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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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

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

Facility ID# 283802
Component 01
Main Building

Based on a Relicensure Survey completed on November 03, 2025 it was determined that Kadima Rehabilitation and Nursing at Luzerne was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a one story, Type V (000), unprotected, wood frame building, with basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Vertical Openings - Enclosure:

Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical openings in one location, affecting two of two floors.

Findings include:

1. Observation on November 03, 2025, at 1:26 p.m., revealed penetrations of the ceiling within the basement-level Maintenance Work Shop.

Exit interview on November 03, 2025, between 2:15 p.m., and 2:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the vertical openings deficiency.

Plan of Correction - To be completed: 12/03/2025

1. The penetrations are being sealed.
2. A facility wide audit was conducted, and no other unsealed penetrations were found.
3. The maintenance director was re-educated to ensure all walls are free from penetration.
4. The NHA, or designee will conduct a one-time audit to ensure soiled utility rooms are free from any wall penetration. The results will be submitted to the QAPI committee for review and analysis of the need for ongoing monitoring

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
2012 EXISTING
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. 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

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, it was determined the facility failed to maintain two hazardous area enclosures, affecting one of two floors.

Findings include:

1. Observation on November 03, 2025, between 12:59 p.m., and 1:24 p.m., revealed the following doors required adjustment to fully latch.

a. 12:59 p.m., basement-level Supply Closet, closest to Maintenance.
b. 1:24 p.m., basement-level Bio-Hazard Room.

Exit interview on November 03, 2025, between 2:15 p.m., and 2:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the hazardous area enclosure deficiencies.

Plan of Correction - To be completed: 12/03/2025

1.The doors were adjusted to fully latch.
2. A facility wide audit was conducted and no other doors in need of adjustment were identified.
3. The maintenance director was re-educated on ensuring all fire doors fully latch.
4. The NHA, or designee will conduct a one-time audit to ensure fire doors are latching correctly

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 documentation review and interview, it was determined the facility failed to maintain cooking facilities in one instance, affecting one of two floors.

Findings include:

1. Observation on November 03, 2025, at 2:05 p.m., revealed the facility lacked one of two required kitchen suppression inspection tests for the preceding twelve month period (10/29/2025, most recent).

Exit interview on November 03, 2025, between 2:15 p.m., and 2:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the cooking facilities deficiency.

Plan of Correction - To be completed: 12/03/2025

1. Facility cannot retroactively go back on kitchen suppression inspections
2. Beach lake sprinklers are contracted to do our kitchen suppression maintenance and inspections. A calendar will be created to oversee hood cleaning by the maintenance director
3. Maintenance director was reeducated on the importance of kitchen suppression system inspections
4. Biannual audit will be done to make sure suppression inspection is performed. The results will be submitted to the QAPI committee for review and analysis of the need of ongoing monitoring

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 01 - Component: 01 - Tag: 0353

Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting two of two floors.

Findings include:

1. Observation on November 03, 2025, at 1:55 p.m., revealed the facility lacked current internal tank inspection data (last internal tank inspection performed March of 2022).

Exit interview on November 03, 2025, between 2:15 p.m., and 2:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the automatic sprinkler system deficiency.

Plan of Correction - To be completed: 12/03/2025

1. NHA and Maintenance Director could not retroactively complete the internal tank inspection
2. Last tank inspection was performed in 2022 corporate office scheduling out of Pittsburgh
3. The maintenance director was reeducated on the importance of internal tank inspections
4. A one-time audit was done to ensure that sprinkler tank inspection is completed for upcoming year requirement

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

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishing devices in two locations, affecting one of two floors.

Findings include:

1. Observation on November 03, 2025, between 1:07 p.m., and 1:14 p.m., revealed the following portable fire extinguishers lacked visual inspection data for October, 2025:

a. 1:07 p.m., basement-level, rear delivery area.
b. 1:14 p.m., basement-level Boiler Room.

