Pennsylvania ›Harmony

Kadima Rehabilitation & Nursing at Harmony

191 Evergreen Mill Road, Harmony, PA 16037 · Butler County · 115 certified beds · avg 110 residents/day · certified since Jun 1, 1988

Abuse citation flag (CMS)

Part of chain: KADIMA HEALTHCARE GROUP (14 facilities, chain avg rating 1.8★)

The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.

1/5
Health inspection rating (on-site)
2
Serious findings on record
$174,201
Fines, last 3 years
3.52
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · May 9, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jun 13, 2025 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Jan 26, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Mar 8, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (76)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Jun 30, 2026D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Apr 30, 2026D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Feb 24, 2026E · Potential for harm, repeatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Jun 12, 2025D · Potential for harm, one-offThe facility did not protect residents from being involuntarily separated — kept apart from other residents, kept out of their own room, or confined to their room. Isolating a resident this way is a form of mistreatment. · from a complaint
May 9, 2025▲ J · Immediate jeopardy, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
May 9, 2025F · Potential for harm, facility-wideThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.
May 9, 2025F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 9, 2025F · Potential for harm, facility-wideThe facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents.
May 9, 2025E · Potential for harm, repeatedThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
May 9, 2025E · Potential for harm, repeatedThe facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life.
May 9, 2025E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
May 9, 2025D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
May 9, 2025D · Potential for harm, one-offThe facility did not keep residents' personal and medical information private and confidential.
May 9, 2025D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
May 9, 2025D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
May 9, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
May 9, 2025D · Potential for harm, one-offThe facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay).
May 9, 2025D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
May 9, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
May 9, 2025D · Potential for harm, one-offThe facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
May 9, 2025D · Potential for harm, one-offThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
May 9, 2025D · Potential for harm, one-offThe facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
May 9, 2025D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 9, 2025D · Potential for harm, one-offThe facility did not have policies on smoking.
May 9, 2025C · Minimal risk, facility-wideThe facility did not post the names, addresses, and phone numbers of state agencies and advocacy groups, along with a notice that residents may file complaints with the state survey agency.
Dec 12, 2024D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Nov 22, 2024E · Potential for harm, repeatedThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Nov 22, 2024E · Potential for harm, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jul 31, 2024D · Potential for harm, one-offThe facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint
Jun 27, 2024D · Potential for harm, one-offThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint
Jun 27, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
May 3, 2024F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 3, 2024E · Potential for harm, repeatedThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
May 3, 2024E · Potential for harm, repeatedThe facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out.
May 3, 2024E · Potential for harm, repeatedThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
May 3, 2024E · Potential for harm, repeatedThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
May 3, 2024E · Potential for harm, repeatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
May 3, 2024E · Potential for harm, repeatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
May 3, 2024E · Potential for harm, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
May 3, 2024E · Potential for harm, repeatedThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
May 3, 2024E · Potential for harm, repeatedThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
May 3, 2024E · Potential for harm, repeatedThe facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service.
May 3, 2024E · Potential for harm, repeatedThe facility did not have enough support staff to safely and effectively run its food and nutrition service.
May 3, 2024E · Potential for harm, repeatedThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint
May 3, 2024E · Potential for harm, repeatedThe facility did not develop, carry out, or maintain an effective training program for all new and existing staff members.
May 3, 2024E · Potential for harm, repeatedThe facility did not educate its staff on residents' rights and the facility's responsibilities toward residents. Staff can only respect rights they've been taught about.
May 3, 2024E · Potential for harm, repeatedThe facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention.
May 3, 2024D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
May 3, 2024D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
May 3, 2024D · Potential for harm, one-offThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
May 3, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
May 3, 2024D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
May 3, 2024D · Potential for harm, one-offThe facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
May 3, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
May 3, 2024D · Potential for harm, one-offThe facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them.
May 3, 2024D · Potential for harm, one-offThe facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
May 3, 2024D · Potential for harm, one-offThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
May 3, 2024D · Potential for harm, one-offThe facility did not dispose of garbage and refuse properly.
May 3, 2024D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
May 3, 2024D · Potential for harm, one-offThe facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life.
Feb 26, 2024E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Jan 26, 2024▲ J · Immediate jeopardy, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jan 26, 2024E · Potential for harm, repeatedThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint
Jan 26, 2024E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Jan 26, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Jan 26, 2024D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Jan 26, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jan 26, 2024D · Potential for harm, one-offThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint
Jan 5, 2024D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Sep 13, 2023D · Potential for harm, one-offThe facility was not properly licensed, or did not operate in compliance with federal, state, and local laws, regulations, and accepted professional standards. · from a complaint
Jun 9, 2023E · Potential for harm, repeatedThe facility did not observe each nurse aide's job performance or provide regular training as required.
Jun 9, 2023E · Potential for harm, repeatedThe facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service.
Jun 9, 2023D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Jun 9, 2023D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jun 9, 2023D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jun 9, 2023D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (29 → 21).

