Cycle 1
Health 2025-05-09 · Fire 2025-05-09
22 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
29 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Harmony, PA
Kadima Rehabilitation & Nursing At Harmony
1-star overall rating with 1-star inspections with abuse icon flag with $174,201 in total fines with 22 recent health deficiencies with 29 fire-safety deficiencies in the latest cycle
191 Evergreen Mill Road, Harmony, PA
(724) 452-6970
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
115
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Kadima Healthcare Group
Operator or chain grouping
Approved since
1988-06-01
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
0.48
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.30
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
0.60
CMS adjusted RN staffing hours
Adjusted total hours
4.51
CMS adjusted total nurse staffing hours
Case-mix index
1.09
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,353
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 60.00% · Performance 62.26% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.54
Baseline 3.28 hours · Performance 3.8 hours · Measure score 2.54 · Achievement 2.54 · Improvement 1.59
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.29% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 6.45% · Lower 95% interval 6.08% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 90.48% |
95.27%
4.8 pts worse
|
Numerator 19 · Denominator 21 |
| Falls with major injury | 4.76% |
0.77%
4 pts worse
|
Numerator 1 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 9.52% |
2.29%
7.2 pts worse
|
Numerator 2 · Denominator 21 · Adjusted rate 10.18% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 109 |
| Staff flu vaccination coverage | 0.13% |
42%
41.9 pts worse
|
Numerator 3 · Denominator 2299 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| 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 | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.7
0.6 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.7 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.5 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 45.2% |
86.9%
41.7 pts worse
|
93.4%
48.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.9% · Q2 49.5% · Q3 44.3% · Q4 35.6% · 4Q avg 45.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.4% |
93.5%
0.9 pts better
|
95.5%
1.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.5% |
3.2%
3.3 pts worse
|
3.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 7.1% · Q3 7.2% · Q4 5.9% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
6.5%
2.8 pts better
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.2% · Q3 2.1% · Q4 6.7% · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 8.3% |
6.5%
1.8 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 7.4% · Q3 9.8% · Q4 10.2% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.9% |
19.9%
4 pts better
|
19.6%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 16.7% · Q3 17.2% · Q4 18.2% · 4Q avg 15.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.3% |
18.7%
4.6 pts worse
|
16.7%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 18.8% · Q3 24.3% · Q4 29.2% · 4Q avg 23.3% · 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 | 23.5% |
19.6%
3.9 pts worse
|
16.3%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 16.7% · Q3 15.1% · Q4 38.6% · 4Q avg 23.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.4% |
18.3%
0.1 pts worse
|
14.9%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 10.9% · Q3 8.0% · Q4 41.5% · 4Q avg 18.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
0.9%
1.5 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.6% · Q3 1.4% · Q4 3.4% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
1.7%
0.6 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.0% · Q3 3.1% · Q4 2.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.4% |
26.4%
1 pts better
|
19.8%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.5% · Q2 23.6% · Q3 22.5% · Q4 19.7% · 4Q avg 25.4% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
5.3%
1.3 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 5.3% · Q3 5.4% · Q4 7.9% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 7.9% |
68.9%
61 pts worse
|
81.7%
73.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 6.2% · Q3 7.8% · Q4 10.3% · 4Q avg 7.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
9.8%
About the same
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 9.1% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.1% |
1.5%
2.6 pts worse
|
1.6%
2.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.5% · Q3 5.4% · Q4 3.7% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 7.6% |
68.7%
61.1 pts worse
|
79.7%
72.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 7.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.2% |
23.1%
6.9 pts better
|
23.9%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 13.6% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-03 · Fire 2024-05-03
35 health deficiencies
Top issue: Resident Rights (9 deficiencies)
16 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2023-06-09 · Fire 2023-06-09
16 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-09
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-08-06
F · Potential for more than minimal harm
2025-05-09
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2025-07-12
F · Potential for more than minimal harm
2025-05-09
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-08-06
F · Potential for more than minimal harm
2025-05-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-06
F · Potential for more than minimal harm
2025-05-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-06
F · Potential for more than minimal harm
2025-05-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-06
F · Potential for more than minimal harm
2025-05-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-12
F · Potential for more than minimal harm
2025-05-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-08-06
F · Potential for more than minimal harm
2025-05-09
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-08-06
F · Potential for more than minimal harm
2025-05-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-06
E · Potential for more than minimal harm
2025-05-09
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-07-12
E · Potential for more than minimal harm
2025-05-09
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-08-06
E · Potential for more than minimal harm
2025-05-09
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-08-06
E · Potential for more than minimal harm
2025-05-09
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-07-12
D · Potential for more than minimal harm
2025-05-09
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-07-12
C · Minimal harm
2025-05-09
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-07-14
C · Minimal harm
2025-05-09
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-07-14
C · Minimal harm
2025-05-09
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2025-07-14
C · Minimal harm
2025-05-09
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2025-07-14
C · Minimal harm
2025-05-09
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-07-14
C · Minimal harm
2025-05-09
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-08-06
C · Minimal harm
2025-05-09
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-07-14
C · Minimal harm
2025-05-09
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-07-14
