Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT LAKESIDE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

KADIMA REHABILITATION & NURSING AT LAKESIDE
Inspection Results For:

There are 102 surveys for this facility. Please select a date to view the survey results.

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

Initial comments:

Based on a revisit completed on August 24, 2026, it was determined that Kadima Rehabilitation & Nursing at Lakeside corrected the federal deficiencies cited during the survey of July 23, 2026, under the requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care but continued to be out of compliance with the following requirements of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 09/11/2026

1.) There were no ill effects suffered by the residents due to the facility's failure to meet ratio for residents to CNAS for the identified shifts.

2.) A facility wide audit was conducted to ensure recruitment has all facility needs posted. A 24-Hour look back was completed to ensure ratios were met.

3.) The DON was re-educated on ensuring ratios are met.

4.) The NHA or designee will conduct an audit of nursing care ratios weekly x 4 weeks then monthly x 2 months to ensure ratios are being met. The results will be submitted to QAPI Committee for review and analysis of ongoing monitoring.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum licensed practical nurse ratio to resident ratio was provided on each shift for six shifts out of 21 shifts reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide a minimum of one LPN per 25 residents during the day shift, a minimum of one LPN per 30 residents during the evening shift, and a minimum of one LPN per 40 residents during the night shift.

August 17, 2026 - 0.53 LPNs on the day shift versus the required 1.0 for a census of 30. August 18, 2026 - 0.87 LPNs on the day shift versus the required 1.20 for a census of 30.
August 20, 2026 - 1.00 LPNs on the day shift versus the required 1.20 for a census of 30.
August 21, 2026 - 1.00 LPNs on the day shift versus the required 1.20 for a census of 30.
August 22, 2026 - 0.07 LPNs on the day shift versus the required 1.20 for a census of 30.
August 22, 2026 - 0.13 LPNs on the night shift versus the required 1.0 for a census of 30.

On the above dates mentioned no additional excess higher-level staff were available to compensate for this deficiency.

An interview with the Director of Nursing, on August 24, 2026, at 1:08 PM confirmed the facility had not met the required LPN to resident ratios on the above dates.

Plan of Correction - To be completed: 09/11/2026

1.) There were no ill effects suffered by the residents due to the facility's failure to meet ratio for residents to LPNs for the identified shifts.

2.) A facility wide audit was conducted to ensure recruitment has all facility needs posted. A 24-Hour look back was completed to ensure ratios were met.

3.) The DON was re-educated on ensuring ratios are met.

4.) The NHA or designee will conduct an audit of nursing care ratios weekly x 4 weeks then monthly x 2 months to ensure ratios are being met. The results will be submitted to QAPI Committee for review and analysis of ongoing monitoring.

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Observations:

Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum registered nurse to resident ratio was provided on each shift for seven shifts out of 21 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following date the facility failed to provide minimum registered nurse (RN) staff of 1:250 on the night shift, based on the facility's census:

August 17, 2026, 0 RNs on the night shift, versus the required 1, for a census of 30.
August 18, 2026, 0 RNs on the night shift, versus the required 1, for a census of 30.
August 19, 2026, 0 RNs on the night shift, versus the required 1, for a census of 30.
August 20, 2026, 0 RNs on the night shift, versus the required 1, for a census of 30.
August 21, 2026, 0 RNs on the night shift, versus the required 1, for a census of 30.
August 22, 2026, 0.56 RNs on the night shift, versus the required 1, for a census of 30.
August 23, 2026, 0 RNs on the night shift, versus the required 1, for a census of 30.

On the above dates mentioned no additional excess higher-level staff were available to compensate for this deficiency.

An interview with the Director of Nursing, on August 24, 2026, at 1:10 PM confirmed the facility had not met the required RN to resident ratios on the above dates.

Plan of Correction - To be completed: 09/11/2026

1. There were no ill effects suffered by the residents due to the facility's failure to meet ratio for residents to RNS for the identified shifts.

2. A facility wide audit was conducted to ensure recruitment has all facility needs posted. A 24-Hour look back was completed to ensure ratios were met.

3. The DON was re-educated on ensuring ratios are met.

4. The NHA or designee will conduct an audit of nursing care ratios weekly x 4 weeks then monthly x 2 months to ensure ratios are being met. The results will be submitted to QAPI Committee for review and analysis of ongoing monitoring.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily two days out of 7 days reviewed.

Findings include:

A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 3.2 hours of general nursing care to each resident:

August 21, 2026 - 3.10 direct care nursing hours per resident.
August 22, 2026 - 2.30 direct care nursing hours per resident.

The facility's general nursing hours were below minimum required levels on the above dates.

During an interview with the Nursing Home Administrator (NHA) on August 24, 2026, at 1:10 PM, the above information was reviewed and confirmed nursing care hours were not met on the above dates.

Plan of Correction - To be completed: 09/11/2026

1. There were no ill effects suffered by the residents due to the facility's failure to meet the required nursing staffing level of 3.2 nursing hours for 2 days.

2. A facility wide audit was conducted to ensure recruitment has all facility needs posted. A 24-Hour look back was completed to ensure direct care nursing hours of 3.2 were met.

3. The DON was re-educated on ensuring the direct care nursing hours of 3.2 are met.

4. The NHA or designee will conduct an audit of nursing care hours of 3.2 weekly x 4 weeks then monthly x 2 months to ensure ratios are being met. The results will be submitted to QAPI Committee for review and analysis of ongoing monitoring.

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