Kadima Rehab Washington: Missed Follow-Up Care Failure - PA
The resident at Kadima Rehabilitation & Nursing at Washington carried a set of diagnoses that made the missed appointment more than a scheduling oversight. Resident R1, as inspectors identified them, had congestive heart failure, a history of deep vein thrombosis, and lymphedema, a condition in which fluid builds up in the body's soft tissues. The resident was already on diuretics to manage the fluid accumulation. Both the nurse practitioner and the physician who examined the resident in late February noted in their records that the lymphedema was chronic and that the resident needed a follow-up at a lymphedema clinic as an outpatient.
That note, "needs f/u with lymphedema clinic as outpatient," appeared in the clinical record on February 24. It appeared again on February 25. It appeared a third time on March 3.
No order was ever written to make it happen.
The care plan for the resident had been updated on March 6 to note the lymphedema diagnosis. The plan for high blood pressure and congestive heart failure, dated February 26, instructed staff to watch for shortness of breath, chest pain, swelling, and elevated blood pressure, the classic signs that the underlying conditions were worsening. The specialist referral that three separate clinical notes called for would have addressed the condition driving some of those risks. It was never pursued.
When inspectors interviewed a registered nurse at the facility at 1:00 p.m. on March 27, the nurse confirmed that Resident R1 had not received a follow-up appointment with the lymphedema clinic. Two hours later, the nursing home administrator said the same thing, confirming to inspectors that the facility had failed to schedule the appointment.
The inspection covered four residents. Only one, Resident R1, had the unscheduled referral. But the finding was unambiguous: three clinical notes over the span of a week and a half, from two different providers, calling for the same specialist follow-up, and nothing done about any of them.
The violation was cited under Pennsylvania's nursing home regulations governing social services, which cover coordination of care and services for residents. Inspectors rated the level of harm as minimal harm or potential for actual harm, the lower end of the severity scale. The inspection was triggered by a complaint.
What the record shows is a resident with a chronic, progressive fluid condition, on medication to manage it, whose providers agreed she needed specialist care, and whose facility let that clinical consensus sit in the chart for a month without acting on it. Whether the lymphedema worsened during that time, whether the missed appointment affected Resident R1's condition or comfort, the inspection report does not say. What it says is that on the day inspectors walked in, the referral still hadn't been made, and the people responsible confirmed it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kadima Rehabilitation & Nursing At Washington from 2026-03-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
KADIMA REHABILITATION & NURSING AT WASHINGTON in WASHINGTON, PA was cited for violations during a health inspection on March 27, 2026.
The resident at Kadima Rehabilitation & Nursing at Washington carried a set of diagnoses that made the missed appointment more than a scheduling oversight.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.