Cycle 1
Health 2025-11-20 · Fire 2025-11-20
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Pottstown, PA
Kadima Rehabilitation & Nursing At Pottstown
1-star overall rating with 1-star inspections with $138,400 in total fines with 8 recent health deficiencies
3031 Chestnut Hill Road, Pottstown, PA
(610) 469-6228
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
41
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Kadima Healthcare Group
Operator or chain grouping
Approved since
1990-06-01
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
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
1.00
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.69
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.28
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.97
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.85
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.18
CMS adjusted RN staffing hours
Adjusted total hours
3.85
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
10,868
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
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
2.64
Baseline 80.95% · Performance 63.33% · Measure score 2.64 · Achievement 0 · Improvement 2.64
Adjusted total nurse staffing
1.12
Baseline 3.40 hours · Performance 3.40 hours · Measure score 1.12 · Achievement 1.12 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.33% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 5.92% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 14 · 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 11 · 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 47 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 42 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · 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 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 1 · 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 | 0.9 |
1.7
0.8 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.2
0.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 24.6% |
86.9%
62.3 pts worse
|
93.4%
68.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 14.3% · Q3 32.3% · Q4 31.2% · 4Q avg 24.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 70.7% |
93.5%
22.8 pts worse
|
95.5%
24.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 70.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.2%
1 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.9% · Q3 3.2% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.1% |
6.5%
9.6 pts worse
|
11.4%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 13.0% · Q3 13.6% · Q4 25.9% · 4Q avg 16.1% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
6.5%
1.1 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 3.3% · Q3 6.7% · Q4 12.5% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.0% |
19.9%
10.9 pts better
|
19.6%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 9.1% · Q3 6.7% · Q4 9.4% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.9% |
18.7%
2.2 pts worse
|
16.7%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 20.8% · Q3 18.2% · Q4 26.1% · 4Q avg 20.9% · 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 | 26.5% |
19.6%
6.9 pts worse
|
16.3%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 10.7% · 4Q avg 26.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.5% |
18.3%
13.2 pts worse
|
14.9%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 21.9% · Q3 31.0% · Q4 36.7% · 4Q avg 31.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.3% |
0.9%
4.4 pts worse
|
1.0%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 5.9% · Q3 3.3% · Q4 3.0% · 4Q avg 5.3% · 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 | 21.6% |
26.4%
4.8 pts better
|
19.8%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.1% · Q2 17.5% · Q3 24.5% · Q4 14.6% · 4Q avg 21.6% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
5.3%
1 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.8% · Q3 7.2% · Q4 3.7% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 24.0% |
68.9%
44.9 pts worse
|
81.7%
57.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 24.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-25 · Fire 2024-10-25
17 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-11-06 · Fire 2023-11-06
9 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-07-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-27
E · Potential for more than minimal harm
2024-07-19
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-08-27
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-20
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 2025-12-20
E · Potential for more than minimal harm
2025-11-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-20
D · Potential for more than minimal harm
2025-11-20
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-20
D · Potential for more than minimal harm
2025-11-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-20
D · Potential for more than minimal harm
2025-11-20
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 2025-12-20
D · Potential for more than minimal harm
2025-11-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-12-20
D · Potential for more than minimal harm
2025-03-28
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-04-08
D · Potential for more than minimal harm
2025-03-28
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2025-04-09
K · Immediate jeopardy
2025-02-27
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 2025-03-16
E · Potential for more than minimal harm
2025-02-27
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-03-16
D · Potential for more than minimal harm
2025-02-27
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 2025-03-16
D · Potential for more than minimal harm
2024-12-30
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 2025-01-26
L · Immediate jeopardy
2024-11-27
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 2024-12-30
L · Immediate jeopardy
2024-11-27
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 2024-12-30
F · Potential for more than minimal harm
2024-11-27
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-01-26
F · Potential for more than minimal harm
2024-11-27
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-10-25
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 2024-12-16
F · Potential for more than minimal harm
2024-10-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-16
E · Potential for more than minimal harm
2024-10-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-16
E · Potential for more than minimal harm
2024-10-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-26
D · Potential for more than minimal harm
2024-10-25
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 2024-12-16
D · Potential for more than minimal harm
2024-10-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-10-25
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-12-16
C · Minimal harm
2024-10-25
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 2024-12-16
D · Potential for more than minimal harm
2024-06-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-05
L · Immediate jeopardy
2023-11-06
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 2024-01-05
F · Potential for more than minimal harm
2023-11-06
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-01-05
F · Potential for more than minimal harm
2023-11-06
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 2024-01-05
E · Potential for more than minimal harm
2023-11-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-06
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-06
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-06
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 2024-01-05
D · Potential for more than minimal harm
2023-11-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-05
C · Minimal harm
2023-11-06
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 2024-01-05
Penalties and ownership
What sits behind the stars
$27,950
2025-02-27
Fine
Fine · fine $27,950
Fine
$57,882
2024-10-25
Fine
Fine · fine $57,882
Fine
$0
2024-10-25
Payment Denial
Payment Denial · denial start 2024-12-27 · 30 days
30 day denial
$52,568
2023-11-06
Fine
Fine · fine $52,568
Fine
Ownership
Morris, Daniel
5% Or Greater Direct Ownership Interest · Individual
Strauss, Jonathan
5% Or Greater Direct Ownership Interest · Individual
Boide, William
Operational/Managerial Control · Individual
Cibc Bank Usa
Operational/Managerial Control · Organization
Cibc Bank Usa
5% Or Greater Mortgage Interest · Organization
Harkins, Andrea
Operational/Managerial Control · Individual
Kadima Healthcare Group Inc
Operational/Managerial Control · Organization
Lowden, Thomas
Operational/Managerial Control · Individual
Morris, Daniel
Operational/Managerial Control · Individual
Parsons, Michelle
Operational/Managerial Control · Individual
Pinnacle Healthcare Solutions Inc
Operational/Managerial Control · Organization
Strauss, Jonathan
Operational/Managerial Control · Individual
Nearby options
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Manatawny Center For Rehabilitation And Nursing
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4-star overall rating with 4-star inspections with $44,985 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Pottstown Skilled Nursing and Rehabilitation Cente
Pottstown, PA
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Southeastern Pennsylvania Veteran's Center
Spring City, PA
4-star overall rating with 2-star inspections with abuse icon flag with $25,044 in total fines with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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