Cycle 1
Health 2024-10-11 · Fire 2024-10-11
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Canonsburg, PA
Kadima Rehabilitation & Nursing At North Strabane
3-star overall rating with 3-star inspections with $4,580 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
100 Tandem Village Road, Canonsburg, PA
(724) 743-9000
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
62
Certified beds
Average residents
58
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Kadima Healthcare Group
Operator or chain grouping
Approved since
2001-01-31
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
0.70
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.51
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
3.83
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
77%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
75%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,202
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
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 79.63% · Performance 82.89% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.70
Baseline 3.11 hours · Performance 3.84 hours · Measure score 2.70 · Achievement 2.70 · Improvement 2.25
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.61% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 11.54% · Lower 95% interval 6.29% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 20 · Denominator 20 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 20 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 20 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 71.52% |
8.2%
63.3 pts better
|
Numerator 108 · Denominator 151 |
| Staff flu vaccination coverage | 11.11% |
42%
30.9 pts worse
|
Numerator 7 · Denominator 63 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · 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 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · 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 | 35.6% |
86.9%
51.3 pts worse
|
93.4%
57.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.8% · Q2 30.8% · Q3 35.3% · Q4 36.0% · 4Q avg 35.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 81.5% |
93.5%
12 pts worse
|
95.5%
14 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 81.5% |
| 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 | 4.7% |
6.5%
1.8 pts better
|
11.4%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 0.0% · Q3 2.3% · Q4 5.1% · 4Q avg 4.7% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
6.5%
1.2 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 9.1% · Q3 4.7% · Q4 2.4% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.0% |
19.9%
1.9 pts better
|
19.6%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 20.5% · Q3 14.0% · Q4 14.3% · 4Q avg 18.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.5% |
18.7%
8.8 pts worse
|
16.7%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 28.1% · Q3 29.6% · Q4 27.3% · 4Q avg 27.5% · 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 | 20.8% |
19.6%
1.2 pts worse
|
16.3%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 10.8% · Q3 28.5% · Q4 19.9% · 4Q avg 20.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.0% |
18.3%
3.3 pts better
|
14.9%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 18.6% · Q3 11.9% · Q4 19.0% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.5% |
0.9%
3.6 pts worse
|
1.0%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 6.8% · Q3 3.5% · Q4 0.0% · 4Q avg 4.5% · 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 | 26.9% |
26.4%
0.5 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.2% · Q2 17.3% · Q3 22.1% · Q4 35.6% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
5.3%
1.7 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 12.4% · Q3 4.5% · Q4 4.6% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 45.3% |
68.9%
23.6 pts worse
|
81.7%
36.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 68.9% · Q2 60.6% · Q3 38.4% · Q4 20.5% · 4Q avg 45.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
9.8%
3.1 pts worse
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 13.0% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.8% · Q4 2.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 58.2% |
68.7%
10.5 pts worse
|
79.7%
21.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 58.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.7% |
23.1%
10.4 pts better
|
23.9%
11.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 13.0% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-06 · Fire 2023-10-06
2 health deficiencies
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-12-02 · Fire 2022-12-02
17 health deficiencies
Top issue: Resident Rights (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-15
C · Minimal harm
2024-10-11
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-11-15
C · Minimal harm
2024-10-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-11-15
C · Minimal harm
2024-10-11
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-11-15
C · Minimal harm
2024-10-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-15
E · Potential for more than minimal harm
2023-10-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-07
E · Potential for more than minimal harm
2023-10-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-11-07
C · Minimal harm
2023-10-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-11-07
E · Potential for more than minimal harm
2022-12-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-19
E · Potential for more than minimal harm
2022-12-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-19
E · Potential for more than minimal harm
2022-12-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-19
D · Potential for more than minimal harm
2022-12-02
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-12-19
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-11
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-10-11
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 2024-11-08
D · Potential for more than minimal harm
2024-10-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-11
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 2024-11-08
D · Potential for more than minimal harm
2024-10-11
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-03-06
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 2024-03-28
E · Potential for more than minimal harm
2023-10-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-06-21
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-07-28
E · Potential for more than minimal harm
2022-12-02
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 2022-12-22
E · Potential for more than minimal harm
2022-12-02
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 2022-12-22
E · Potential for more than minimal harm
2022-12-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-12-22
E · Potential for more than minimal harm
2022-12-02
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 2022-12-22
E · Potential for more than minimal harm
2022-12-02
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 2022-12-22
E · Potential for more than minimal harm
2022-12-02
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 2022-12-22
E · Potential for more than minimal harm
2022-12-02
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-12-22
E · Potential for more than minimal harm
2022-12-02
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2022-12-22
E · Potential for more than minimal harm
2022-12-02
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-12-22
D · Potential for more than minimal harm
2022-12-02
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-12-22
D · Potential for more than minimal harm
2022-12-02
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 2022-12-22
D · Potential for more than minimal harm
2022-12-02
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-12-22
D · Potential for more than minimal harm
2022-12-02
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-12-22
D · Potential for more than minimal harm
2022-12-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-22
D · Potential for more than minimal harm
2022-12-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-22
D · Potential for more than minimal harm
2022-12-02
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 2022-12-22
Penalties and ownership
What sits behind the stars
$4,580
2023-03-20
Fine
Fine · fine $4,580
Fine
Ownership
Cibc Bank Usa
Operational/Managerial Control · Organization
Cibc Bank Usa
5% Or Greater Security Interest · Organization
Gilbert, Susan
Operational/Managerial Control · Individual
Kadima Healthcare Group Inc
Operational/Managerial Control · Organization
Kirksey, Kimberly
Operational/Managerial Control · Individual
Lowden, Thomas
Operational/Managerial Control · Individual
Morris, Daniel
Operational/Managerial Control · Individual
Naylor, Diedre
Operational/Managerial Control · Individual
Pinnacle Healthcare Solutions Inc
Operational/Managerial Control · Organization
Strauss, Jonathan
Operational/Managerial Control · Individual
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