Kadima Rehabilitation & Nursing At North Strabane
100 Tandem Village Road, Canonsburg, PA 15317 · For profit - Corporation · 62 certified beds · (724) 743-9000 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2022
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (65%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 18.8% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.6% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.7% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 0.5% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 8.6% | 10.8% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.0% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 25.2% | 17.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 17.1% | 20.0% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 81.5% | 93.5% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 5.4% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 25.2% | 25.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.8% | 17.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.0% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 58.2% | 68.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 17.2% | 22.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 8.6% | 9.5% | 12.0% | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 45.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 22 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.41 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 6.3–15.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 45.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 22.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 59.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 62 beds and averages 60.1 residents a day — about 97% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.21 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.63 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.90 hrs/resident/day on weekends vs 3.34 on weekdays — 13% thinner on weekends. RN hours go from 0.70 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 65% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · D2026-04-02 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information for one of nine residents observed (R1).Findings include:Review of facility policy Confidentiality Policy indicated employees are required, at all times, to comply with HIPAA requirements and other federal and state laws applicable to the confidentiality of personal health information (PHI), and employees must reasonably protect confidential information.Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included depression, and acute respiratory failure (lungs cannot effectively exchange oxygen and carbon dioxide in the blood).Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 1/16/26, indicated the diagnoses are current.Review of a physician order dated 2/22/26, indicated endocrine referral for osteoporosis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-02 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to properly secure a treatment cart for one of three carts observed (treatment supply cart).Findings include: Review of facility policy Storage of Medications indicated compartments containing medications are locked when not in use. Trays or carts used to transport such items are not left unattended. During an observation on 4/2/26, at 9:00 a.m. a treatment cart was located outside of resident room [ROOM NUMBER]A, unlocked and unattended. During an interview on 4/2/26, at 9:04 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed the treatment cart should not be left unlocked and unattended. During an interview on 4/2/26, at 9:30 a.m. the Director of Nursing confirmed the facility failed to properly secure a treatment cart. Pa Code: 205.28(c)(3)(4) Nurses' StationPa Code: 211.9(a)(1)()h)(k)(l)(1) Pharmacy ServicesPa Code: 211.12(d)(1)(2)(3)(5) Nursing Services
- Potential for harm · F2026-02-18 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — the official record, unedited, may be distressing
Based on a review of select facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections.Findings include:During an interview on 2/18/26, at 12:08 p.m., the Director of Nursing (DON) stated that the facility just hired the Infection Control Nurse and that the DON is acting as the Infection Control Nurse at this time, as she has the training. The DON confirmed that the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 201.19(3) Personnel records.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
- Potential for harm · Fcited before2024-10-11 · tag F0887 — widespreadEducate 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and procedure, clinical record review, and staff interview, it was determined that the facility failed to offer the COVID-19 vaccine as indicated by the Centers for Disease Control (CDC) for five of five residents reviewed (Residents R6, R18, R21, R23, and R40). Findings include: A review of the facility policy, Covid 19 Vaccination Policy, dated 1/12/23, indicated the facility will comply with all applicable laws and is based on guidance from the Centers for Disease Control and Prevention and local health authorities, as applicable. Immunizations will be offered as indicated. A review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of immunization information revealed that the last COVID-19 immunization was on 11/19/21. There was no evidence that the facility provided vaccine information or offered COVID-19 immunization after 2021. A review of the clinical record indicated Resident