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Health Inspection Summary
Kadima Rehabilitation & Nursing at Lititz
125 South Broad Street
Lititz, PA 17543
(717) 626-0211
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Deficiency Category
Inspection Date:
6/7/24
Complaint Reporting Period:
4/1/24 - 3/31/25
Inspection Date:
8/31/23
Complaint Reporting Period:
4/1/23 - 3/31/24
Inspection Date:
9/30/22
Complaint Reporting Period:
4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies002
Quality of Life and Care Deficiencies204
Infection Control Deficiencies102
Resident Assessment and Care Planning Deficiencies024
Nursing and Physician Services Deficiencies001
Resident Rights Deficiencies013
Nutrition and Dietary Deficiencies101
Pharmacy Service Deficiencies010
Environmental Deficiencies000
Administration Deficiencies002

Detailed result for inspection on 6/7/24
Date of last standard health inspection:6/7/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25
No complaint inspections
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25
No infection control inspections
Total number of Health Deficiencies for this nursing home:4
Average number of Health Deficiencies in Pennsylvania:10.3
Average number of Health Deficiencies in the United States:9.6
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

6/7/248/6/24
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

6/7/248/6/24
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

6/7/248/6/24
2 - Minimal harm or potential for actual harm
Few
Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

6/7/248/6/24
2 - Minimal harm or potential for actual harm
Many
Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 8/31/23
Date of last standard health inspection:8/31/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24
No complaint inspections
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24
No infection control inspections
Total number of Health Deficiencies for this nursing home:4
Average number of Health Deficiencies in Pennsylvania:10.3
Average number of Health Deficiencies in the United States:9.4
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
No Quality of Life and Care Deficiencies were found during this inspection period.
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure each resident receives an accurate assessment.

8/31/2310/30/23
1 - Potential for minimal harm
Some

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

8/31/2310/30/23
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

8/31/2310/30/23
1 - Potential for minimal harm
Many
Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

8/31/2310/30/23
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 9/30/22
Date of last standard health inspection:9/30/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23
Total number of Health Deficiencies for this nursing home:19
Average number of Health Deficiencies in Pennsylvania:9.6
Average number of Health Deficiencies in the United States:8.7
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

9/30/2211/28/22
2 - Minimal harm or potential for actual harm
Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

9/30/2211/28/22
4 - Immediate jeopardy to resident health or safety
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

9/30/2211/28/22
3 - Actual harm
Few

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

9/30/2211/28/22
4 - Immediate jeopardy to resident health or safety
Few

Provide enough food/fluids to maintain a resident's health.

9/30/2211/28/22
2 - Minimal harm or potential for actual harm
Few

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

9/30/2211/28/22
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

9/30/2211/28/22
2 - Minimal harm or potential for actual harm
Few

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

9/30/2211/28/22
2 - Minimal harm or potential for actual harm
Few
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

11/21/2212/22/22
2 - Minimal harm or potential for actual harm
Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

9/30/2211/28/22
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

9/30/2211/28/22
2 - Minimal harm or potential for actual harm
Few

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

9/30/2211/28/22
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Observe each nurse aide's job performance and give regular training.

9/30/2211/28/22
2 - Minimal harm or potential for actual harm
Few
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

9/30/2211/28/22
2 - Minimal harm or potential for actual harm
Few

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

9/30/2211/28/22
2 - Minimal harm or potential for actual harm
Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

9/30/2211/28/22
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

2/17/233/20/23
2 - Minimal harm or potential for actual harm
Few
Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

9/30/2211/28/22
2 - Minimal harm or potential for actual harm
Few

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

9/30/2211/28/22
2 - Minimal harm or potential for actual harm
Few
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

11/21/2212/22/22
2 - Minimal harm or potential for actual harm
Few

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

2/17/233/20/23
2 - Minimal harm or potential for actual harm
Few
Infection control inspection deficiencies in the past 3 years
This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years.
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