Kadima Rehabilitation Greenville: Order Failures - PA
Federal inspectors documented both failures during a November 2025 complaint inspection, citing the facility for failing to follow and clarify physician orders for two of the 13 residents whose records were reviewed.
The first resident, identified in inspection records only as Resident R1, was admitted to the facility on September 7, 2025, following a fracture. The transfer paperwork from the sending hospital included a physician's order for wound care: an Aquacel dressing on the left side was to be removed on September 4 and the incision left open to air after that.
The order was already three days old when the resident walked through the door. The dressing was still on.
Aquacel is a sterile, highly absorbent dressing designed to conform to a wound. Whether it should have stayed in place longer, or whether the original removal date still applied, was a question that required a phone call to the physician. That call was never made. Progress notes confirmed the dressing remained intact on the resident's left side at admission. No one documented reaching out to clarify what should happen next.
The Director of Nursing, interviewed by inspectors on October 9, confirmed the conflicting orders should have been caught. The conflicting orders "should have been clarified with the physician," she said.
The second case involved a resident, Resident R2, admitted in March 2025 with pneumonia, a history of falling, and chronic obstructive pulmonary disease that had acutely worsened. On September 4, a physician ordered a urinalysis with culture and sensitivity, a standard test used to detect a urinary tract infection and identify which antibiotics will work against it. The order was written because the resident was experiencing dysuria, the clinical term for painful urination, and increased frequency. The order specified the test was to be collected one time only, within five days.
The urine was not collected until September 12. That is eight days after the physician ordered it, and three days past the outer limit the order specified.
A urinalysis with culture and sensitivity typically takes additional days to process after the sample is collected. Every day of delay on the front end is another day a resident in pain waits to find out whether an infection is present and, if so, what will treat it. Inspectors noted the clinical record contained no evidence the sample was collected within the required window.
The Director of Nursing confirmed that finding as well. The record, she said, "lacked evidence that the UA C&S was collected timely after receiving the physician's order."
The facility's own policy on transcribing physician orders, dated June 2, 2025, states that orders will be transcribed when received and that questionable treatment orders will be called to the physician for clarification. The Aquacel dressing order was exactly the kind of order that policy was written for. A resident arriving with a dressing that should have been removed before admission, and an order directing that it come off and the wound be left open to air, is a direct conflict that demands a clarifying call. No such call was documented.
Inspectors classified the violations under a tag requiring that residents receive appropriate treatment and care according to physician orders and resident goals. The level of harm was assessed as minimal harm or potential for actual harm, and the findings affected few residents.
That classification reflects regulatory language more than it resolves what the residents experienced. Resident R2 reported painful urination. A physician responded the same day with a specific, time-limited order. Eight days passed before anyone collected the sample.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kadima Rehabilitation & Nursing At Greenville from 2025-11-21 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 20, 2026 · Our methodology
KADIMA REHABILITATION & NURSING AT GREENVILLE in GREENVILLE, PA was cited for violations during a health inspection on November 21, 2025.
The first resident, identified in inspection records only as Resident R1, was admitted to the facility on September 7, 2025, following a fracture.
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.