R18 was admitted to the facility on [DATE]. Review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-11 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for four of 10 residents (Resident R14, R22, R48, and R57). Review of facility policy Flow of Care dated 2/22/24, indicated the provision targeted care needs shall be documented on Care Tracker/Point of Care/ADL Flow Records (clinical documents). Residents are to have 2 showers a week unless resident states otherwise. Review of the admission record indicated Resident R14 admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/13/24, indicated the diagnoses of Diabetes Mellitus, kidney disease, Schizoaffective disorder, and morbid obesity. Review of Resident R14's Bath/ Shower Task for 30 days Report dated September and October 2024 did not include documentation of showers being provided for seven of seven days( 9/16, 9/17, 9/23,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain call bells were in reach for three of eight residents as required (Resident R30, Resident R35, and Resident R36). Findings include: The facility policy Call Light Response dated 2/22/24, indicated a call bell or alternative device will be placed within the reach of each resident while in their room, toilet, or bathing area. Review of Resident R30's clinical record indicated admission to the facility on 4/25/24. Review of Resident R30's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/1/24, indicated diagnoses of hypertension (high blood pressure) hyperlipidemia (high fats in the blood) and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). During an interview on 10/8/24, at 10:30 a.m. Resident R30's was laying in his bed, his call light button was on the floor. When Resident R30 was asked what he would do if he…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, observation, clinical record review and resident and staff interview, it was determined that the facility failed to provide adequate hygienic care for four of seven residents (Resident R15, R25, R38 and R54). Findings include: Review of the facility policy Flow of care dated 2/22/24, indicated that residents are to be provided care as needed on a 24 hour basis to attain and maintain the highest level of functioning. Review of the facility policy Nail Care dated 2/22/24, indicated that resident's fingernails will be cleaned and trimmed as needed or per request. During an observation on 10/9/24, from 8:25 a.m., through 9:18 a.m., the following was observed: Resident R15 was in bed, her fingernails were very long and unclean. She had her feet covered but when asked she showed toenails that were long and had sharp edges and were unclean. Review of Resident R15's shower sheet documentation dated 9/30/24, did not include documentation of whether or not her fingernails needed trimmed. Resident R25 was sleeping with her feet uncovered and her fingernails…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-11 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that a pneumococcal immunization was offered to two of five residents (Resident R18, R40). Findings include: Review of the facility policy Resident Immunizations dated 1/12/23, indicated the facility will offer Pneumovax and Influenza vaccines as indicated. Review of the Centers for Disease Control (CDC) document, Pneumococcal Vaccination: Summary of Who and When to Vaccinate last reviewed 1/24/22, indicated that CDC recommends pneumococcal vaccination for all adults 65 years or older, and for adults 19 through [AGE] years old who have certain chronic medical conditions or other risk factors. Review of the admission Record indicated that Resident R18 was admitted to the facility on [DATE]. Review of Minimum Data Set (MDS-periodic assessment of care needs) dated 6/27/23, included diagnoses of Multiple Sclerosis, paraplegia, and seizure disorder. Section O0300 Pneumococcal Vaccine…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-03-06 · tag F0836 — widespreadEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of vendor invoices, facility financial documents, and interviews with vendors and staff, it was determined that facility failed to pay bills in a timely manner. Findings include: Review of 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection §201.14(g), dated 7/1/23, indicated that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are jeopardized. Review of vendor submitted communication dated 12/27/23, indicated that the Ambulance Vendor was no longer providing services to the company, and was owed $29,361.90. During an interview on 3/6/24, at approximately 1:46 p.m., the Nursing Home Administrator confirmed that the facility no longer utilizes the services of the Ambulance Vendor, and provided alternative transportation with another vendor and the use of the facility transport van. Review of the facility provided contractor report on 3/6/24, at approximately 1:44 p.m. revealed a balance of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-06 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for four of seven Residents (Residents R5, R12, R15, and R29). