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

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KADIMA REHABILITATION & NURSING AT IRWIN
Inspection Results For:

There are  225 surveys for this facility. Please select a date to view the survey results.

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KADIMA REHABILITATION & NURSING AT IRWIN - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Based on an Abbreviated Survey in response to two complaints, completed on November 20, 2025, it was determined that Kadima Rehabilitation and Nursing at Irwin was in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities; however, the facility was not in compliance with the 28. Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations. 


 Plan of Correction:


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

Observations: Findings include: Review of the nursing schedules and census information for 10/12/25, through 11/1/25, revealed that the facility failed to meet the following: 10/12/25: Day shift required 84.00 hours of nurse aide care, facility provided 75.00. 10/13/25: Evening shift required 77.05 hours of nurse aide care, facility provided 75.00; night shift required 56.50 hours of nurse aide care, facility provided 45.00. 10/14/25: Evening shift required 76.36 hours of nurse aide care, facility provided 61.25. 10/18/25: Day shift required 82.50 hours of nurse aide care, facility provided 81.25; night shift required 54.00 hours of nurse aide care, facility provided 52.50. 10/19/25: Day shift required 80.25 hours of nurse aide care, facility provided 75.00. 10/20/25: Day shift required 83.25 hours of nurse aide care, facility provided 66.00; night shift required 55.50 hours of nurse aide care, facility provided 45.00. 10/21/25: Night shift required 56.00 hours of nurse aide care, facility provided 52.50. 10/22/25: Day shift required 84.00 hours of nurse aide care, facility provided 72.50; night shift required 56.00 hours of nurse aide care, facility provided 52.50. 10/23/25: Day shift required 84.00 hours of nurse aide care, facility provided 79.50. 10/24/25: Day shift required 84.00 hours of nurse aide care, facility provided 80.00; evening shift required 76.36 hours of nurse aide care, facility provided 71.25. 10/25/25: Day shift required 83.25 hours of nurse aide care, facility provided 75.00; night shift required 55.20 hours of nurse aide care, facility provided 37.50. 10/26/25: Night shift required 55.50 hours of nurse aide care, facility provided 52.50. 10/27/25: Night shift required 55.00 hours of nurse aide care, facility provided 45.00. 10/28/25: Night shift required 55.00 hours of nurse aide care, facility provided 52.50. 10/29/25: Day shift required 83.25 hours of nurse aide care, facility provided 82.50; evening shift required 75.68 hours of nurse aide care, facility provided 52.50. 10/31/25: Day shift required 82.50 hours of nurse aide care, facility provided 72.00; evening shift required 75.00 hours of nurse aide care, facility provided 60.00; night shift required 55.00 hours of nurse aide care, facility provided 48.00. 11/01/25: Day shift required 82.50 hours of nurse aide care, facility provided 48.00; evening shift required 75.00 hours of nurse aide care, facility provided 68.00. During an interview on 11/20/25, at approximately 6:00 p.m. the Nursing Home Administrator confirmed that the facility administrative staff failed to provide a minimum of one nurse aide per 10 residents during the day shifts, one nurse aide per 11 residents on evening shift, and one nurse aide per 15 residents on night shift, on 16 of 21 days.
 Plan of Correction - To be completed: 12/04/2025

The facility will ensure state-required nurse aide ratios are met for all shifts. The facility cannot correct that nurse aide staffing ratios were not met on the cited dates.

The facility will ensure that nurse aide staffing ratios are met every shift.

The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5520 and ensuring nurse aide staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meeting. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist as needed. Facility recently added a new $3/shift differential for evening shift to promote recruitment and retention. Facility also signed with new staffing agency to supplement needs.

The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure nurse aide staffing ratios are being met.

