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

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 47 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 NEW WILMINGTON - 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 March 10, 2026, it was determined that Kadima Rehabilitation and Nursing at New Wilmington was in compliance with the requirements of 42 CFR 416.54.

Plan of Correction:

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

Facility ID #150502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 10, 2026, it was determined that Kadima Rehabilitation and Nursing at New Wilmington 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 one-story, Type III (200), unprotected, ordinary building, with a partial basement, 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

Based on document review, observation, and interview, the facility failed to maintain general requirements of the Life Safety Code that are not addressed by specific K-tags affecting the entire facility.

Findings include:

1. Document review on March 10, 2026, at 9:05 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.

Interview with the maintenance supervisor on March 10, 2026, at 9:05 a.m., confirmed the Life Safety Code Floor Plan provided during the survey failed to accurately contain the listed items.

2. Observation on March 10, 2026, between 10:01 and 11:00 a.m., revealed the facility failed to obtain required approval from the Department of Health State Plan Review and a granted occupancy from Life Safety Division for the change of use of the following rooms:

A.(10:01 a.m.) Therapy office space was being used as a storage room;
B. (10:14 a.m.) Bathroom and shower rooms were being used for soiled utility storage;
C. (11:00 a.m.) Basement shower room, outside of the kitchen, was being used as a storage room.

The facility was unable to provide accurate and approved floor plans to identify correct storage locations.

Interview with the administrator and maintenance director on March 10, 2026, at 11:00 a.m., confirmed the facility was unable to provide the rooms' change of use approvals at the time of the survey.

Plan of Correction - To be completed: 04/30/2026

"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."

Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction.

1. The facility will provide an accurate, portable floor plan in accordance with the Life Safety Code.

2. The therapy office, bathroom and shower rooms that had stored items and soiled utility storage in them will be corrected. These rooms will not be used for storage. All storage items will be removed from these rooms.

3. The maintenance director/designee will audit the rooms weekly for 1 month and then monthly for 3 months.

4. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.

NFPA 101 STANDARD Multiple Occupancies - Construction Type:

This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.

Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0133

Based on observation and interview, the facility failed to meet multiple occupancy requirements on one of two building levels.

Findings include:

Observation on March 10 2026, at 10:55 a.m., revealed the basement building separation door had holes through it where the fire exit hardware was removed. The only hardware on the door was a turning knob.

Interview with the administrator and maintenance director on March 10, 2026, at 10:55 a.m., confirmed the holes in the fire-rated door.

Plan of Correction - To be completed: 04/30/2026

1. The hardware on the basement building separation door was replaced with fire rated hardware and the holes through the door were filled in with fire rated caulking.

2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on document review, observation and interview, the facility failed to meet cooking facility requirements for one of one kitchen.

Findings include:

1. Interview on March 10 2026, at 11:33 a.m., revealed three of four kitchen staff members were unaware of the location of the ansul pull station. These employees were new hires.

Interview with the administrator and maintenance director on March 10, 2026, at 11:33 a.m., confirmed the staff were new hires and unaware of the location.

2. Document review on March 10 2026, at 11:35 a.m., revealed the facility lacked documentation for the monthly ansul pull station inspections at the time of the survey,

Interview with the administrator and maintenance director on March 10, 2026, at 11:35 a.m., confirmed the documentation was unavailable.

Plan of Correction - To be completed: 04/30/2026

1. The kitchen staff will be re-educated on the location of the manual pull activation for the kitchen hood suppression system. All new hires will also have this education upon orientation.

2. Monthly inspections will be completed and documented for the ansul pull station.

3. The maintenance Director/designee will audit the documentation of the inspection monthly.

4. Results will be shared with the Quality Assurance Performance Improvement

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on observation and interview, the facility failed to meet multiple occupancy requirements on one of two building levels.

Findings include:

Observation on March 10 2026, at 11:20 a.m., revealed the basement, outside the kitchen doors, had a smoke detector hanging from exposed wires from the ceiling tile.

Interview with the administrator and maintenance director on March 10, 2026, at 11:20 a.m., confirmed the the smoke detector was not secured.

Plan of Correction - To be completed: 04/30/2026

1. The smoke detector outside of the kitchen doors was secured and is no longer hanging from exposed wires from the ceiling tile.

2. Maintenance director/designee will complete facility rounds weekly to ensure no other smoke detectors are unsecured.

3. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

1. Based on observation, document review, and interview, the facility failed to meet portable fire extinguisher requirements for one of one annual fire extinguisher report.

Findings include:

Observation on March 10, 2026, at 11:22 a.m., revealed the basement elevator room had an expired fire extinguisher from 2024.

Interview with the administrator and maintenance director on March 10, 2026, at 11:22 a.m., confirmed the outdated fire extinguisher.

2. Document review on March 10, 2026, at 8:33 a.m., revealed the following fire extinguisher deficiencies, which were listed on the June 2, 2025, annual report:

A. (8:33 a.m.) 10 ABC extinguishers need recharged as well as maintenance shop;
B. (8:33 a.m.) Five ABC maintenance shops need six-year;
C. (8:33 a.m.) 10-pound extinguisher kitchen storage room requires service;
D (8:33 a.m.) Classs K in kitchen needs hydro test;
E. (8:33 a.m.) 10-pound fire extinguisher by physical therapy and cabinet needs serviced;
F. (8:33 a.m.) 10-pound extinguisher at main nurse station requires maintenance.

Interview with the administrator and maintenance director on March 10, 2026, at 8:33 a.m., confirmed the fire extinguisher deficiencies.

Plan of Correction - To be completed: 04/30/2026

1. The basement elevator room will have an updated fire extinguisher in the room.
2. The fire extinguisher deficiencies which were listed on the June 2, 2025 annual report will be corrected.
3. The maintenance director/designee will complete monthly audits to ensure all fire extinguishers are in compliance
4. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement