Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT GREENVILLE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 49 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


KADIMA REHABILITATION & NURSING AT GREENVILLE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on June 30, 2026, at Kadima Rehab and Nursing at Greenville, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID #070402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 30, 2026, it was determined that Kadima Rehab and Nursing at Greenville was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type V (111), protected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Document review on June 30, 2026, at 9:45 a.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan shall include the following:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 hour walls);
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls;
g. Door schedule.

Interview with the maintenance director on June 30, 2026, at 9:45 a.m., confirmed the facility's Life Safety Code Floor Plan was not accurate at the time of the survey.

Plan of Correction - To be completed: 07/27/2026

"The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements."

Facility is not able to show proper floor plans as per request.

NHA (Nursing Home Administrator) educated Maintenance Director on the importance of having a Life Safety Code Floor Plan.

Maintenance Director and/or Designee is working on locating drawings of facility that include smoke barrier walls, fire barrier walls, etc. Per Life safety request, will be available for review once located.

Drawings will then be updated as changes to the facility are made if applicable and reviewed at Quarterly Quality Assurance Performance Improvement (QAPI) meetings.

NFPA 101 STANDARD Discharge from Exits:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0271

Based on observation and interview, the facility failed to meet exit discharge requirements for one of over five emergency exits.

Findings include:

Observation on June 30, 2026, at 11:22 a.m., revealed the exit discharge from the resident dining room had a build-up of leaves and bed storage that created obstructions to the egress passageway.

Interview with the maintenance supervisor on June 30, 2026, at 11:22 a.m., confirmed the egress discharge had obstructions at the time of the survey.

Plan of Correction - To be completed: 07/27/2026

The exit from the resident dining room has been cleared of leaves and bed storage. All other exits were inspected and no obstructions were noted.

Maintenance Director and Maintenance Technicians were educated by Nursing Home Administrator (NHA) that all exits need to be clear of any type of debris that would hinder resident and staff exiting the building.

Maintenance Director and/or designee will monitor exit areas weekly x 3 weeks to make sure exits are clear, then monthly x 2 months.

This will be reviewed at the QAPI (Quality Assurance/Performance Improvement) meetings.

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, the facility failed to maintain inspection and testing requirements for one of one emergency lighting system.

Findings include:

Document review on June 30, 2026, at 9:17 a.m., revealed the facility was unable to provide documentation for emergency lighting thirty-second maintenance for two of twelve months.

Interview with the maintenance supervisor on June 30, 2026, at 9:17 a.m., confirmed the facility was unable to provide the emergency lighting maintenance documentation for two of twelve months.

Plan of Correction - To be completed: 07/27/2026

The facility cannot go back and fix that inspection and testing of the emergency lighting was not completed for two months, out of twelve months.

Maintenance Director and Maintenance Technicians were educated by Nursing Home Administrator (NHA) on the importance of making sure inspections and testing are completed as required and that inspections and testing are documented as required.

Maintenance Director and/or designee will monitor inspections and testing monthly x 6 months to make sure documentation is completed per requirements.

This will be reviewed at the QAPI (Quality Assurance/Performance Improvement) meetings.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, the facility failed to meet hazardous area requirements on two of two building levels.

Findings include:

Observation on June 30, 2026, between 11:44 a.m. and 11:50 a.m., revealed combustible storage that included boxes, a Christmas tree, mattresses, flooring, etc. in the following locations not protected by a hazardous enclosure:

A.(11:44 a.m.) First floor alcove near resident room 300;
B. (11:50 a.m.) Second floor near occupational therapy.

Interview with the maintenance supervisor on June 30, 2026, at 11:50 a.m., confirmed items were being stored in areas not approved for storage use.

Plan of Correction - To be completed: 07/27/2026

The Facility has removed the combustible storage from the first-floor area near resident room 300 and on the second floor near Occupational Therapy.

Maintenance Director and Maintenance Technicians, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were educated by Nursing Home Administrator (NHA) on the importance of making sure combustibles are not stored near resident care areas and are stored in areas approved by storage.

Maintenance Director and/or designee will monitor areas to make sure nothing is being stored in unapproved areas weekly x 4 weeks then monthly x 3 months.

This will be reviewed at the QAPI (Quality Assurance/Performance Improvement) meetings.

NFPA 101 STANDARD Smoking Regulations:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on observation and interview, the facility failed to meet smoking regulations for one of one facility.

Findings include:

Observation on June 30, 2026, at 11:33 a.m., revealed five staff members smoking outside of the laundry next to the generator. The staff members were in a non-designated smoking area. Cigarette butts also littered the ground in this area.

Interview with the maintenance supervisor on June 30, 2026, at 11:33 a.m., confirmed the staff members were smoking in a non-designated smoking area.

Plan of Correction - To be completed: 07/27/2026

Facility cannot go back and correct that staff were smoking in a non-designated area. Cigarette butts that were littering the ground have been cleaned up.

Staff have been educated by the Nursing Home Administrator that smoking is to be done in designated areas and if caught smoking in non-designated areas, disciplinary action will be taken.

NHA (Nursing Home Administrator) and/or Designee will monitor generator area and other non-designated smoking areas weekly x 3 weeks then monthly x 2 months to make sure staff are not smoking in areas and that there are no cigarette butts in area.

This will be reviewed at the QAPI (Quality Assurance/Performance Improvement) meetings.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on observation and interview, the facility failed to meet maintenance, inspection, and testing requirements for one of over five fire doors.

Findings include:

Observation on June 30, 2026, at 11:00 a.m., revealed the fire door between units one and two failed to latch at the time of the survey.

Interview with the maintenance supervisor on June 30, 2026, at 11:00 a.m., confirmed the fire door failed to latch.

Plan of Correction - To be completed: 07/27/2026

The facility cannot go back and make the fire doors latch during the survey. The doors have been fixed so that they latch. All other fire doors have been checked and do latch.

Maintenance Director and Maintenance Technicians have been educated by the Nursing Home Administrator (NHA) on the importance of making sure Fire Doors latch according to Life Safety regulations.

Maintenance Director and/or Designee will monitor 4 fire doors weekly x 3 weeks to make sure they latch correctly then 4 doors monthly x 3 months.

This will be reviewed at the QAPI (Quality Assurance/Performance Improvement) meetings.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, the facility failed to maintain inspection and testing requirements for one of one essential electrical system.

Findings include:

Document review on June 30, 2026, at 9:10 a.m., revealed the facility was unable to provide documentation for generator weekly and monthly maintenance requirements for two of twelve months.

Interview with the maintenance supervisor on June 30, 2026, at 9:10 a.m., confirmed the facility was unable to provide the generator maintenance documentation for two of twelve months.

Plan of Correction - To be completed: 07/27/2026

The facility cannot go back and fix that generator weekly and monthly maintenance documentation was not completed for two months, out of twelve months.

Maintenance Director and Maintenance Technicians were educated by Nursing Home Administrator (NHA) on the importance of making sure maintenance and documenting of generator testing is completed as required.

Maintenance Director and/or designee will monitor generator testing weekly x 4 weeks and then monthly x 3 months to make sure testing is completed as per regulations.

This will be reviewed at the QAPI (Quality Assurance/Performance Improvement) meetings.

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