YearCitationsSerious (G–L)Worst severity that year
202370E
2024441J ▲
2025221J ▲
202630E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

2 fines totaling $174,201.

DateTypeAmount / length
May 9, 2025Fine$43,450
Jan 5, 2024Fine$130,751

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityPennsylvania avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.523.943.95bottom 44% in Pennsylvania; bottom 38% in the U.S.
Registered Nurse hours0.540.800.69bottom 35% in Pennsylvania; bottom 44% in the U.S.
Weekend total nurse staffing3.313.583.50bottom 48% in Pennsylvania; bottom 48% in the U.S.
Weekend RN hours (not acuity-adjusted)0.380.560.48bottom 40% in Pennsylvania; bottom 48% in the U.S.
Total nursing staff turnover (%)0.044.545.8—
RN turnover (%)0.039.942.9—

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.33, RN 0.51, weekend 3.13. Staffing rating: 2/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 2/5 · short-stay residents: 4/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Buchanan, ChelsieIndividualOperational/Managerial ControlNOT APPLICABLE11/01/2024
Buchanan, ChelsieIndividualADP of the SNFNOT APPLICABLE11/01/2024
Cibc Bank USAOrganization5% or Greater Security InterestNOT APPLICABLE11/01/2024
Cibc Bank USAOrganizationOperational/Managerial ControlNOT APPLICABLE11/01/2024
Harmont Realty Management LLCOrganization5% or Greater Mortgage InterestNOT APPLICABLE11/01/2024
Harmont Realty Management LLCOrganizationADP of the SNFNOT APPLICABLE11/01/2024
Kadima Healthcare Group INCOrganizationOperational/Managerial ControlNOT APPLICABLE11/01/2024
Kadima Healthcare Group INCOrganizationADP of the SNFNOT APPLICABLE11/01/2024
Lowden, ThomasIndividualOperational/Managerial ControlNOT APPLICABLE11/01/2024
Lowden, ThomasIndividualADP of the SNFNOT APPLICABLE11/01/2024
Morris, DanielIndividualManaging Control - Governing BodyNOT APPLICABLE11/01/2024
Morris, DanielIndividualOperational/Managerial ControlNOT APPLICABLE11/01/2024
Morris, DanielIndividualADP of the SNFNOT APPLICABLE11/01/2024
Naylor, DiedreIndividualOperational/Managerial ControlNOT APPLICABLE11/01/2024
Naylor, DiedreIndividualADP of the SNFNOT APPLICABLE11/01/2024
Nestler, DevinIndividualOperational/Managerial ControlNOT APPLICABLE11/01/2024
Nestler, DevinIndividualADP of the SNFNOT APPLICABLE11/01/2024
Pinnacle Healthcare Solutions INCOrganizationOperational/Managerial ControlNOT APPLICABLE11/01/2024
Pinnacle Healthcare Solutions INCOrganizationADP of the SNFNOT APPLICABLE11/01/2024
Romeo, MichelleIndividualADP of the SNFNOT APPLICABLE11/01/2024

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

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Facility data as of CMS processing date 2026-08-01. CCN 395758.