Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT CAMPBELLTOWN
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 45 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 CAMPBELLTOWN - 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 January 20, 2026, at Kadima Rehabilitation &; Nursing at Campbelltown, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000
Facility ID #720502

Component 01

Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 20, 2026, it was determined that Kadima Rehabilitation &; Nursing at Campbelltown 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 V (111), protected wood frame structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Emergency Lighting:

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.

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 - Component: 01 - Tag: 0291 Based on document review and interview, it was determined the facility failed to provide documentation verifying monthly inspections of battery back-up emergency lighting fixtures had occurred within the previous twelve months, affecting the entire component. Findings include: 1. Review of documentation and interview on January 20, 2026, at 10:14 AM, revealed the facility failed to provide documentation verifying monthly inspections of battery back-up emergency lighting fixtures occurred between December 2024 and July 2025. Interview with the Facility Representative on January 20, 2026, at 10:14 AM, confirmed the lack of documentation verifying monthly inspections of battery back-up emergency lighting fixtures occurred within the previous twelve months.

Plan of Correction - To be completed: 02/23/2026

1. Systemic Changes / Corrective Action
The facility implemented a standardized Monthly Battery Back-Up Emergency Lighting Inspection Log to ensure all battery back-up emergency lighting fixtures are inspected for functionality and proper illumination facility-wide. Maintenance staff were re-educated on monthly inspection and documentation requirements, including testing battery function and documenting results. Any identified deficiencies will be corrected. All emergency lighting fixtures were inspected to ensure current compliance.

2. Monitoring / Quality Assurance
The Maintenance Director or designee will review completed monthly emergency lighting inspection logs not less than quarterly to ensure inspections are completed, documentation is present, and any identified deficiencies were addressed timely. Findings will be trended and monitored through the facility's QAPI program to ensure ongoing compliance.

NFPA 101 STANDARD Exit Signage:

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.

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0293 Based on document review, observation and interview, it was determined the facility failed to provide documentation verifying monthly inspections of exit signs had occurred within the previous twelve months, and to maintain the illumination of exit signage, affecting the entire component. Findings include: 1. Review of documentation on January 20, 2026, at 10:13 AM, revealed the facility failed to provide documentation verifying exit signs had been visually inspected between December 2024 and July 2025. Interview with the Facility Representative on January 20, 2026, at 10:13 AM, confirmed the lack of documentation verifying exit signs had been visually inspected, on a monthly basis within the previous twelve months. 2. Observation on January 20, 2026, at 11:36 AM, revealed the exit sign, by Resident Room 30, was not illuminated, and the interior bulbs were not lit. Interview with the Facility Representative on January 20, 2026, at 11:36 AM, confirmed the exit sign was not illuminated.

Plan of Correction - To be completed: 02/23/2026

1. All exit signs throughout the facility were inspected for proper illumination and function. Any deficient bulbs/signs were replaced to ensure proper operation. The facility implemented a Monthly Exit Sign Inspection Log to document visual inspections of all exit signage to ensure continued compliance.

2. The Maintenance Director or designee will complete and document monthly inspections of all exit signs. The Administrator or designee will audit the inspection logs monthly through the QAPI process to ensure inspections are completed and that all exit signs remain illuminated. Compliance will be monitored ongoing.

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 - Component: 01 - Tag: 0345 Based on document review, observation and interview, it was determined the facility failed to provide documentation verifying a visual inspection of fire alarm components had occurred within the previous twelve months, and the maintain unobstructed access to manual pull stations, affecting the entire component. Findings include: 1. Review of documentation on January 20, 2026, at 9:49 AM, revealed the facility failed to provide documentation verifying a visual inspection of fire alarm components had occurred within the previous twelve months. Interview with the Facility Representative on January 20, 2026, at 9:49 AM, confirmed the lack of documentation verifying a visual inspection of fire alarm components had occurred within the previous twelve months. 2. Observation on January 20, 2026, at 11:35 AM, revealed the manual pull station, by Resident Room 30, was obstructed by a patient lift. Interview with the Facility Representative on January 20, 2026, at 11:35 AM, confirmed the obstructed pull station.

Plan of Correction - To be completed: 02/23/2026

1. The facility conducted a visual inspection of all fire alarm components to ensure proper function and accessibility. The obstructed manual pull station identified during survey was cleared at the time of discovery. Documentation verifying the completed semi-annual fire alarm system inspection dated 04/18/2025 was recovered and placed in the Life Safety compliance binder. In addition, a standardized Monthly Fire Alarm Visual Inspection Log was implemented to document routinely.