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · E2022-12-02 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records reviews and staff interview, it was determined that the facility failed to sure residents maintain basic rights preserved in the Federal and State laws and regulations for five of seven residents (Residents R27, R43, R46, R47, and R49) by having residents sign an Assumption of the Risk and Waiver of Liability Relating to Coronavirus/Covid-19 (Covid-19 waiver). Findings Include: The facility form Assumption of the Risk and Waiver of Liability Relating to Coronavirus/Covid-19 states The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. NORTH STRABANE REHABILITATION AND WELLNESS CENTER (*the Facility*) has put in place preventative measures…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-02 · tag F0578 — failed to honor advance directives / code status — patternHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for six of eight residents reviewed (Resident R1, R26, R47, R52, R54, and R259). Findings include: A review of the facility policy Advanced Directive last reviewed 7/22/21 and 9/8/22, indicated that information will be provided upon admission of the policies and procedures, or at such time as may be appropriate. A review of the medical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included diabetes, and high blood pressure. A review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 11/14/22, indicated the diagnoses remain current. A review of the clinical record failed to reveal an advanced directive or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-02 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate injuries of unknown origin for three of six residents (Residents R310, R9, R25). Findings include: A review of the facility's policy Abuse Protection dated 9/8/22, previously dated 7/22/21, stated the facility will complete timely and thorough investigations of all reports and allegations of abuse to include injuries of unknown origin. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed that Resident R310 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to assess a resident for smoking safety for one of three residents (Resident R54). Findings include: A review of the facility Smoking Policy last reviewed 9/8/22, indicated that upon admission residents who smoke will be reviewed for safety with independence in smoking A review of the clinical record indicated Resident R54 was admitted to the facility on [DATE], with diagnoses that included depression, anxiety, and high blood pressure. A review of the MDS dated [DATE], indicated the diagnoses remain current and the resident is a current tobacco user. A review of the clinical record indicated an admission assessment was completed on 11/12/22, and indicated Resident R54 was a current smoker. A review of the clinical records failed to reveal a smoking assessment was completed for Resident R54. A review of the progress notes dated 11/20/22, revealed medical staff were aware of resident R54 going…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-02 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record reviews, and staff interviews, it was determined the facility failed to make certain monthly Medication Regimen Reviews (MRR) were conducted for four of nine residents (Residents R8, R36, R40, and R46). Findings include: Review of facility policy titled Medication Regimen Review last reviewed by the facility on 7/22/21 and 9/8/22, indicated the consultant pharmacist will perform a comprehensive review of each resident's medication regimen at least monthly. A review of the clinical record revealed that Resident R8 was admitted to the facility on [DATE]. The Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/26/22 included diagnoses of lymphedema (swelling in the arm or leg due to a blockage in the lymphatic system), major depression disorder (a mental health disorder characterized by depressed mood or loss of interest in activities), osteoarthritis (a condition when flexible tissue at the end of the bones wears down), and anxiety. There was no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-12-02 · tag F0761 — failed to label and store drugs safely — patternEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to date multi-dose over the counter (OTC) medication bottles in one of four medication carts (Avalon Hall Med Cart). Findings include: The facility policy Storage of Medication last reviewed 7/22/21 and 9/8/22, indicated medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. During an observation on 11/29/22, at 8:35 a.m. of the Avalon Hall medication cart revealed the following OTC medications were observed open without a date of opening: One bottle- Vitamin D 10 microgram (mcg) (vitamin supplement) Two bottles - Melatonin 3 milligrams (mg; sleep aid) One bottle - Melatonin 1 mg One bottle - Melatonin 5 mg Two bottles - Antacid tablets (stomach acid relief) Three bottles - Aspirin 81 mg (fever/pain reducer) One bottle - Magnesium oxide 400 mg (supplement) One bottle - Polyethylene Glycol 3350 (laxative) One bottle - Ibuprofen 200 mg (fever/pain reducer) One bottle - Optimum probiotic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-02 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of the facility's infection control policies and procedures, documents, and staff interview, it was determined the facility failed to implement an antibiotic stewardship program for eleven of twelve months (January, February, March, April, May, June, July, August, September, October, and November 2022). Findings include: Review of the facility policy entitled Antibiotic Stewardship Program dated 9/8/22, previously reviewed 7/22/21, indicated the facility Antibiotic Stewardship Program will track or delegate the tracking of antibiotic days, number of residents on prescribed antibiotics, prescribing practice as they relate to antibiotic usage, antibiotic usage in residents that did not meet the criteria for active infection, types of antibiotics prescribed, overall infection rages, and