Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kadima Rehabilitation & Nursing At New Castle during CMS and state inspections, most recent first.
Physician orders were not consistently signed and dated during required visits for six residents. Records for residents with conditions including COPD, dementia, diabetes, epilepsy, bipolar disorder, cerebral palsy, GERD, schizoaffective disorder, colon cancer, paraplegia, and high blood pressure showed missing or outdated physician review documentation, and the DON acknowledged the records lacked evidence that all orders were signed and dated as required.
The facility failed to send necessary clinical information with two residents when they were transferred to the hospital, including residents with neuropathy, weakness, COPD, schizoaffective disorder, and colon cancer. The facility also failed to give a resident and/or representative a written bed-hold policy at transfer, including how long the bed could be held and the daily cost; the DON and Admissions/Social Services Coordinator confirmed the missing documentation.
An LPN was observed in the West wing med room with an open vial of Tubersol that had no open date marked. Facility policy required multi-dose vials to be dated when opened, and the LPN confirmed the vial was opened and not dated, so staff could not determine whether it had been in use for 30 days.
The facility failed to notify the Office of the State LTC Ombudsman when a resident with Type 2 DM with a foot ulcer, HIV, a history of self-harm, and PTSD was transferred to a hospital and later issued an eviction letter. Review of the record showed no documentation that the Ombudsman was informed of the transfer and discharge, and the NHA confirmed that the required notification was not made.
The facility did not consistently monitor or record refrigerator and freezer temperatures as required by policy, with numerous missed entries in both the main kitchen and basement logs. The Dietary Manager confirmed that daily temperature checks were not being completed as expected.
Multiple residents reported excessive delays in call bell response times, often waiting 30 minutes or more for assistance, due to staff being observed on personal cell phones or engaged in personal conversations during shifts. Resident council minutes and direct interviews confirmed that staff cell phone use was a persistent issue, leading to unmet care needs and resident frustration, despite facility policy prohibiting such behavior.
The facility did not post daily menus, failed to notify residents of menu changes or substitutions, and did not provide a nutritionally adequate menu for a resident with a gluten free allergy. Staff confirmed that residents were not informed when their chosen meals were unavailable, and a resident with dietary restrictions had limited food options due to insufficient gluten free items.
The facility did not meet the required minimum NA staffing ratios on the overnight shift for four specific dates. With a census of 58 to 59 residents, the facility required approximately 3.87 to 3.93 NAs but only had 3.00 to 3.63 NAs present. This deficiency was confirmed by the Assistant Director of Nursing.
The facility did not meet the required LPN staffing ratio on an overnight shift, with only 1.32 LPNs available for 58 residents, falling short of the 1.45 LPNs required. This deficiency was confirmed by the Assistant DON.
A resident with multiple health conditions, requiring assistance with bathing, was left unattended in a shower room by a PTA, resulting in a fall and a right shoulder fracture. Despite the care plan indicating the need for assistance, the resident was allowed to bathe unsupervised, leading to the incident. Staff interviews confirmed that leaving residents unattended in the shower is against facility practice.
A resident with complex medical conditions, including schizophrenia and diabetes, required assistance with bathing. The facility failed to implement the care plan, leaving the resident unattended in the shower, resulting in a fall and injury. Staff interviews confirmed the care plan was not followed, highlighting inconsistencies in care delivery.
Physician Orders Not Signed and Dated During Required Visits
Penalty
Summary
The facility failed to ensure that the physician signed and dated all orders during required visits for six of 20 residents reviewed. Clinical record review showed that Resident R7, who had COPD, dementia, and diabetes, had the last documented physician review, signature, and date on the orders on 10/21/24. Resident R11, with diabetes, epilepsy, and bipolar disorder, had the last documented physician review, signature, and date on the orders on 11/20/24. Resident R23, with cerebral palsy, GERD, and COPD, had the last documented physician review, signature, and date on the orders on 1/7/25. Resident R59, who had COPD, schizoaffective disorder, and colon cancer, had the last documented physician review, signature, and date on the orders on 1/23/24. Resident R60, with paraplegia, COPD, and GERD, lacked evidence of the last time the physician reviewed, signed, and dated the orders. Resident R61, with COPD, high blood pressure, and GERD, also lacked evidence of the last time the physician reviewed, signed, and dated the orders. During an interview on 5/7/2026, the DON reviewed the information and acknowledged that the physician is required to sign and date all orders during visits and that these six residents' records lacked evidence that this was completed as required.