2. Monitoring / Quality Assurance
The Maintenance Director or designee will complete and document monthly visual inspections of fire alarm components, including verification that all manual pull stations remain unobstructed. Life Safety documentation, including fire alarm inspection records, will be audited not less than quarterly by the Administrator or designee to ensure required inspections are completed, documentation is maintained, and any identified issues are addressed timely. Findings will be trended through the facility's QAPI program to ensure ongoing compliance.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0353 Based on review of documentation, observation and interview, it was determined the facility failed to provide documentation verifying quarterly waterflow device inspections had occurred within the previous twelve months, an internal obstruction investigation had occurred within the previous five years, and that permanent corrective action had been taken to maintain the automatic sprinkler protection system in a continuously reliable operating condition, affecting the entire component. Findings include: 1. Review of documentation on January 20, 2026, at 9:50 AM, revealed the facility failed to provide documentation verifying quarterly inspections of water flow initiating devices had occurred between 4/25/25 and 11/4/25. Interview with the Facility Representative on January 20, 2026, at 9:50 AM, confirmed the lack of documentation verifying quarterly inspection of water flow devices had occurred within the previous twelve months. 2. Review of documentation on January 20, 2026, at 9:55 AM, revealed the facility failed to provide documentation verifying an internal obstruction investigation had occurred within the previous five years. Interview with the Facility Representative on January 20, 2026, at 9:55 AM, confirmed the lack of documentation verifying an internal obstruction investigation had occurred within the previous five years. 3. Review of documentation and observation on January 20, 2026, between 10:00 AM and 1:00 PM, revealed the following from a sprinkler inspection dated 4/25/25, "Dry system is loosing air and compressor is dying." Observation revealed the facility was using a temporary store bought air compressor within the Sprinkler Riser Room. Interview with the Facility Representative on January 20, 2026, at 1:00 PM, confirmed the use of a temporary air compressor and no verification of plans to permanently correct the deficiency.

Plan of Correction - To be completed: 02/23/2026

1. The facility established a Life Safety tracking system for quarterly waterflow device inspections and the required five-year internal obstruction investigation. Sprinkler Test was completed on 8/27/2025 report was added to Life Safety binder. Maintenance staff were re-educated on inspection schedules, documentation requirements, and system reliability expectations.

2. The Administrator or designee will review sprinkler system inspection and testing documentation quarterly. Compliance will be audited and tracked through QAPI.

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 - Component: 01 - Tag: 0355 Based on document review and interview, it was determined the facility failed to maintain documentation verifying portable fire extinguishers were inspected on monthly and annual basis, affecting the entire component. Findings include: 1. Review of documentation on January 20, 2026, at 9:40 AM, revealed one portable fire extinguisher was not visually inspection between 7/10/2025 and 9/4/2025. Interview with the Facility Representative on January 20, 2026, at 9:40 AM, confirmed the lack of documentation verifying fire extinguishers were inspected on a monthly basis within the previous twelve months. 2. Review of documentation on January 20, 2026, at 12:50 PM, revealed the fire extinguisher, located within the Sprinkler Riser Room, had not been subjected to an annual inspection since October 2024. Interview with the Facility Representative on January 20, 2026, at 12:50 PM, confirmed the lack of documentation verifying fire extinguishers had been subjected to an annual inspection within the previous twelve months.

Plan of Correction - To be completed: 02/23/2026

1. The facility cannot retroactively correct the deficient practice related to the lack of documentation for annual fire extinguisher inspections. Upon identification, all fire extinguishers throughout the facility were inspected in-house by the Maintenance Director.

The facility has scheduled the annual fire extinguisher inspection with a licensed fire protection vendor, awaiting appointment. Upon completion, the fire extinguisher technician's certificate and inspection report will be placed in the Life Safety Book.

2. A facility-wide audit of all fire extinguishers was conducted to verify accessibility, pressure status, and proper placement. No additional concerns were identified during the in-house audit.

3.The facility implemented a monthly in-house Fire Extinguisher Inspection Log to document routine visual inspections. Maintenance staff were re-educated on inspection requirements, documentation, and Life Safety record retention.

The facility has established a tracking system and vendor service agreement to ensure annual inspections are scheduled timely moving forward.

4. The Maintenance Director or designee will complete and document monthly inspections. The Administrator or designee will review inspection logs and annual vendor reports quarterly. Compliance will be monitored through the facility's QAPI program.

