Lititz, PA

Kadima Rehabilitation & Nursing At Lititz

1-star overall rating with 1-star inspections with 25 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle

125 South Broad Street, Lititz, PA

(717) 626-0211

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Kadima Healthcare Group

Operator or chain grouping

Approved since

1983-07-01

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

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

0.89

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.83

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

1.64

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.37

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.72

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.15

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.57

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.94

CMS adjusted RN staffing hours

Adjusted total hours

3.55

CMS adjusted total nurse staffing hours

Case-mix index

1.30

Higher values indicate more complex resident acuity

RN turnover

100%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

100%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,008

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

Performance score

28.06

Composite VBP score used to determine payment impact.

Payment multiplier

0.9848

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

5.71

Baseline 7.79% · Performance 6.13% · Measure score 5.71 · Achievement 5.71 · Improvement 5.45

Total nurse turnover

Baseline 66.67% · Performance 81.82% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

2.70

Baseline 3.29 hours · Performance 3.85 hours · Measure score 2.70 · Achievement 2.70 · Improvement 1.75

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.75%	10.72% About the same	No Different than the National Rate · Eligible stays 66 · Observed rate 12.12% · Lower 95% interval 7.38%
Discharge to community	49.49%	50.57% 1.1 pts worse	No Different than the National Rate · Eligible stays 58 · Observed rate 43.1% · Lower 95% interval 36.18%
Medicare spending per beneficiary	0.88	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 30 · Denominator 30
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 30
Discharge self-care score	50%	53.69% 3.7 pts worse	Numerator 10 · Denominator 20
Discharge mobility score	35%	50.94% 15.9 pts worse	Numerator 7 · Denominator 20
Pressure ulcers or injuries, new or worsened	3.33%	2.29% 1 pts worse	Numerator 1 · Denominator 30 · Adjusted rate 3.39%
Healthcare-associated infections requiring hospitalization	6.13%	7.12% 1 pts better	No Different than the National Rate · Eligible stays 26 · Observed rate 0% · Lower 95% interval 3.08%
Staff COVID-19 vaccination coverage	24.44%	8.2% 16.2 pts better	Numerator 11 · Denominator 45
Staff flu vaccination coverage	0%	42% 42 pts worse	Numerator 0 · Denominator 52
Discharge function score	50%	56.45% 6.5 pts worse	Numerator 10 · Denominator 20
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 8 · 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	2.3	1.7 0.6 pts worse	1.9 0.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.8 · Expected 1.5 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.0	1.2 0.8 pts worse	1.8 0.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.6 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	71.2%	86.9% 15.7 pts worse	93.4% 22.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 76.7% · Q2 63.3% · Q3 66.7% · Q4 78.6% · 4Q avg 71.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	81.8%	93.5% 11.7 pts worse	95.5% 13.7 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 81.8%
Percentage of long-stay residents experiencing one or more falls with major injury	1.7%	3.2% 1.5 pts better	3.3% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.3% · Q4 3.6% · 4Q avg 1.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	6.3%	6.5% 0.2 pts better	11.4% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · Q4 13.0% · 4Q avg 6.3%
Percentage of long-stay residents who lose too much weight	5.9%	6.5% 0.6 pts better	5.4% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 4.0% · Q3 3.7% · Q4 4.3% · 4Q avg 5.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	29.5%	19.9% 9.6 pts worse	19.6% 9.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 26.9% · Q3 25.9% · Q4 36.0% · 4Q avg 29.5%
Percentage of long-stay residents who received an antipsychotic medication	14.1%	18.7% 4.6 pts better	16.7% 2.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 14.3% · Q3 13.6% · Q4 18.2% · 4Q avg 14.1% · 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	38.2%	19.6% 18.6 pts worse	16.3% 21.9 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 38.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	27.6%	18.3% 9.3 pts worse	14.9% 12.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 23.1% · Q3 29.6% · Q4 24.0% · 4Q avg 27.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	4.6%	0.9% 3.7 pts worse	1.0% 3.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 2.3% · Q3 6.5% · Q4 3.3% · 4Q avg 4.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.7% 1.7 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	36.7%	26.4% 10.3 pts worse	19.8% 16.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 45.9% · Q2 24.4% · Q3 33.9% · Q4 44.8% · 4Q avg 36.7%
Percentage of long-stay residents with pressure ulcers	9.4%	5.3% 4.1 pts worse	5.1% 4.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 8.8% · Q3 6.2% · Q4 6.3% · 4Q avg 9.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	30.1%	68.9% 38.8 pts worse	81.7% 51.6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 38.2% · Q2 30.7% · Q3 22.1% · Q4 30.5% · 4Q avg 30.1%
Percentage of short-stay residents who had an outpatient emergency department visit	12.2%	9.8% 2.4 pts worse	12.0% 0.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 11.8% · Expected 10.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.9%	1.5% 0.4 pts worse	1.6% 0.3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.7% · Q4 4.0% · 4Q avg 1.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	42.1%	68.7% 26.6 pts worse	79.7% 37.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 42.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	27.5%	23.1% 4.4 pts worse	23.9% 3.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 27.5% · Observed 26.5% · Expected 23.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-18 · Fire 2025-07-18

