize cycle of the first test run of the dish machine. The chlorine strength value is to be recorded on the dish machine temperature and sanitizer monitoring log. If the test strip indicates a value greater than or lesser than 50 ppm (parts per million), notify the Dining Services Manager and/or Administrator immediately for appropriate corrective action. Observation on June 7, 2024, at 9:37 a.m. in presence of Employee E4 revealed the sanitizer strip revealed a value of 10 ppm. Observation at the log for June 2024 revealed water temperatures were recorded but there was no documentation of sanitizer strength. Interview with Employee E4 at that time revealed that sanitizer is checked daily or sometimes every other day and is usually 200 ppm. Interview with the Nursing Home Administrator (NHA) on June 7, 2024, at 1:15 p.m. revealed that the log had been updated and the space to record the sanitizer had been omitted. The NHA also confirmed that the sanitizer should not have been 10 ppm and the service company had been contacted. 28 Pa. code 211.6(f) Dietary services
Aug 2023 4 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a discharge summary contained a reconciliation of all medications for one of three closed reco...

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Based on clinical record review and staff interview, it was determined that the facility failed to ensure a discharge summary contained a reconciliation of all medications for one of three closed records (Resident 48). Findings include: Review of progress note of May 31, 2023, revealed that discharged was planned for June 5, 2023, with resident's son providing transportation to resident's home. Further review of Resident 48's closed clinical record revealed no documented evidence of the reconciliation of the medications or the disposition at the time of discharge from the facility. Interview with the Director of Nursing on August 31, 2023, at 12:08 p.m. confirmed that there was no documentation of the reconciliation of the medications. 28 Pa. Code 201.14 (a) Responsibility of licensee Previouslu cited 9/30/22 28 Pa. Code 201.18 (b)(2) Management Previouslu cited 9/30/22 28 Pa. Code 201.18 (b)(3) Management Previously cited 2/17/23 28 Pa. Code 211.5 (f) Clinical records Previously cited 11/21/22, 9/30/22 28 Pa. Code 211.9 (j) Pharmacy services 28 Pa. Code 211.12 (d)(3) Nursing services
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

Based on review of facility policy and clinical records, it was determined that facility failed to respond to recommendations made by the consultant pharmacist for four of five residents reviewed for ...

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Based on review of facility policy and clinical records, it was determined that facility failed to respond to recommendations made by the consultant pharmacist for four of five residents reviewed for unnecessary medications (Residents 4, 23, 28, and 44). Findings include: Review of facility policy Documentation and Communication of Consultant Pharmacist Recommendations, undated, revealed that comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medicationm regimen review. Recommendations are acted upon and documented by the facility staff and/or the prescriber. Review of Resident 4's Note to Attending Physician/Prescriber revealed monthly medication regimen reviews (MRRs) from November 6, 2022, December 11, 2022, February 9, 2023, March 6, 2023, and April 7, 2023, where the physician failed to respond to recommendations made by the pharmacist. Review of Resident 23's Note to Attending Physician/Prescriber revealed MRRs from November 6, 2022, December 11, 2022, May 7, 2023, and June 8, 2023, where the physician failed to respond to recommendations made by the pharmacist. Review of Resident 28's Note to Attending Physician/Prescriber revealed a MRR from March 6, 2023, was not addressed until July 18, 2023. Review of Resident 44's Note to Attending Physician/Prescriber revealed MRRs from May 7, 2023, and June 8, 2023, where the physician failed to respond to recommendations made by the pharmacist. Interview with the Director of Nursing on August 31, 2023, at approximately 2:00 p.m. confirmed the facility failed to ensure a physician's timely response to the above mentioned MRRs. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.5(f)(h) Clinical records 28 Pa. Code 211.12(c)(d)(3)(d)(5) Nursing services
MINOR (B)

Minor Issue - procedural, no safety impact

Assessment Accuracy (Tag F0641)

