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

Staffing

Hours and turnover

RN hours / resident day

0.89

Registered nurse staffing

LPN hours / resident day

0.83

Licensed practical nurse staffing

Aide hours / resident day

1.64

Nurse aide staffing

Weekend hours

3.15

Weekend nurse staffing

RN turnover

100%

Annual RN turnover

Total nurse turnover

100%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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