25 health deficiencies

Top issue: Quality of Life and Care (9 deficiencies)

15 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 2 Health 2024-06-07 · Fire 2024-06-07

4 health deficiencies

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

2 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 3 Health 2023-08-31 · Fire 2023-08-31

4 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

13 fire-safety deficiencies

Top issue: Egress (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-07-18

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2025-08-19

F · Potential for more than minimal harm 2025-07-18

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-08-19

F · Potential for more than minimal harm 2025-07-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-08-19

F · Potential for more than minimal harm 2025-07-18

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2025-08-19

E · Potential for more than minimal harm 2025-07-18

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2025-08-19

E · Potential for more than minimal harm 2025-07-18

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 2025-08-19

E · Potential for more than minimal harm 2025-07-18

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2025-08-19

E · Potential for more than minimal harm 2025-07-18

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 2025-08-19

C · Minimal harm 2025-07-18

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2025-08-19

C · Minimal harm 2025-07-18

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2025-08-19

C · Minimal harm 2025-07-18

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-08-19

C · Minimal harm 2025-07-18

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-08-19

C · Minimal harm 2025-07-18

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2025-08-19

C · Minimal harm 2025-07-18

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2025-08-19

C · Minimal harm 2025-07-18

K700 · Miscellaneous Deficiencies

Fire Safety

Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.

Corrected 2025-08-19

E · Potential for more than minimal harm 2024-06-07

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2024-08-17

E · Potential for more than minimal harm 2024-06-07

K325 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-08-17

F · Potential for more than minimal harm 2023-08-31

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2023-10-06

F · Potential for more than minimal harm 2023-08-31

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2023-10-06

E · Potential for more than minimal harm 2023-08-31

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2023-10-06

E · Potential for more than minimal harm 2023-08-31

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2023-10-06

E · Potential for more than minimal harm 2023-08-31

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-10-06

E · Potential for more than minimal harm 2023-08-31

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 2023-10-06

E · Potential for more than minimal harm 2023-08-31

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-10-06

E · Potential for more than minimal harm 2023-08-31

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2023-10-06

E · Potential for more than minimal harm 2023-08-31

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-10-06

E · Potential for more than minimal harm 2023-08-31

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2023-10-06

C · Minimal harm 2023-08-31

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2023-10-06

C · Minimal harm 2023-08-31

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2023-10-06

C · Minimal harm 2023-08-31

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 2023-10-06

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-23

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2026-02-13

D · Potential for more than minimal harm 2026-01-23

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2026-02-13

D · Potential for more than minimal harm 2025-12-17

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 2026-01-16

D · Potential for more than minimal harm 2025-12-17

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2026-01-16

G · Actual harm 2025-07-18

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2025-08-08

F · Potential for more than minimal harm 2025-07-18

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-08-08

F · Potential for more than minimal harm 2025-07-18

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 2025-08-08

E · Potential for more than minimal harm 2025-07-18

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-08-08

E · Potential for more than minimal harm 2025-07-18

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-08-08

E · Potential for more than minimal harm 2025-07-18

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 2025-08-08

E · Potential for more than minimal harm 2025-07-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-08

E · Potential for more than minimal harm 2025-07-18

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2025-08-08