Minor procedural issue · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure MDS assessments accura...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure MDS assessments accurately reflected the resident's status for three of 16 residents reviewed (Residents 28, 33, and 39). Findings include: Review of Resident 28's quarterly MDS assessment (Minimum Data Set - periodic assessment of resident needs) dated July 13, 2023, Section H0100 - Appliances, indicated that the resident had an indwelling catheter (tube maintained within the bladder for continuous drainage of urine). Review of the clinical record revealed Resident 28 did not have an indwelling catheter at the time of the assessment. Review of Resident 33's quarterly MDS dated [DATE], Section O0100 - Special Treatments, Procedures, and Programs indicated that the resident was not receiving hospice services. Review of Resident 33's physician orders included an order for hospice dated November 17, 2022. Review of Resident 39's quarterly MDS assessment (Minimum Data Set - periodic assessment of resident needs) dated June 28, 2023, Section H0100 - Appliances, indicated that the resident had an indwelling catheter (tube maintained within the bladder for continuous drainage of urine). Review of Resident 39's clinical record revealed the resident did not have an indwelling catheter at the time of the assessment. Interview with the Director of Nursing, on August 31, 2023, at 1:20 p.m. confirmed that the assessments did not accurately reflect the resident's status. 28 Pa. Code 211.5(f) Clinical records Previously cited 11/21/22, 9/30/22 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 9/30/22
MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0582 (Tag F0582)

Minor procedural issue · This affected most or all residents

Based on review of facility documentation and staff interview, it was determined that the facility failed to provide the required Notice of Medicare Provider Non-Coverage (NOMNC) and Skilled Nursing F...

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Based on review of facility documentation and staff interview, it was determined that the facility failed to provide the required Notice of Medicare Provider Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) to the resident or resident's representative for three of three records reviewed (Residents 100, 101, and 102). Findings include: Review of form titled Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (notice that informs the recipient when care receive from skilled nursing facility is ending and how you can contact a Quality Improvement Organization (QIO) to appeal) instructs that a Medicare provider must be delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. Review of the form title Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) states that this notice is given to make residents aware of care that no longer meets Medicare coverage requirements and they may have to pay out of pocket for the care listed. The provider must ensure that the beneficiary or their representative signs and dates the SNFABN to demonstrate that the beneficiary or their representative received the notice of possible out of pocket costs. Review of facility documentation revealed that Resident 100 was discontinued from Medicare Part A on April 3, 2023, with benefit days remaining. There was no documentable evidence that the resident or resident's representative was provided the required NOMNC or SNF-ABN form. Review of facility documentation revealed that Resident 101 was discontinued from Medicare Part A on June 5, 2023, with benefit days remaining. There was no documented evidence that the resident or resident's representative was provided the required NOMNC or SNF-ABN form. Review of facility documentation revealed that Resident 102 was discontinued from Medicare Part A on April 10, 2023, with benefit days remaining. There was no documentated evidence that the resident or resident's representative was provided the required NOMNC or SNF-ABN form. Interview with the Employee E3 on August 31, 2023, at 12:40 p.m. confirmed that there was no evidence that the NOMNC and SNF-ABN notices were provided to the above residents or their representative. 483.10(g)(18)(i) Medicaid/Medicare Coverage/liability notice Previously cited 9/30/22 28 Pa. Code 201.18(b)(2) Management Previously cited 9/30/22 28 Pa. Code 201.18(e)(1) Management Previously cited 9/30/22 28 Pa. Code 201.29(a) Resident rights Previously cited 9/30/22
Feb 2023 1 deficiency
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

Based on facility policy review, resident interview, observation, and staff interview, it was determined that the facility failed to provide foods that were served at the proper temperature to ensure ...

