Kadima Rehabilitation: Seizure Medication Gap - PA
The resident, identified only as Resident R1, takes Briviact 100 mg twice daily to control epilepsy, a condition involving recurrent, unprovoked seizures caused by abnormal electrical activity in the brain. A physician had ordered the medication in July 2025. By May 1, 2026, it was gone.
The electronic medication record tells the story in three entries. At 10:03 in the morning, a nurse documented that the Briviact tablet was unavailable, with a note reading "awaiting medication from pharmacy." At 6:38 that evening, the same note appeared again. The morning dose had been missed. The evening dose had been missed. An on-call note entered just before midnight confirmed that a prescription hadn't even been sent to the pharmacy until 9:46 that same morning, hours after the first missed dose was already recorded.
The facility's own policy required staff to reorder medications three to five days before the supply ran out. For a twice-daily seizure medication prescribed to a resident with a documented epilepsy diagnosis, that window existed precisely to prevent what happened on May 1.
Nobody had reordered it in time.
A registered nurse, interviewed by inspectors on May 8, confirmed that R1's medications did not arrive before the supply was exhausted. The Director of Nursing went further. She confirmed that the facility had failed to refill the medication in time, and she confirmed the consequence: R1 experienced an adverse reaction, suffered additional seizures, and was sent to the hospital for evaluation and treatment.
The care plan for this resident, in place since November 2021, instructed staff to observe for signs and symptoms of an impending seizure and to maintain a safe environment. It also said, simply, to give medications as ordered.
On May 1, that didn't happen.
The inspection, conducted as a complaint investigation and completed May 25, 2026, cited the facility under Pennsylvania nursing services regulations. Inspectors classified the violation as causing minimal harm or the potential for actual harm, a designation that reflects the lower end of the federal harm scale, though the Director of Nursing's own account described a resident who had additional seizures and required hospitalization.
Kadima Rehabilitation & Nursing at Washington is a long-term care and rehabilitation facility in Washington, Pennsylvania. The inspection covered three residents and found the medication reordering failure in one of them.
The gap here was not a complex clinical judgment call. It was a reorder. The pharmacy does not automatically refill every medication. When that's the case, the facility's own written policy put the responsibility on staff to act three to five days before the bottle ran out. The prescription wasn't sent until the morning the medication was already missing.
R1 had been living with epilepsy, high blood pressure, and anxiety, diagnoses confirmed as recently as a February 2026 assessment. Seizure control in a long-term care resident depends on consistent medication levels. A missed dose is not a minor inconvenience for someone with active epilepsy. It is a gap in the pharmacological barrier between a managed condition and a medical emergency.
That emergency arrived on May 1. The resident was sent to the hospital.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kadima Rehabilitation & Nursing At Washington from 2026-05-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 15, 2026 · Our methodology
KADIMA REHABILITATION & NURSING AT WASHINGTON in WASHINGTON, PA was cited for violations during a health inspection on May 25, 2026.
A physician had ordered the medication in July 2025.
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.