Failure to Send Transfer Information and Provide Bed-Hold Notice
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider when two residents were transferred to the hospital. Resident R4 had diagnoses including idiopathic peripheral autonomic neuropathy, generalized muscle weakness, abnormalities of gait, immobility, and need for assistance with personal care, and progress notes documented transfers to the hospital on 1/23/26 and 2/8/26. Resident R59 had diagnoses including COPD, schizoaffective disorder, and colon cancer, and a progress note documented a hospital transfer on 1/9/26. In both records, there was no evidence that the residents’ necessary clinical information was sent to the receiving provider, and the DON confirmed this during interview. The facility also failed to provide a written copy of its bed-hold policy to a resident and/or the resident representative upon transfer to the hospital. Resident CR64 had diagnoses including pneumonia, muscle weakness, abnormalities of gait and mobility, and need for assistance with personal care, and was transferred to the hospital on 4/14/26. The record lacked documentation that CR64 and/or the representative received the bed-hold policy explaining how long the bed could be held during a leave of absence and the cost per day. The Admissions and Social Services Coordinator confirmed that the policy was not provided and stated it should have been given at the time of transfer.
Undated Tubersol Vial in Medication Room
Penalty
Summary
The facility failed to appropriately date and store medications in one of two nursing medication rooms, specifically the West wing medication room. Facility policy required multi-dose vial medications to be dated when opened so the discard date could be determined based on manufacturer instructions, and manufacturer guidance for Tubersol stated that a vial entered and in use for 30 days should be discarded. During observation of the West Wing medication room, an open vial of Tubersol was found without an open date marked on the vial. At the time of the observation, an LPN confirmed that the vial had been opened and was not dated, and therefore staff were unable to determine whether it had been in use for 30 days. The LPN also confirmed that the Tubersol vial should have been dated when opened.
Failure to Notify State LTC Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to send a copy of a discharge notice to the Office of the State LTC Ombudsman for one resident. The resident was admitted on 6/22/24 with diagnoses including Type 2 diabetes with a foot ulcer, HIV, a history of self-harm, and PTSD. Departmental notes showed that the resident was transferred to the hospital on an unspecified date and was given a letter of eviction on 10/22/25. Review of the clinical record revealed no evidence that the Office of the State LTC Ombudsman was notified of the resident’s transfer and discharge. In an interview on 1/8/25, the Nursing Home Administrator confirmed that the facility did not notify the Office of the State LTC Ombudsman of this resident’s transfer and discharge. This deficiency was cited under 28 Pa. Code 201.14(a) Responsibility of licensee and 28 Pa. Code 201.29(a) Resident rights.
Failure to Monitor and Record Food Storage Temperatures
Penalty
Summary
The facility failed to ensure that food was stored in accordance with food safety standards, as required by its own policy and professional guidelines. Review of the kitchen's refrigeration and freezer temperature logs revealed significant gaps in monitoring, with only 104 out of 216 required temperature recordings documented for the main kitchen's refrigerators and freezers over a specified period, leaving 112 instances unrecorded. Additionally, the basement refrigeration log showed no recorded temperatures for two freezers and one refrigerator over a nearly three-week period. During an interview, the Dietary Manager confirmed that the required daily monitoring of morning and evening temperatures was not being performed as outlined in facility policy.
Failure to Provide Sufficient Nursing Staff and Timely Care Due to Staff Cell Phone Use
Penalty
Summary
The facility failed to provide sufficient nursing staff and services to meet the needs of residents, as evidenced by multiple complaints and observations. Resident council minutes over a three-month period documented repeated concerns about staff being on their personal cell phones during work hours, particularly on day and afternoon shifts. Residents reported excessive call bell wait times, often 30 minutes or longer, with some residents waiting up to 60 minutes for assistance with activities of daily living such as toileting. These delays were attributed to staff being observed using their phones or engaging in personal conversations rather than attending to resident needs. Interviews with alert and oriented residents confirmed that staff cell phone use was a persistent issue, leading to delayed responses to call bells and causing resident frustration. Observations during the survey period corroborated these reports, with staff seen sitting at nurses' stations and in hallways on their personal phones. Facility policy prohibits personal cell phone use during work time, and grievances had previously been filed regarding this issue, with education provided by the DON. Despite these measures, the problem persisted, and administration acknowledged ongoing resident complaints about staff cell phone use.
