Drums, PA

Kadima Rehabilitation & Nursing At Luzerne

1-star overall rating with 1-star inspections with Special Focus status with $86,122 in total fines with 16 recent health deficiencies

463 North Hunter Hwy, Drums, PA

(570) 788-4175

Compare this facility

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

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Kadima Healthcare Group

Operator or chain grouping

Approved since

1980-04-01

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

0.84

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.97

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.34

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

4.15

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.81

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.67

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.59

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

0.96

CMS adjusted RN staffing hours

Adjusted total hours

4.75

CMS adjusted total nurse staffing hours

Case-mix index

1.19

Higher values indicate more complex resident acuity

RN turnover

72%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

65%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,968

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

Performance score

31.16

Composite VBP score used to determine payment impact.

Payment multiplier

0.9863

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

3.02

Baseline 47.62% · Performance 51.35% · Measure score 3.02 · Achievement 3.02 · Improvement 0

Adjusted total nurse staffing

3.22

Baseline 2.56 hours · Performance 3.76 hours · Measure score 3.22 · Achievement 2.40 · Improvement 3.22

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.32%	10.72% 0.6 pts worse	No Different than the National Rate · Eligible stays 30 · Observed rate 16.67% · Lower 95% interval 7.86%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	0.83	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 13 · 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 52
Staff flu vaccination coverage	0%	42% 42 pts worse	Numerator 0 · Denominator 65
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 5 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 9 · 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	1.3	1.7 0.4 pts better	1.9 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.4 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.8	1.2 0.6 pts worse	1.8 About the same	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.1 · Expected 2.0 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.0%	86.9% 10.1 pts better	93.4% 3.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 91.4% · Q2 96.8% · Q3 100.0% · Q4 100.0% · 4Q avg 97.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	93.5% 6.5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	3.2% 3.2 pts better	3.3% 3.3 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 who have depressive symptoms	2.5%	6.5% 4 pts better	11.4% 8.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 10.0% · 4Q avg 2.5%
Percentage of long-stay residents who lose too much weight	6.1%	6.5% 0.4 pts better	5.4% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 12.9% · Q3 6.5% · Q4 5.9% · 4Q avg 6.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	33.8%	19.9% 13.9 pts worse	19.6% 14.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 35.5% · Q3 34.4% · Q4 37.1% · 4Q avg 33.8%
Percentage of long-stay residents who received an antipsychotic medication	41.9%	18.7% 23.2 pts worse	16.7% 25.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q4 35.0% · 4Q avg 41.9% · 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	41.4%	19.6% 21.8 pts worse	16.3% 25.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 53.4% · 4Q avg 41.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	39.8%	18.3% 21.5 pts worse	14.9% 24.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 58.6% · Q3 34.5% · Q4 40.6% · 4Q avg 39.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.9% 0.9 pts better	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% · 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	20.7%	26.4% 5.7 pts better	19.8% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 18.4% · Q3 26.6% · Q4 21.7% · 4Q avg 20.7%
Percentage of long-stay residents with pressure ulcers	2.5%	5.3% 2.8 pts better	5.1% 2.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.9% · Q4 5.9% · 4Q avg 2.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	57.7%	68.9% 11.2 pts worse	81.7% 24 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 57.7%
Percentage of short-stay residents who newly received an antipsychotic medication	6.2%	1.5% 4.7 pts worse	1.6% 4.6 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 6.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-16 · Fire 2025-01-16

16 health deficiencies

Top issue: Nutrition and Dietary (6 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-02-29 · Fire 2024-02-29

21 health deficiencies

Top issue: Resident Rights (6 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-04-20 · Fire 2023-04-20

20 health deficiencies

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

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Fire safety

Fire-safety citations

C · Minimal harm 2023-04-20

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-05-29

Inspection history

Recent health citations

L · Immediate jeopardy 2025-06-11

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 2025-07-11

L · Immediate jeopardy 2025-06-11

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2025-07-11

F · Potential for more than minimal harm 2025-06-11

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 2025-07-11

E · Potential for more than minimal harm 2025-06-11

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 2025-07-11

E · Potential for more than minimal harm 2025-06-11

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-07-11

D · Potential for more than minimal harm 2025-04-17

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 2025-06-11

D · Potential for more than minimal harm 2025-04-17

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 2025-06-11

D · Potential for more than minimal harm 2025-04-17

F626 · Resident Rights Deficiencies

Health

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Corrected 2025-06-11

F · Potential for more than minimal harm 2025-01-16

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 2025-02-14

F · Potential for more than minimal harm 2025-01-16

F838 · Administration Deficiencies

Health

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected 2025-02-14

E · Potential for more than minimal harm 2025-01-16

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-02-14

E · Potential for more than minimal harm 2025-01-16

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-02-14

D · Potential for more than minimal harm 2025-01-16

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 2025-02-14

D · Potential for more than minimal harm 2025-01-16

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-02-14

D · Potential for more than minimal harm 2025-01-16

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2025-02-14

B · Minimal harm 2025-01-16

F912 · Environmental Deficiencies

Health

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Corrected 2025-02-14

D · Potential for more than minimal harm 2024-11-15

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2025-01-16

E · Potential for more than minimal harm 2024-07-23

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 2024-08-18

E · Potential for more than minimal harm 2024-06-18

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 2024-08-18

E · Potential for more than minimal harm 2024-06-18

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 2024-07-23

D · Potential for more than minimal harm 2024-06-18

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 2024-07-23

G · Actual harm 2024-02-29

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-04-29

F · Potential for more than minimal harm 2024-02-29

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 2024-04-29

F · Potential for more than minimal harm 2024-02-29

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2024-04-29

F · Potential for more than minimal harm 2024-02-29

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-04-29

F · Potential for more than minimal harm 2024-02-29

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 2024-04-29

E · Potential for more than minimal harm 2024-02-29

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 2024-04-29

E · Potential for more than minimal harm 2024-02-29

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 2024-04-29

E · Potential for more than minimal harm 2024-02-29

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-04-29

E · Potential for more than minimal harm 2024-02-29

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-04-29

D · Potential for more than minimal harm 2024-02-29

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2024-04-29

D · Potential for more than minimal harm 2024-02-29

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 2024-04-29

D · Potential for more than minimal harm 2024-02-29

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-04-29

D · Potential for more than minimal harm 2024-02-29

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 2024-04-29

B · Minimal harm 2024-02-29

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-04-29

B · Minimal harm 2024-02-29

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 2024-04-29

B · Minimal harm 2024-02-29

F912 · Environmental Deficiencies

Health

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Corrected 2024-04-29

F · Potential for more than minimal harm 2023-10-26

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 2023-12-28

E · Potential for more than minimal harm 2023-10-26

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2023-12-28

D · Potential for more than minimal harm 2023-10-26

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2023-12-28

D · Potential for more than minimal harm 2023-09-07

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-10-26

F · Potential for more than minimal harm 2023-04-20

F909 · Environmental Deficiencies

Health

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Corrected 2023-05-22

E · Potential for more than minimal harm 2023-04-20

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-05-22

E · Potential for more than minimal harm 2023-04-20

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2023-05-22

E · Potential for more than minimal harm 2023-04-20

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 2023-05-22

E · Potential for more than minimal harm 2023-04-20

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 2023-05-22