Cycle 1
Health 2025-12-19 · Fire 2025-12-19
16 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
North Huntingdon, PA
Kadima Rehabilitation & Nursing At Irwin
1-star overall rating with 1-star inspections with $184,982 in total fines with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
249 Maus Drive, North Huntingdon, PA
(724) 863-4374
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
110
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Kadima Healthcare Group
Operator or chain grouping
Approved since
1977-08-22
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
0.50
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.78
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
3.17
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.80
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.50
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
78%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,158
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
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 72.11% · Performance 74.22% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.57
Baseline 2.67 hours · Performance 3.93 hours · Measure score 3.57 · Achievement 3.01 · Improvement 3.57
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.9% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 13.33% · Lower 95% interval 7.3% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 6.92% |
8.2%
1.3 pts worse
|
Numerator 9 · Denominator 130 |
| Staff flu vaccination coverage | 27.78% |
42%
14.2 pts worse
|
Numerator 40 · Denominator 144 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.5% |
86.9%
1.4 pts worse
|
93.4%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.8% · Q2 86.6% · Q3 84.8% · Q4 81.0% · 4Q avg 85.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.4% |
93.5%
1.1 pts worse
|
95.5%
3.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.2%
0.1 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.1% · Q3 4.0% · Q4 6.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.1% |
6.5%
4.4 pts better
|
11.4%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 6.2% · Q4 1.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who lose too much weight | 9.1% |
6.5%
2.6 pts worse
|
5.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 7.1% · Q3 4.4% · Q4 13.2% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.8% |
19.9%
6.9 pts worse
|
19.6%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 31.4% · Q3 27.2% · Q4 28.0% · 4Q avg 26.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.5% |
18.7%
2.8 pts worse
|
16.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 25.5% · Q3 18.3% · Q4 20.3% · 4Q avg 21.5% · 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 | 22.9% |
19.6%
3.3 pts worse
|
16.3%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 30.0% · Q3 12.8% · Q4 20.3% · 4Q avg 22.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.6% |
18.3%
5.3 pts worse
|
14.9%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 22.6% · Q3 24.1% · Q4 20.5% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.9%
0.4 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.9% · Q3 1.4% · Q4 2.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
1.7%
1.7 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 7.1% · Q4 3.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
26.4%
1.5 pts better
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 31.1% · Q3 21.2% · Q4 23.7% · 4Q avg 24.9% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
5.3%
3.2 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 9.2% · Q3 7.3% · Q4 7.1% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 38.2% |
68.9%
30.7 pts worse
|
81.7%
43.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 41.9% · Q2 56.0% · Q3 37.2% · Q4 19.8% · 4Q avg 38.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 1.9% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 38.2% |
68.7%
30.5 pts worse
|
79.7%
41.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 38.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-01-31 · Fire 2025-01-31
15 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-12-21 · Fire 2023-12-21
34 health deficiencies
Top issue: Nutrition and Dietary (10 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-01-29
D · Potential for more than minimal harm
2025-12-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2026-01-29
C · Minimal harm
2025-12-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-29
C · Minimal harm
2025-12-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-29
F · Potential for more than minimal harm
2025-01-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-15
F · Potential for more than minimal harm
2025-01-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-15
D · Potential for more than minimal harm
2025-01-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-15
C · Minimal harm
2025-01-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-15
C · Minimal harm
2025-01-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-15
C · Minimal harm
2025-01-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-15
E · Potential for more than minimal harm
2023-12-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-18
E · Potential for more than minimal harm
2023-12-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-26
E · Potential for more than minimal harm
2023-12-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-18
E · Potential for more than minimal harm
2023-12-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-26
E · Potential for more than minimal harm
2023-12-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-18
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-19
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2026-02-03
F · Potential for more than minimal harm
2025-12-19
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2026-02-03
F · Potential for more than minimal harm
2025-12-19
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2026-02-03
E · Potential for more than minimal harm
2025-12-19
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2026-02-03
E · Potential for more than minimal harm
2025-12-19
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 2026-02-03
E · Potential for more than minimal harm
2025-12-19
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 2026-02-03
D · Potential for more than minimal harm
2025-12-19
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 2026-02-03
D · Potential for more than minimal harm
2025-12-19
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 2026-02-03
D · Potential for more than minimal harm
2025-12-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-03
D · Potential for more than minimal harm
2025-12-19
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 2026-02-03
D · Potential for more than minimal harm
2025-08-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-27
D · Potential for more than minimal harm
2025-08-05
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 2025-08-27
D · Potential for more than minimal harm
2025-08-05
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 2025-08-27
D · Potential for more than minimal harm
2025-07-15
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.
