Greenville, PA

Kadima Rehabilitation & Nursing At Greenville

4-star overall rating with 4-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

110 Fredonia Road, Greenville, PA

(724) 588-8090

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

154

Certified beds

Average residents

127

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Kadima Healthcare Group

Operator or chain grouping

Approved since

1967-01-26

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

No

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

0.43

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.97

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

1.89

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.28

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.39

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.00

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.23

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.46

CMS adjusted RN staffing hours

Adjusted total hours

3.52

CMS adjusted total nurse staffing hours

Case-mix index

1.28

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

43%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,983

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

Performance score

46.59

Composite VBP score used to determine payment impact.

Payment multiplier

1.0000

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.45

Performance 19.37% · Measure score 4.45 · Achievement 4.45 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

6.26

Baseline 6.22% · Performance 5.96% · Measure score 6.26 · Achievement 6.26 · Improvement 1.56

Total nurse turnover

6.10

Baseline 41.98% · Performance 38.75% · Measure score 6.10 · Achievement 6.10 · Improvement 1.38

Adjusted total nurse staffing

1.83

Baseline 3.56 hours · Performance 3.60 hours · Measure score 1.83 · Achievement 1.83 · Improvement 0

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 53 · Observed rate 5.66% · Lower 95% interval 5.58%
Discharge to community	50.18%	50.57% 0.4 pts worse	No Different than the National Rate · Eligible stays 34 · Observed rate 44.12% · Lower 95% interval 35.2%
Medicare spending per beneficiary	0.68	1.02 0.3 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 45 · Denominator 45
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 45
Discharge self-care score	68.42%	53.69% 14.7 pts better	Numerator 26 · Denominator 38
Discharge mobility score	73.68%	50.94% 22.7 pts better	Numerator 28 · Denominator 38
Pressure ulcers or injuries, new or worsened	4.44%	2.29% 2.2 pts worse	Numerator 2 · Denominator 45 · Adjusted rate 3.85%
Healthcare-associated infections requiring hospitalization	5.96%	7.12% 1.2 pts better	No Different than the National Rate · Eligible stays 35 · Observed rate 0% · Lower 95% interval 2.9%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 111
Staff flu vaccination coverage	15.56%	42% 26.4 pts worse	Numerator 21 · Denominator 135
Discharge function score	76.32%	56.45% 19.9 pts better	Numerator 29 · Denominator 38
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 20 · Denominator 20
Resident COVID-19 vaccinations up to date	26.09%	25.2% 0.9 pts better	Numerator 6 · Denominator 23