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Based on facility policy review, resident interview, observation, and staff interview, it was determined that the facility failed to provide foods that were served at the proper temperature to ensure resident satisfaction on one of three units South Hall. Findings include: Review of facility policy titled, Food Procurement, Temperatures, and Consistency revealed all hot food shall be served at 135 Degrees F [Farenheit] or above. All cold foods shall be served at 41 Degrees F or below. Interview with Resident R2 on February 17, 2023, at 4:10 p.m. revealed that the food is often cold. Observation of the evening meal on February 17, 2023, revealed that the food cart left the kitchen at 5:30 p.m. and arrived on the South floor at 5:31 p.m. Staff began passing trays from the cart at 5:31 p.m. The last resident was assisted with their meal at 5:35 p.m., at which time a test tray was evaluated with the Directory Manager, Employee E3. The test tray revealed the following temperatures: Hot dog 121 degrees F, baked beans 149.2 degrees F, and Juice 55 degrees F. Interview with the Dietary Manager at that time revealed that these temperatures were not acceptable and should be above 135 degrees F at the point of service for hot items and below 41 degrees F for cold items. 28 Pa. Code: 201.18 (b)(3) Management
Nov 2022 1 deficiency
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review and interview, it was determined that the facility failed to ensure a baseline care plan was c...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review and interview, it was determined that the facility failed to ensure a baseline care plan was completed after admission for one of 3 records reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE]. Further review of Resident R1's clinical record revealed Resident R1's baseline care plan was not initiated until October 16, 2022. Interview with the Director of Nursing on November 21, 2022 at 1:30 p.m. revealed that a baseline care plan was not completed until October 16, 2022 following Resident R1's admission on [DATE]. 28 Pa Code 211.5 (f) Clinical Records 28 Pa Code 211.10(d) Resident Care Policies 28 Pa Code 211.11(c)(d) Resident Care Plan
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No fines on record. Clean compliance history, better than most Pennsylvania facilities.
Concerns
  • • 31 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
  • • Grade F (35/100). Below average facility with significant concerns.
Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.

About This Facility

What is Kadima Rehabilitation & Nursing At Lititz's CMS Rating?

CMS assigns KADIMA REHABILITATION & NURSING AT LITITZ an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Kadima Rehabilitation & Nursing At Lititz Staffed?

CMS rates KADIMA REHABILITATION & NURSING AT LITITZ's staffing level at 3 out of 5 stars, which is average compared to other nursing homes.

What Have Inspectors Found at Kadima Rehabilitation & Nursing At Lititz?

State health inspectors documented 31 deficiencies at KADIMA REHABILITATION & NURSING AT LITITZ during 2022 to 2025. These included: 1 that caused actual resident harm, 28 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Kadima Rehabilitation & Nursing At Lititz?

KADIMA REHABILITATION & NURSING AT LITITZ is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by KADIMA HEALTHCARE GROUP, a chain that manages multiple nursing homes. With 42 certified beds and approximately 37 residents (about 88% occupancy), it is a smaller facility located in LITITZ, Pennsylvania.

How Does Kadima Rehabilitation & Nursing At Lititz Compare to Other Pennsylvania Nursing Homes?

Compared to the 100 nursing homes in Pennsylvania, KADIMA REHABILITATION & NURSING AT LITITZ's overall rating (1 stars) is below the state average of 3.0 and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Kadima Rehabilitation & Nursing At Lititz?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Kadima Rehabilitation & Nursing At Lititz Safe?

Based on CMS inspection data, KADIMA REHABILITATION & NURSING AT LITITZ has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Kadima Rehabilitation & Nursing At Lititz Stick Around?

KADIMA REHABILITATION & NURSING AT LITITZ has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.

Was Kadima Rehabilitation & Nursing At Lititz Ever Fined?

KADIMA REHABILITATION & NURSING AT LITITZ has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Kadima Rehabilitation & Nursing At Lititz on Any Federal Watch List?

KADIMA REHABILITATION & NURSING AT LITITZ is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

KADIMA REHABILITATION & NURSING AT LITITZ

125 SOUTH BROAD STREET, LITITZ, PA 17543 | (717) 626-0211

F
Trust Grade (35/100)
1.0
CMS Rating
31
Deficiencies

Strengths

  • Licensed facility

Concerns

  • 1-star rating
  • 31 deficiencies

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nursinghomedata.org | Data: CMS November 2025