antibiotic resistant organisms within the facility. Review of the facility provided Infection Control Monthly Data Analysis documentation forms (form that tracks number of infection, , facility tracking maps, and infection ling-listings from January 2022, through November 2022,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-12-02 · tag F0887 — patternEducate 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility documentation, clinical records, and staff interview it was determined that the facility failed to provide accurate and timely documentation related to the COVID-19 vaccine for 15 of 56 residents (Resident R4, R10, R13, R18, R24, R32, R38, R43, R45, R47, R48, R52, R53, R54, and R259). During an interview on 11/30/22, at 1:00 p.m. the Director of Nursing confirmed that all vaccination information for residents was maintained in the electronic medical record. Review of the electronic medical record for Residents R4, R10, R13, R18, R24, R32, R38, R43, R45, R47, R48, R52, R53, R54, and R259 failed to include documentation if the COVID-19 vaccine was provided, previously received, or refused. During an interview on 12/1/22, at 11:15 a.m. the Interim Director of Nursing confirmed that no further documentation of COVID-19 vaccine status was available for the above residents. During an interview on 12/1/22, at 11:15 a.m. Nursing Home Administrator confirmed that the facility failed to provide accurate and timely documentation related to the COVID-19 vaccine for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-02 · tag F0888 — patternEnsure staff are vaccinated for COVID-19
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of observations, clinical records, facility employee vaccination data, and staff interviews, it was determined that the facility failed to implement policies and procedures to ensure that all staff were vaccinated for COVID-19 four six of 46 staff members (Therapy Employees E7, E8, E9, E10, E11, and E12). Findings include: The Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality/Quality, Safety and Oversight Group memo (QSO-22-07-ALL) dated 12/28/21, revised 04/05/22, indicated the facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. Regardless of clinical responsibility or resident contact, the policies and procedures must apply to the following facility staff, who provide any care, treatment, or other services for the facility and/or its residents: facility employees, licensed practitioners, students, trainees, and volunteers, and individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-02 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, resident interview, resident observation, and staff interview, it was determined the facility failed to assess the clinical appropriateness of medication self-administration for two of 14 residents (Resident R1 and R259). Findings include: Review of facility policy Medication Administration last reviewed 9/8/22, indicated residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration for medications. Review of the medical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included diabetes, and high blood pressure. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 11/14/22, indicated the diagnoses remain current. Review of Resident R1's physician orders dated 11/28/22, included medications of aspirin (fever/pain reducer), Eliquis (apixaban - a blood thinner/anticoagulant),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-02 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, incident reports, and staff interview, it was determined that the facility failed to make certain residents were free from neglect by not providing appropriate assistance and assistive devices for two of four residents (Resident R25 and R12). Findings include: The facility's Abuse Protection policy dated 9/8/22, and updated 7/22/21, indicated that neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety adequate, and appropriate services. A review of the clinical record revealed that Resident R12 was admitted to the facility on [DATE]. The Minimum Data Set (MDS - periodic assessment of care needs) dated 8/2/22, and 11/2/22, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), osteoarthritis (degeneration of the joint…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-02 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and clinical records, and resident and staff interviews, it was determined that the facility failed to assess residents for appropriate use of an alarming device for one of three residents (Resident R49). Findings include: The facility's policy entitled Resident Rights dated 9/8/22, previously dated 7/22/21, stated that residents have the right to be free from chemical and physical restraints. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 5/10/22, indicated that Resident R49 had diagnoses that included repeated falls, muscle weakness and thyroid disorder and had a Brief Interview of Mental Status (BIMS) score of 14, indicating little to no cognitive impairment. Review of the elopement risk assessment dated [DATE], identified poor decision-making skills, Resident is independently mobile, and Resident has the ability to leave the facility has risk factors prompting Resident R49 as at risk for elopement. Review of the physician orders…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-02 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record, facility policy, and staff interview, it was determined that the facility failed to develop a baseline care plan that includes smoking and interventions needed to provide