NFPA 101 STANDARD Utilities - Gas and Electric:

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0511 Based on observation and interview, it was determined the facility failed to restrict access to electrical panels to solely authorized persons, affecting the entire component. Findings include: 1. Observation on January 20, 2026, at 11:44 AM, revealed three unlocked electrical panels, next to the 12 Central Bath. Interview with the Facility Representative on January 20, 2026, at 11:44 AM, confirmed access to the electrical panels was accessible to unauthorized persons.

Plan of Correction - To be completed: 02/23/2026

1. The facility implemented routine Life Safety rounds to ensure all electrical panels remain locked and accessible only to authorized personnel. Maintenance staff were re-educated on securing panels after servicing.

2. Life Safety findings will be reviewed during routine audits by the Administrator or designee and trended through QAPI.

NFPA 101 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0712 Based on document review and interview, it was determined the facility failed to provide documentation verifying staff were subjected to quarterly fire drills within the previous twelve months, affecting the entire component. Findings include: 1. Review of documentation on January 20, 2026, at 9:47 AM, revealed the facility failed to provide documentation verifying fire drills occurred between 12/4/24 and 7/29/25. Interview with the Facility Representative on January 20, 2026, at 9:47 AM, confirmed the lack of documentation verifying quarterly fire drills were conducted within the previous twelve months.

Plan of Correction - To be completed: 02/23/2026

1. The facility implemented a documented quarterly fire drill schedule covering all shifts, supported by a standardized Fire Drill Log. Staff were re-educated on fire drill procedures and documentation requirements.

2. The Administrator or designee will review fire drill documentation quarterly and monitor compliance through QAPI.

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 - Component: 01 - Tag: 0918 Based on document review and interview, it was determined the facility failed to provide documentation verifying monthly load exercises of the generator, and battery conductance testing had occurred within the previous twelve months, affecting the entire component. Findings include: 1. Review of documentation on January 20, 2026, at 10:16 AM, revealed the facility failed to provide documentation verifying load exercises of the generator occurred between December 2024 and July 2025. Interview with the Facility Representative on January 20, 2026, at 10:16 AM, confirmed the lack of documentation verifying monthly load exercises of the generator occurred within the previous twelve months. 2. Review of documentation on January 20, 2026, at 10:17 AM, revealed the facility failed to provide documentation verifying monthly conductance testing of the batteries servicing the generator had occurred within the previous twelve months. Interview with the Facility Representative on January 20, 2026, at 10:17 AM, confirmed the lack of documentation verifying monthly conductance testing of generator batteries had occurred within the previous twelve months.

Plan of Correction - To be completed: 02/23/2026

1. The facility implemented a documented schedule for monthly generator load exercises and battery conductance testing. Maintenance staff were re-educated on generator testing and documentation requirements.

2. The Administrator or designee will review generator testing and maintenance logs monthly and track compliance through QAPI.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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.

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0920 Based on observation and interview, it was determined the facility failed to monitor the use of extension cords, affecting one of four smoke compartments within the component. Findings include: 1. Observation on January 20, 2026, at 11:50 AM, revealed an air conditioner was plugged into an extension cord, which in turn was supplied with electrical power by a surge protector. Interview with the Facility Representative on January 20, 2026, at 11:50 AM, confirmed the high draw appliance was supplied with electrical power by an extension cord and surge suppressor.

Plan of Correction - To be completed: 02/23/2026

1. The facility re-educated nursing and maintenance staff on the prohibited use of extension cords and surge protectors with high-draw appliances. Routine Life Safety rounds were implemented to monitor electrical safety compliance.

2. Life Safety round findings will be reviewed by the Administrator or designee and trended through QAPI.

NFPA 101 STANDARD Gas Equipment - Precautions for Handling Oxyg:

Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds
Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99)
11.6.2 (NFPA 99)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0929 Based on observation and interview, it was determined the facility failed to secure portable oxygen cylinders, affecting one of four smoke compartments within the component. Findings include: 1. Observation on January 20, 2026, at 11:37 AM, revealed an unsecured portable oxygen "E" cylinder, located within the Oxygen Storage Room, next to Resident Room 31. Interview with the Facility Representative on January 20, 2026, at 11:37 AM, confirmed the unsecured portable oxygen cylinder.

Plan of Correction - To be completed: 02/23/2026

1. The facility re-educated nursing and maintenance staff on proper storage and securing of portable oxygen cylinders. Routine Life Safety rounds were implemented to ensure ongoing compliance.

2. Life Safety findings will be reviewed during routine audits by the Administrator or designee and monitored through QAPI.

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