Exit interview on November 03, 2025, between 2:15 p.m., and 2:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the fire extinguished deficiencies.

Plan of Correction - To be completed: 12/03/2025

1. The maintenance director could not retroactively do monthly fire extinguisher inspections
2. A facility wide audit of fire extinguishers was completed and updated
3. 3. The Maintenance Director was re-educated on the maintenance of portable fire extinguishers
4. NHA or designee will do a whole house monthly audit x 3 months of fire extinguisher testing

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
2012 EXISTING
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.
There is no impediment to the closing of the doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted.
Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.
19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain two corridor openings, affecting two of two floors.

Findings include:

1. Observation on November 03, 2025, between 12:44 p.m., and 1:12 p.m., revealed the following doors required adjustment to fully latch:

a. 12:44 p.m., first floor, Clean linen Room.
b. 1:12 p.m., basement-level, Water Room.

Exit interview on November 03, 2025, between 2:15 p.m., and 2:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the corridor opening deficiencies.

Plan of Correction - To be completed: 12/03/2025

1.The doors were adjusted to fully latch.
2. A facility wide audit was conducted and no other doors in need of adjustment were identified.
3. The maintenance director was re-educated on ensuring all doors fully latch.
4. The NHA, or designee will conduct a one-time audit to ensure room basement level doors positively latch. The results will be submitted to the QAPI committee for review and analysis of need of ongoing monitoring.

NFPA 101 STANDARD Operating Features - Other:

Operating Features - Other
List in the REMARKS section any LSC Section 18.7 and 19.7 Operating Features requirements that are not addressed by the provided S-tags, but are deficient.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0700

Based on documentation review and interview, it was determined the facility failed to maintain fire doors, affecting two of two floors.

Findings include:

1. Observation on November 03, 2025, at 2:00 p.m., revealed the facility lacked annual fire door inspection data.

Exit interview on November 03, 2025, between 2:15 p.m., and 2:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the fire door deficiencies.

Plan of Correction - To be completed: 12/03/2025

1. Maintenance director cannot retroactively report fire doors.
2. Audit of all fire doors have been checked to maintain proper functionality.
3. ongoing Audit created and will be done by maintenance director to ensure proper functionality of fire doors moving forward
4. Nha or designee will audit fire doors monthly for 3 months and report findings to 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 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. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to maintain fire drills in eight instances, affecting two of two floors.

Findings include:

1. Observation on November 03, 2025, at 1:45 p.m., revealed the facility lacked eight of twelve required fire drills for the preceding twelve month period (First and second quarter of calendar year 2025, and first and second shift fire drills for fourth quarter of 2024, or 2025).

Exit interview on November 03, 2025, between 2:15 p.m., and 2:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the fire drill deficiencies.

Plan of Correction - To be completed: 12/03/2025

1. NHA and Maintenance Director could not retroactively complete the missed annual fire drills.
2. NHA and the Director of Maintenance were re-educated on the importance of completing scheduled annual fire drills.
3. NHA and the Maintenance Director created a new schedule for fire drills to ensure they happen monthly on each shift (12 per year).
4. NHA will perform monthly audits to ensure one fire drill was performed that month.

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 and readily identifiable. 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 documentation review and interview, it was determined the facility failed to maintain the generator set in one instance, affecting two of two floors.

Findings include:

1. Observation on November 03, 2025, at 12:10 p.m., revealed the facility lacked 30- minute, monthly, load testing and data for the preceding twelve month period.

Exit interview on November 03, 2025, between 2:15 p.m., and 2:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the generator set deficiency.

Plan of Correction - To be completed: 12/03/2025

1. There was no negative effect or loss of generator power.
2. Genserve will be performing 4-hour load bank testing annually and service
3. Maintenance director reeducated on importance of generator service and 30 minute monthly testing
4. The maintenance director will conduct random audits that generator is fully functional. NHA or designee will audit monthly for 3 months 30 min load test.

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