C · Minimal harm
2025-05-09
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2025-07-12
C · Minimal harm
2025-05-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-08-06
C · Minimal harm
2025-05-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-12
B · Minimal harm
2025-05-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-12
B · Minimal harm
2025-05-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-06
B · Minimal harm
2025-05-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-12
F · Potential for more than minimal harm
2024-05-03
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-05-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-05-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-05-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-05-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-05-03
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-05-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-01
E · Potential for more than minimal harm
2024-05-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-05-03
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-05-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-05-03
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-05-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-05-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-04
C · Minimal harm
2024-05-03
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-06-04
C · Minimal harm
2024-05-03
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-06-04
B · Minimal harm
2024-05-03
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-06-04
F · Potential for more than minimal harm
2023-06-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-30
F · Potential for more than minimal harm
2023-06-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-29
F · Potential for more than minimal harm
2023-06-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-29
E · Potential for more than minimal harm
2023-06-09
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-07-29
E · Potential for more than minimal harm
2023-06-09
K231 · Egress Deficiencies
Fire Safety
Provide large enough exits.
Corrected 2023-07-29
E · Potential for more than minimal harm
2023-06-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-06-09
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 2023-07-29
D · Potential for more than minimal harm
2023-06-09
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-06-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-29
C · Minimal harm
2023-06-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-12
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2025-07-14
J · Immediate jeopardy
2025-05-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-13
F · Potential for more than minimal harm
2025-05-09
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-06-13
F · Potential for more than minimal harm
2025-05-09
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 2025-06-13
F · Potential for more than minimal harm
2025-05-09
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-05-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-05-09
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-05-09
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-09
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-09
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-09
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 2025-06-13
D · Potential for more than minimal harm
2025-05-09
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-09
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-09
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-09
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2025-06-13
C · Minimal harm
2025-05-09
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2025-06-13
D · Potential for more than minimal harm
2024-12-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-01-13
E · Potential for more than minimal harm
2024-11-22
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-07-31
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-06-27
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-26
F · Potential for more than minimal harm
2024-05-03
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 2024-06-13
E · Potential for more than minimal harm
2024-05-03
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-03
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-03
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-03
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-03
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-03
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-03
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-03
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-03
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-03
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-03
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 2024-06-13
D · Potential for more than minimal harm
2024-05-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-03
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-03
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-03
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-03
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-03
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-03
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-02-26
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-03-29
J · Immediate jeopardy
2024-01-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-01-26
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-01-26
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 2024-03-08
D · Potential for more than minimal harm
2024-01-26
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 2024-03-08
D · Potential for more than minimal harm
2024-01-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-09-13
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2023-10-13
E · Potential for more than minimal harm
2023-06-09
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-06-09
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-06-09
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 2023-07-11
D · Potential for more than minimal harm
2023-06-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-06-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-06-09
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-07-11
Penalties and ownership
What sits behind the stars
$43,450
2025-05-09
Fine
Fine · fine $43,450
Fine
$130,751
2024-01-05
Fine
Fine · fine $130,751
Fine
Ownership
Morris, Daniel
5% Or Greater Direct Ownership Interest · Individual
Strauss, Jonathan
5% Or Greater Direct Ownership Interest · Individual
Buchanan, Chelsie
Operational/Managerial Control · Individual
Cibc Bank Usa
Operational/Managerial Control · Organization
Cibc Bank Usa
5% Or Greater Security Interest · Organization
Harmont Realty Management LLC
5% Or Greater Mortgage Interest · Organization
Kadima Healthcare Group Inc
Operational/Managerial Control · Organization
Lowden, Thomas
Operational/Managerial Control · Individual
Morris, Daniel
Operational/Managerial Control · Individual
Naylor, Diedre
Operational/Managerial Control · Individual
Nestler, Devin
Operational/Managerial Control · Individual
Pinnacle Healthcare Solutions Inc
Operational/Managerial Control · Organization
Strauss, Jonathan
Operational/Managerial Control · Individual
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