Your report for Kadima Rehabilitation & Nursing at Luzerne
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- PennsylvaniaLowest tier among peers653 rated homes · average 3.0★
- Luzerne CountyLowest tier among peers22 rated homes · average 2.2★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.8 vs PA avg
- StaffingCan add or remove a star4★+0.7 vs PA avg
- Quality measuresCan add or remove a star3★−0.5 vs PA avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
- Special Focus Facility candidateThis facility is on the CMS candidate list for the Special Focus Facility program, meaning it is among the poorest-performing facilities in its state on recent inspections.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersPA avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover4★Above 58% of peersPA avg3.3★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 20% of peersPA avg3.5★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff4.15hrsAbove 74% of peersPA avg3.89Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.84hrsAbove 69% of peersPA avg0.78Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better65%Above only 9% of peersPA avg47%RN turnover72%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$86,122Above only 10% of peersPA avg$28,640Fines · denials2 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthApr 2023 – Jun 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Jun 11, 2025Cycle 1worst L · immediate jeopardy
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryL · widespreadCorrected Jul 11, 2025
- F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryF · widespreadCorrected Jul 11, 2025
- F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Nutrition and DietaryE · patternCorrected Jul 11, 2025
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Jul 11, 2025
- Ensure meals and snacks are served at times in accordance with residentâs needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Nutrition and DietaryL · widespreadCorrected Jul 11, 2025
Apr 17, 2025Cycle 1worst D · no actual harm$22,639
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Jun 11, 2025
- F626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.Resident RightsD · isolatedCorrected Jun 11, 2025
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsD · isolatedCorrected Jun 11, 2025
Jan 16, 2025Cycle 1worst F · no actual harm
- F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.EnvironmentalB · patternCorrected Feb 14, 2025
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareE · patternCorrected Feb 14, 2025
- F838Conduct 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.AdministrationF · widespreadCorrected Feb 14, 2025
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Feb 14, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Feb 14, 2025
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareE · patternCorrected Feb 14, 2025
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Feb 14, 2025
- F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryF · widespreadCorrected Feb 14, 2025
Nov 15, 2024Cycle 2worst D · no actual harm
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesD · isolatedCorrected Jan 16, 2025
Jul 23, 2024Cycle 2worst E · no actual harm
- F584Honor 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.Resident RightsE · patternCorrected Aug 18, 2024
Jun 18, 2024Cycle 2worst E · no actual harm
- F584Honor 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.Resident RightsE · patternCorrected Aug 18, 2024
- F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareD · isolatedCorrected Jul 23, 2024
- F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareE · patternCorrected Jul 23, 2024
Feb 29, 2024Cycle 2worst G · actual harm$63,483
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Apr 29, 2024
- F814Dispose of garbage and refuse properly.Nutrition and DietaryF · widespreadCorrected Apr 29, 2024
- F578Honor 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.Resident RightsE · patternCorrected Apr 29, 2024
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsB · patternCorrected Apr 29, 2024
- F584Honor 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.Resident RightsE · patternCorrected Apr 29, 2024
- F602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 29, 2024
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsB · patternCorrected Apr 29, 2024
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningE · patternCorrected Apr 29, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Apr 29, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Apr 29, 2024
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Apr 29, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Apr 29, 2024
- F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Apr 29, 2024
- F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryF · widespreadCorrected Apr 29, 2024
- F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection ControlF · widespreadCorrected Apr 29, 2024
- F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.EnvironmentalB · patternCorrected Apr 29, 2024
Oct 26, 2023Cycle 3worst F · no actual harm
- F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Dec 28, 2023
- F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationD · isolatedCorrected Dec 28, 2023
- F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection ControlF · widespreadCorrected Dec 28, 2023
Sep 7, 2023Cycle 3worst D · no actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Oct 26, 2023
Apr 20, 2023Cycle 3worst F · no actual harm
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningE · patternCorrected May 22, 2023
- F660Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care PlanningD · isolatedCorrected May 22, 2023
- F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareD · isolatedCorrected May 22, 2023
- F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareD · isolatedCorrected May 22, 2023
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected May 22, 2023
- F700Try 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.Quality of Life and CareE · patternCorrected May 22, 2023
- F713Provide or arrange emergency care by a doctor 24 hours a day.Nursing and Physician ServicesD · isolatedCorrected May 22, 2023
- F791Provide or obtain dental services for each resident.Quality of Life and CareD · isolatedCorrected May 22, 2023
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected May 22, 2023
- F909Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.EnvironmentalF · widespreadCorrected May 22, 2023
- F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.EnvironmentalB · patternCorrected May 22, 2023
- F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareE · patternCorrected May 22, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 22, 2023
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsD · isolatedCorrected May 22, 2023
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected May 22, 2023
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningE · patternCorrected May 22, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined4.15hrs
- Registered nursesRN hours only0.84hrs
- Licensed practical nursesLPN hours0.97hrs
- Nurse aidesCNA hours2.34hrs
- Weekend nursingAll staff on Saturdays and Sundays3.67hrs
- Pennsylvania average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better65%Above only 9% of peersPA avg 47%
- RN turnoverRegistered nurses only72%Not ranked by CMS
- Administrators who leftIn the past year5Leadership changed
- Occupancy37 certified beds · ~33 residents a day88%Above 52% of peersPA avg 82%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $86,122In fines
- 2Fines
- 0Payment denials
- $28,640PA avg in fines
Actions on record
- Apr 17, 2025Civil money penalty$22,639
- Feb 29, 2024Civil money penalty$63,483
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Corporation
- Chain
- Kadima Healthcare Group15 facilities in the chain1.8★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Daniel Morris
- Jonathan Strauss
- Cibc Bank Usa
- Kadima Healthcare Group INC
- Pinnacle Healthcare Solutions INC
- Dylan Armson
- Andrea Harkins
- Thomas Lowden
- Daniel Morris
- Jonathan Strauss
- +1 more
- Cibc Bank Usa
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 395484 · 463 NORTH HUNTER HWY, DRUMS, PA, 18222.
- Percentiles compare this facility with every rated nursing home in Pennsylvania and Luzerne County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