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.6	1.7 1.1 pts better	1.9 1.3 pts better	Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.2	1.2 1 pts worse	1.8 0.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.2 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	88.5%	86.9% 1.6 pts better	93.4% 4.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 92.8% · Q3 96.8% · Q4 82.1% · 4Q avg 88.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	99.0%	93.5% 5.5 pts better	95.5% 3.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0%
Percentage of long-stay residents experiencing one or more falls with major injury	5.1%	3.2% 1.9 pts worse	3.3% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 5.2% · Q3 4.3% · Q4 4.5% · 4Q avg 5.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.8%	6.5% 5.7 pts better	11.4% 10.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.9% · 4Q avg 0.8%
Percentage of long-stay residents who lose too much weight	6.8%	6.5% 0.3 pts worse	5.4% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 9.0% · Q3 9.1% · Q4 4.9% · 4Q avg 6.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	16.7%	19.9% 3.2 pts better	19.6% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 15.2% · Q3 14.3% · Q4 18.9% · 4Q avg 16.7%
Percentage of long-stay residents who received an antipsychotic medication	16.3%	18.7% 2.4 pts better	16.7% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 14.3% · Q3 15.9% · Q4 16.3% · 4Q avg 16.3% · 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	23.3%	19.6% 3.7 pts worse	16.3% 7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 35.2% · Q3 26.6% · Q4 13.4% · 4Q avg 23.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	21.3%	18.3% 3 pts worse	14.9% 6.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 29.9% · Q3 18.8% · Q4 19.8% · 4Q avg 21.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.0%	0.9% 0.1 pts worse	1.0% About the same	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.9% · Q3 0.0% · Q4 0.9% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.8%	1.7% 0.9 pts better	1.7% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	32.8%	26.4% 6.4 pts worse	19.8% 13 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 36.8% · Q2 36.0% · Q3 30.9% · Q4 28.6% · 4Q avg 32.8%
Percentage of long-stay residents with pressure ulcers	6.3%	5.3% 1 pts worse	5.1% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 7.6% · Q3 5.6% · Q4 4.6% · 4Q avg 6.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	72.8%	68.9% 3.9 pts better	81.7% 8.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 90.8% · Q2 80.2% · Q3 66.7% · Q4 59.8% · 4Q avg 72.8%
Percentage of short-stay residents who had an outpatient emergency department visit	13.0%	9.8% 3.2 pts worse	12.0% 1 pts worse	Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 14.3% · Expected 12.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.6%	1.5% 0.1 pts worse	1.6% About the same	Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 2.0% · Q4 1.7% · 4Q avg 1.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	80.2%	68.7% 11.5 pts better	79.7% 0.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 80.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	15.1%	23.1% 8 pts better	23.9% 8.8 pts better	Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 16.7% · Expected 26.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-06 · Fire 2025-06-06

7 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2024-07-18 · Fire 2024-07-18

0 health deficiencies

No concentrated health issue counts in this cycle.

12 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 3 Health 2023-08-18 · Fire 2023-08-18

2 health deficiencies

Top issue: Nursing and Physician Services (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-06-06

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-07-15

F · Potential for more than minimal harm 2025-06-06

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-07-15

F · Potential for more than minimal harm 2025-06-06

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-07-15

E · Potential for more than minimal harm 2025-06-06

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-07-15

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

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-07-15

C · Minimal harm 2025-06-06

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2025-07-15

C · Minimal harm 2025-06-06

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2025-07-15

F · Potential for more than minimal harm 2024-07-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-10-22

E · Potential for more than minimal harm 2024-07-18

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2024-08-26

E · Potential for more than minimal harm 2024-07-18

K325 · Smoke Deficiencies

Fire Safety

Have properly installed hallway dispensers for alcohol-based hand rub.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-07-18

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-07-18

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-07-18

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-08-26

C · Minimal harm 2024-07-18

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-10-22

C · Minimal harm 2024-07-18

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-10-22

C · Minimal harm 2024-07-18

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-08-26

C · Minimal harm 2024-07-18

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2024-08-26

C · Minimal harm 2024-07-18

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-10-22

B · Minimal harm 2024-07-18

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-08-26

F · Potential for more than minimal harm 2023-08-18

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-09-21

D · Potential for more than minimal harm 2023-08-18

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-09-21

D · Potential for more than minimal harm 2023-08-18

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-09-21

C · Minimal harm 2023-08-18

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2023-09-21

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-29

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Not marked corrected

D · Potential for more than minimal harm 2025-11-21

F576 · Resident Rights Deficiencies

Health

Ensure residents have reasonable access to and privacy in their use of communication methods.

Corrected 2025-12-18

D · Potential for more than minimal harm 2025-11-21

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-12-18

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

F698 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-07-15

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

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 2025-07-15

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

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-07-15

D · Potential for more than minimal harm 2025-03-17

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-04-15

E · Potential for more than minimal harm 2023-08-18

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2023-09-14

D · Potential for more than minimal harm 2023-08-18

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 2023-09-14

Penalties and ownership

What sits behind the stars

Ownership

Morris, Daniel

5% Or Greater Direct Ownership Interest · Individual

50% 15 facilities 2024-11-01

Strauss, Jonathan

5% Or Greater Direct Ownership Interest · Individual

50% 20 facilities 2024-11-01

Dallam, Angela