effective and person-centered care for one of 14 residents (Resident R54). Findings include: The facility policy Care Plans-Baseline dated 9/8/22, indicated the admitting nurse will complete the baseline care plan upon admission and includes any services and treatments to be administered by the facility. A review of the clinical record indicated Resident R54 was admitted to the facility on [DATE], with diagnoses that included depression, anxiety, and high blood pressure. A review of the MDS dated [DATE], indicated the diagnoses remain current and the resident is a current tobacco user. During a review of Resident R54 baseline care plan completed on 11/14/22, did not include a baseline care plan indicating interventions for smoking. During an interview on 11/29/22, at 9:20 a.m. the Director of Nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to assess a resident for signs and symptoms of hypoglycemia and notify a physician of a change in condition for one of six residents with high glucose (blood sugar) levels (Resident R10),. Findings include: Review of the facility Nursing care of the Diabetic Resident policy last reviewed 7/22/21 and 9/8/22, indicated the facility will recognize, assist, and document the treatment of complications commonly associated with diabetes. Additionally, it states to obtain physician orders for testing including parameters for intervention; and documentation should reflect the carefully assessed diabetic resident and include interventions to stabilize blood glucose levels and response to same, and notification to the physician and of significant variances from baseline per physician ' s order. A review of the clinical record revealed that Resident R10 was admitted to the facility on [DATE]. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, clinical record review, and professional standards, the facility failed to ensure respiratory services were provided according to physician orders and professional standards for one of two residents reviewed (Resident R34). [NAME] Respironics, manufacturer of respiratory devices recommends mechanical ventilator (A mechanical ventilator is a machine that helps a patient breathe when he or she cannot breathe on his or her own for any reason) equipment including tubing, masks and headgear should be cleaned weekly to prevent growth of bacteria and mold in equipment. A review of the clinical record revealed that R34 was admitted to the facility on [DATE]. The Minimum Data Set (MDS-a periodic assessment of care needs) dated 10/8/22 indicates Resident R34 was admitted to the facility on [DATE], with diagnoses that included shortness of breath while lying flat, cerebral infarction (stroke), epilepsy (neurological condition causing seizures), and Chronic Obstructive Pulmonary Disease…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-02 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility document review and interviews with residents and staff, it was determined that the facility failed to maintain sufficient nursing staff levels to provide nursing care and services for one of eleven residents (Resident R45). Findings include: Review of facility assessment dated [DATE], indicated the facility will provide services by sufficient numbers of staff provide nursing care to all residents in accordance with resident care plans. Review of a progress note dated 11/28/22, at 1:32 a.m. indicated Resident R45 was having exit seeking behaviors and did make it outside through an fire exit door and was found squatting in the bushes. Progress notes also stated that once the resident Resident R45 was back in the facility, Resident R45 fell and hit her head needing a transfer to the hospital. During an interview on 11/30/22, at 1:05 p.m. Maintenance Director Employee E13 indicated that the door Resident R45 exited through does have a beeping audible alarm at five seconds, then a solid audible…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to KADIMA HEALTHCARE GROUP — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 1.8 | +1.2 vs chain |
| Health inspection | 3 of 5 | 1.8 | +1.2 vs chain |
| Staffing | 2 of 5 | 1.8 | +0.2 vs chain |
| Quality measures | 3 of 5 | 2.5 | +0.5 vs chain |
The other 13 homes this chain runs (chain average 1.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MORRIS, DANIEL | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2024 |
| STRAUSS, JONATHAN | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2024 |
| CIBC BANK USA | Organization | 5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 11/01/2024 |
| KADIMA HEALTHCARE GROUP INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2024 |
| PINNACLE HEALTHCARE SOLUTIONS INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2024 |
| GILBERT, SUSAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2024 |
| KIRKSEY, KIMBERLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2024 |
| LOWDEN, THOMAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2024 |
| NAYLOR, DIEDRE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2024 |
| NORTH STRABANE PROPERTY MANAGEMENT, LLC | Organization | ADP OF THE SNF | since 11/01/2024 |
| ROMEO, MICHELLE | Individual | ADP OF THE SNF | since 11/01/2024 |
| THIMONS, DAVID | Individual | ADP OF THE SNF | since 11/01/2024 |
CMS files one row per role, so the 23 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 92% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $213K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in PA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 396073. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.