The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(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: Findings include: Review of the nursing schedules and census information for 10/12/25, through 11/1/25, revealed that the facility failed to meet the following: 10/12/25: Day shift required 35.84 hours of LPN care, facility provided 32.00. 10/17/25: Night shift required 22.00 hours of LPN care, facility provided 16.00. 10/20/25: Night shift required 22.20 hours of LPN care, facility provided 16.00. 10/21/25: Night shift required 22.40 hours of LPN care, facility provided 8.00. 10/22/25: Night shift required 22.40 hours of LPN care, facility provided 16.00. 10/24/25: Night shift required 22.40 hours of LPN care, facility provided 16.00. 10/26/25: Day shift required 35.52 hours of LPN care, facility provided 27.75; night shift required 22.20 hours of LPN care, facility provided 16.00. 10/28/25: Evening shift required 29.33 hours of LPN care, facility provided 24.00; night shift required 22.00 hours of LPN care, facility provided 16.00. 10/29/25: Night shift required 22.20 hours of LPN care, facility provided 16.00. 10/30/25: Night shift required 22.00 hours of LPN care, facility provided 16.00. During an interview on 11/20/25, at approximately 6:00 p.m. the Nursing Home Administrator confirmed that the facility administrative staff failed to provide a minimum of one LPN per 25 residents during the day shift, one LPN per 30 residents during the evening shift, and one LPN per 40 residents during the night shift for ten of 21 days.
 Plan of Correction - To be completed: 12/04/2025

The facility will ensure state-required LPN ratios are met for all shifts. The facility cannot correct that LPN staffing ratios were not met on the cited dates.

The facility will ensure that LPN staffing ratios are met every shift.

The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meeting. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist as needed. Facility also signed with new staffing agency to supplement needs.

The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure LPN staffing ratios are being met.

The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(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: Findings include: Review of the nursing schedules and census information for 10/12/25, through 11/1/25, revealed that the facility failed to maintain 3.20 hours of general nursing care to each resident in a 24-hour period on the following dates: -10/12/25, Census 112. PPD 3.15. -10/13/25, Census 113. PPD 3.19. -10/14/25, Census 112. PPD 2.98. -10/17/25, Census 110. PPD 3.06. -10/20/25, Census 111. PPD 2.86. -10/22/25, Census 112. PPD 2.96. -10/24/25, Census 112. PPD 2.96. -10/25/25, Census 111. PPD 3.04. -10/26/25, Census 111. PPD 3.13. -10/27/25, Census 110. PPD 3.02. -10/28/25, Census 110. PPD 3.11. -10/29/25, Census 111. PPD 2.77. -10/30/25, Census 110. PPD 3.17. -10/31/25, Census 110. PPD 2.87. -11/01/25, Census 110. PPD 2.80. During an interview on 11/20/25, at approximately 6:00 p.m. the Nursing Home Administrator confirmed that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on 15 of 21 days.
 Plan of Correction - To be completed: 12/04/2025

The facility will ensure that the state minimum staffing requirement of 3.2 PPD is met in order to ensure the health and safety of all residents. Facility is unable to retroactively correct concern of minimum staffing requirement not being met on the cited dates.

Facility will continue to ensure all efforts are exhausted to maintain the minimum staffing requirement of 3.2 PPD on a daily basis to ensure the health and safety of all residents. Facility will continue to acquire agency staff as needed to meet the 3.2 PPD requirement. Recruitment efforts are under way and a plan is in place. Bonuses will be offered to all staff to pick up shifts. Facility recently added a new $3/shift differential for evening shift CNAs to promote recruitment and retention. Facility also signed with new staffing agency to supplement needs.

Regional Clinical Consultant will re-educate Administrator, Director of Nursing, and staffing coordinator on "Nursing Department Staff" policy which outlines the minimum staffing requirements and steps that are to be taken in order to ensure staffing requirements are met in order to ensure the health and safety of all residents.

Administrator or designee will audit staffing levels five times a week for four weeks and then monthly for three months to ensure the minimum staffing requirement of 3.2 PPD is met to ensure the health and safety of all residents.

The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.

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