Skip to main content
Complaint Investigation

Kadima Rehabilitation & Nursing At Greenville

November 21, 2025 · Greenville, PA · 110 Fredonia Road
Citations 2
CMS Rating 2/5
Beds 154
Provider ID 395158
Healthcare Facility
Kadima Rehabilitation & Nursing At Greenville
Greenville, PA  ·  View full profile →
Inspection Summary

KADIMA REHABILITATION & NURSING AT GREENVILLE in GREENVILLE, PA — inspection on November 21, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Advertisement

Inspection Findings

FF0576
Resident Rights Deficiencies
Potential for More Than Minimal Harm

Based on review of facility policies, resident and staff interviews, it was determined that the facility failed to ensure that mail was delivered unopened to one of nine residents interviewed (Resident R3).Findings include: Review of facility policy entitled, Mail dated 6/2/25, revealed, The resident has the right to privacy in written communications, including the right to send and promptly receive mail that is unopened.

Review of a facility policy entitled, Resident Rights dated 6/2/25, revealed, This facility will promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, will be able to assert these rights based on his or her degree of capability.

This facility will protect and promote the rights of each resident, including each of the following rights: Exercise his or her rights as a citizen.Privacy and confidentiality.Privacy in sending and receiving mail.

During an interview with Resident R3 on 9/30/25, at approximately 1:15 p.m.

Resident R3 reported, The facility is opening his/her mail prior to delivery, and he/she feels this is an invasion of his/her privacy.

Resident R3's Brief Interview for Mental Status (BIMs-15-point cognitive screening measure that evaluates memory and orientation and includes free and cued recall items) was 13 (cognitively intact).

During an interview on 9/30/25, at approximately 1:30 p.m. the Nursing Home Administrator indicated he/she opens some of Resident R3's mail prior to delivering it to Resident R3. 28 Pa.

Code 201.14(a) Responsibility of licensee 28 Pa.

Code 201.29(j) Resident rights

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Kadima Rehabilitation & Nursing at Greenville

110 Fredonia Road Greenville, PA 16125

SUMMARY STATEMENT OF DEFICIENCIES

Based on review of facility policies, clinical records, and staff interview it was determined that the facility failed to clarify physician's orders related to a surgical dressing for one of 13 residents reviewed (Resident R1) and failed to follow physician's orders related to obtaining a Urinalysis and Culture & Sensitivity (UA C&S- a test used to indicate whether or not there is an infection in the urine and what treatment the infection is sensitive to) timely for one of 13 residents reviewed (Resident R2).Findings include: Facility policy entitled Transcribing Physician Orders dated 6/2/25 states, Physician orders will be transcribed when they are received.Questionable treatment orders will be called to the physician for clarification.

Resident R1's clinical record revealed an initial admission date of 9/7/25, with diagnoses that included subsequent encounter for fracture with routine healing, encounter for other orthopedic aftercare, and history of falling.

Review of Resident R1's clinical record revealed a transfer/admission physician's order regarding the surgical dressing wound/incision care and dressing change instructions that the Aquacel dressing (a sterile dressing that is highly absorbent and conforms to the wound) was to be removed on 9/4/25, then leave the incision open to air.

Resident R1's progress notes indicated he/she arrived to the facility on 9/7/25, and the Aquacel dressing was intact on his/her left side.

Resident R2's clinical record revealed an admission date of 3/10/25, with diagnoses that included pneumonia, history of falling, and chronic obstructive pulmonary disease with acute exacerbation (progressive lung disease with a sudden worsening of symptoms).

Review of Resident R2's clinical record revealed a physician's order dated 9/4/25, for a UA C&S for dysuria (painful urination)/frequency one time only for five days.

Resident R2's progress notes revealed the urine was not collected until 9/12/25.

During an interview on 10/9/25, at 12:25 p.m., the Director of Nursing confirmed that the conflicting orders for Resident R1's Aquacel dressing should have been clarified with the physician and that Resident R2's clinical record lacked evidence that the UA C&S was collected timely after receiving the physician's order. 28 Pa.

Code 201.18(b)(1) Management 28 Pa.

Code 211.12(d)(1)(5) Nursing services 28 Pa.

Code 201.14(a) Responsibility of licensee 28 Pa.

Code 211.5(f) Clinical records

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GREENVILLE, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from KADIMA REHABILITATION & NURSING AT GREENVILLE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

Advertisement