Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT LAKESIDE
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 LAKESIDE - 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 September 15, 2025, at Kadima Rehabilitation and Nursing at Lakeside, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000
Facility ID# 290902Component 01Main BuildingBased on a Medicare/Medicaid Recertification Survey completed on September 15, 2025, it was determined that Kadima Rehabilitation and Nursing at Lakeside 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 building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.

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 01 - Component: 01 - Tag: 0345 Based on documentation review and interview, it was determined the facility failed to maintain the building fire alarm system in one instance, affecting one of one floor. Findings include: Observation on September 15, 2025, at 12:35 p.m., revealed the facility lacked semi-annual, visual inspection data of the building fire alarm system.Exit interview with the Facility Administrator and the Facilities Manager on September 15, 2025, between 1:00 p.m., and 1:15 p.m., confirmed the fire alarm system deficiency.

Plan of Correction - To be completed: 10/01/2025

1.)The facility contacted vendor to complete the semi-annual visual inspection of the fire alarm system.
2.)Semi-annual visual inspections of the fire alarm system were placed on an automatic schedule with vendor.
3.)The maintenance director was re-educated on ensuring that semi-annual fire alarm system inspections are completed, and documentation is kept in the life safety binder.
4.)The NHA or Designee will conduct an audit of semi-annual fire alarm inspections x1 year, then x 2 years to ensure semi-annual fire alarm inspections are completed. The results will be submitted to the QAPI Committee for review and analysis of the need for ongoing monitoring.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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, affecting one of one floor. Findings include: Observation on September 15, 2025, between 12:43 p.m., and 12:50 p.m., revealed the following:a. 12:43 p.m., the facility lacked two of four required quarterly mechanical waterflow device testing data. b. 12:44 p.m., the facility lacked annual main drain and control valve testing data. c. 12:45 p.m., the facility lacked dry system trip data, as well as three-year, full flow trip data. d. 12:46 p.m., the facility lacked five-year, sprinkler gauge replacement data. e. 12:47 p.m., the facility lacked current, annual fire pump testing and inspection data (last report dated 5/15/24). f. 12:48 p.m., numerous deficiencies were cited during the five-year, internal tank inspection, dated 2/17/25, that have not been remediated. Exit interview with the Facility Administrator and the Facilities Manager on September 15, 2025, between 1:00 p.m., and 1:15 p.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 10/01/2025

1.)The facility contacted vendor to complete mechanical waterflow device test, annual main drain and control valve test, dry system trip test, three-year full flow trip test, five-year sprinkler gauge replacement, annual fire pump inspection, and contacted a second company to complete the 5-year internal tank inspection for a second opinion.
2.)Wet system inspections were placed on an automatic schedule with vendor.
3.)The maintenance director was re-educated on ensuring that all inspections and testing related to the facilities wet system were completed and in compliance.
4.)The NHA or Designee will conduct an audit quarterly x 1 year, then x 2 years to ensure all inspections and testing required for the facilities wet system are completed. The results will be submitted to the QAPI Committee for Review and analysis of the need for ongoing monitoring.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761 Based on documentation review and interview, it was determined the facility failed to maintain fire doors, affecting one of one floor. Findings include: Observation on September 15, 2025, at 12:30 p.m., revealed the facility lacked annual fire door functional and visual testing data.Exit interview with the Facility Administrator and the Facilities Manager on September 15, 2025, between 1:00 p.m., and 1:15 p.m., confirmed the fire door deficiency.

Plan of Correction - To be completed: 10/01/2025

1.)The facility contacted vendor to schedule annual fire door inspection
2.)The annual fire door inspection was placed on an automatic schedule with vendor.
3.)The maintenance director was re-educated on ensuring annual fire door inspection is completed, and that documentation is retained in the life safety binder.
4.)The NHA or Designee will conduct an audit x 1 year then x 3 years to ensure annual fire door inspections are completed. The results will be submitted to the QAPI Committee for review and analysis and the need for ongoing monitoring.

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 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 one of one floor. Findings include: Observation on September 15, 2025, at 12:40 p.m., revealed the facility lacked annual, generator set, fuel quality testing data.Exit interview with the Facility Administrator and the Facilities Manager on September 15, 2025, between 1:00 p.m., and 1:15 p.m., confirmed the generator set deficiency.

Plan of Correction - To be completed: 10/01/2025

1.)The generators fuel quality testing is scheduled with the vendor to be completed on 9/25/2025.
2.)The annual fuel quality testing was placed on an automatic schedule with vendor.
3.)The maintenance director was re-educated on ensuring facility vendor completes annual fuel quality testing and that results are retained in the life safety binder.
4.)The NHA or Designee will complete an audit x 1 year then x 3 years to ensure annual fuel quality testing is completed. The results will be submitted to the QAPI Committee for review and analysis and the need for ongoing monitoring.

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