Not marked corrected
D · Potential for more than minimal harm
2025-07-15
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.
Not marked corrected
D · Potential for more than minimal harm
2025-07-15
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Not marked corrected
E · Potential for more than minimal harm
2025-01-31
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 2025-02-25
E · Potential for more than minimal harm
2025-01-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-31
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 2025-02-25
D · Potential for more than minimal harm
2025-01-31
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-31
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-31
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 2025-02-25
F · Potential for more than minimal harm
2025-01-07
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 2025-01-16
F · Potential for more than minimal harm
2024-08-02
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 2024-08-22
E · Potential for more than minimal harm
2024-08-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-22
E · Potential for more than minimal harm
2024-08-02
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 2024-08-22
D · Potential for more than minimal harm
2024-08-02
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-08-22
F · Potential for more than minimal harm
2024-06-18
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 2024-06-27
E · Potential for more than minimal harm
2024-03-05
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 2024-04-02
E · Potential for more than minimal harm
2024-03-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-02
F · Potential for more than minimal harm
2023-12-27
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 2024-01-30
F · Potential for more than minimal harm
2023-12-21
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 2024-01-30
E · Potential for more than minimal harm
2023-12-21
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 2024-01-30
E · Potential for more than minimal harm
2023-12-21
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 2024-01-30
E · Potential for more than minimal harm
2023-12-21
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 2024-01-30
E · Potential for more than minimal harm
2023-12-21
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 2024-01-30
E · Potential for more than minimal harm
2023-12-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-30
E · Potential for more than minimal harm
2023-12-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-30
E · Potential for more than minimal harm
2023-12-21
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 2024-01-30
E · Potential for more than minimal harm
2023-12-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-30
E · Potential for more than minimal harm
2023-12-21
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 2024-01-30
E · Potential for more than minimal harm
2023-12-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-30
E · Potential for more than minimal harm
2023-12-21
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-01-30
E · Potential for more than minimal harm
2023-12-21
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2024-01-30
E · Potential for more than minimal harm
2023-12-21
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-12-21
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-12-21
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 2024-01-30
C · Minimal harm
2023-12-21
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2024-01-30
F · Potential for more than minimal harm
2023-11-29
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 2023-12-28
D · Potential for more than minimal harm
2023-11-29
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-12-28
F · Potential for more than minimal harm
2023-08-23
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 2023-09-05
D · Potential for more than minimal harm
2023-08-23
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-09-05
J · Immediate jeopardy
2023-07-25
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 2023-08-22
J · Immediate jeopardy
2023-07-25
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 2023-08-22
J · Immediate jeopardy
2023-07-25
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-08-22
F · Potential for more than minimal harm
2023-07-25
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-08-22
F · Potential for more than minimal harm
2023-07-25
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-07-25
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-08-22
F · Potential for more than minimal harm
2023-07-11
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 2023-07-27
F · Potential for more than minimal harm
2023-07-11
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 2023-07-27
E · Potential for more than minimal harm
2023-06-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-01
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 2023-05-31
E · Potential for more than minimal harm
2023-05-01
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 2023-05-31
D · Potential for more than minimal harm
2023-05-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-31
Penalties and ownership
What sits behind the stars
$148,292
2023-06-15
Fine
Fine · fine $148,292
Fine
$4,587
2023-05-30
Fine
Fine · fine $4,587
Fine
$4,587
2023-05-23
Fine
Fine · fine $4,587
Fine
$4,587
2023-05-15
Fine
Fine · fine $4,587
Fine
$4,587
2023-05-08
Fine
Fine · fine $4,587
Fine
$13,762
2023-04-17
Fine
Fine · fine $13,762
Fine
$4,580
2023-03-20
Fine
Fine · fine $4,580
Fine
Ownership
Morris, Daniel
5% Or Greater Indirect Ownership Interest · Individual
Strauss, Jonathan
5% Or Greater Direct Ownership Interest · Individual
Kadima Healthcare Group Inc
Operational/Managerial Control · Organization
Lowden, Thomas
Operational/Managerial Control · Individual
Morris, Daniel
Operational/Managerial Control · Individual
Naylor, Dalton
Operational/Managerial Control · Individual
Naylor, Diedre
Operational/Managerial Control · Individual
Pinnacle Healthcare Solutions Inc
Operational/Managerial Control · Organization
Schmeltz, Jennifer
Operational/Managerial Control · Individual
Strauss, Jonathan
Operational/Managerial Control · Individual
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#3
Monroeville Post Acute
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2-star overall rating with 2-star inspections with abuse icon flag with $39,416 in total fines with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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