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:

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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 November 19, 2025, it was determined that Kadima Rehabilitation &; Nursing at Lakeside corrected the federal deficiencies cited during the survey of September 4, 2025, 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)(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 nursing staffing hours and staff interview, it was determined the facility failed to ensure a minimum of one Registered Nurse (RN) staff to resident ratio was provided on the night shift for seven shifts out of 21 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum Registered Nurse (RN) staff of 1 per 250 residents on all shifts.

Review of nursing staff care hours provided by the facility revealed the facility resident census of 26 for night shift on October 2, 2025, which required 1.00 RN during night shift. Review of the nursing time schedules revealed 0 RN's worked the night shift on October 2, 2025.

Review of nursing staff care hours provided by the facility revealed the facility resident census of 26 for night shift on October 3, 2025, which required 1.00 RN during night shift. Review of the nursing time schedules revealed 0 RN's worked the night shift on October 3, 2025.

Review of nursing staff care hours provided by the facility revealed the facility resident census of 27 for night shift on October 4, 2025, which required 1.00 RN during night shift. Review of the nursing time schedules revealed 0 RN's worked the night shift on October 4, 2025.

Review of nursing staff care hours provided by the facility revealed the facility resident census of 26 for night shift on October 5, 2025, which required 1.00 RN during night shift. Review of the nursing time schedules revealed 0 RN's worked the night shift on October 5, 2025.

Review of nursing staff care hours provided by the facility revealed the facility resident census of 26 for night shift on October 6, 2025, which required 1.00 RN during night shift. Review of the nursing time schedules revealed 0 RN's worked the night shift on October 6, 2025.

Review of nursing staff care hours provided by the facility revealed the facility resident census of 26 for night shift on October 7, 2025, which required 1.00 RN during night shift. Review of the nursing time schedules revealed 0 RN's worked the night shift on October 7, 2025.

Review of nursing staff care hours provided by the facility revealed the facility resident census of 26 for night shift on October 8, 2025, which required 1.00 RN during night shift. Review of the nursing time schedules revealed 0 RN's worked the night shift on October 8, 2025.

During an interview on November 19, 2025, 12:00 PM, the Nursing Home Administrator (NHA) confirmed the facility failed to provide a minimum Registered Nurse (RN) staffing ratios on the above shifts.

Plan of Correction - To be completed: 12/08/2025

1)There were no ill effects suffered by any residents due to the facility's failure to meet the ratio for residents to RN for 7 shifts. The facility hired a FT RN starting on 12/1/2025.
2)A facility wide audit was completed to ensure ratios were met. RN wages are competitive with surrounding areas.
3)The DON and recruitment were re-educated on ensuring that nursing care ratios are provided and that the facility is actively recruiting RNs. The DON will review census and schedules daily to ensure adequate staffing of overnight RNS
4)The DON or designee will conduct an audit of nursing care ratios to ensure it is provided weekly x 4 weeks, then monthly x2 months. The results will be submitted to QAPI committee for review and analysis of need of ongoing monitoring

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