Failure to Provide Posted Menus, Notify Residents of Substitutions, and Meet Special Dietary Needs
Penalty
Summary
The facility failed to provide daily menus, update menu changes, and notify residents of changes to the menu, as well as failed to provide a nutritionally adequate menu for a resident with a gluten free allergy. Facility policies required that menus be posted in all dining rooms and resident units, that menus be followed, and that substitutions be of equal nutritive value and approved by the dietitian. However, observations and interviews revealed that menus were not posted, and residents were not informed of substitutions or menu changes. Residents reported that alternatives were not always available, and that they were not notified when their chosen food items were unavailable, only learning of substitutions when meals were delivered. One resident with a gluten free allergy was found to have limited food choices due to insufficient gluten free food items available at the facility. The dietary manager confirmed that only gluten free pasta and hamburger buns were purchased, with no bread, cereal, crackers, or other gluten free items available. This resulted in the resident not receiving a nutritionally adequate menu during their stay, as the menu could not be followed in its entirety for this resident. Staff interviews confirmed that the daily menu and alternate menu were not posted for residents and family members to view, and that residents were not notified in a timely manner of food substitutions. The activity assistant collected residents' meal choices each morning but did not inform residents if their choices were unavailable, leading to residents receiving unexpected substitutions at mealtimes. The nursing home administrator acknowledged that menus should be posted and followed, and that residents should be notified of substitutions, confirming the deficiencies identified.
Overnight Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing ratios on the overnight shift for four specific dates. The regulation mandates a minimum of one NA per 15 residents overnight, but the facility did not comply on 10/21/24, 10/25/24, 11/18/24, and 11/19/24. On these dates, the facility had a census of 58 to 59 residents, requiring approximately 3.87 to 3.93 NAs, but only 3.00 to 3.63 NAs were present. This deficiency was confirmed during an interview with the Assistant Director of Nursing, who acknowledged the shortfall in staffing on the specified dates.
Plan Of Correction
1. The facility is unable to correct the nurse aide staffing ratios that were not met during the overnight shifts on 10/21/24, 10/25/24, 11/18/24 and 11/19/24 due to unplanned absences. However, we will educate all nurse aides on the importance of staffing levels and their responsibilities to prevent absences. 2. The facility will work to ensure that nurse aide ratios are met every shift. 3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing and HR Director/Scheduler on regulation P5520 to ensure nurse aide ratios are met every shift. Daily shift staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible for calling off duty personnel or for calling extra support staff to assist. 4. The Nursing Home Administrator will audit staffing daily for four weeks and then monthly for two months to ensure nurse aide ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations and frequency of audits. 5. The facility will conduct an Employee Retention survey from 12/27/2024 through 1/6/2025 to evaluate staffing concerns and reasons for call-offs. This will be done to prevent further call-off concerns meeting daily staffing ratios. 6. A DON/designee will ensure staffing levels meet direct care requirements and report to DON or Nursing Home Administrator every day with needs or call-offs.
LPN Staffing Deficiency on Overnight Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of having a minimum of one Licensed Practical Nurse (LPN) per 40 residents on the overnight shift. This deficiency was identified during a review of nursing staffing documents and confirmed through staff interviews. Specifically, on the night of October 25, 2024, the facility had a census of 58 residents but only 1.32 LPNs were on duty, whereas 1.45 LPNs were required to meet the minimum staffing ratio. The Assistant Director of Nursing confirmed the shortfall in staffing during an interview conducted on December 2, 2024.
Plan Of Correction
Plan of Correction: 1. The facility cannot correct that LPN staffing ratios that were not met during the overnight shift on one of 21 days (10/25/24). However, we will educate staff on the importance of staffing levels and their responsibilities to prevent absences. 2. The facility will ensure that LPN staffing ratios are met every shift. 3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at the daily staffing meeting. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for two months to ensure LPN staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Employee Retention survey will be taken from 12/27/24 through 01/06/2025 to evaluate staffing concerns and reasons for call-offs. To prevent further call off concerns in order to achieve needed staff ratios daily. 6. ADON and DON will ensure staffing levels meet direct care requirements and report to Director every day with needs or call-offs.
Resident Left Unattended in Shower Room Resulting in Fall and Injury
Penalty
Summary
The facility failed to provide proper assistance during bathing, resulting in a fall and a fracture for a resident. The resident, who had multiple diagnoses including schizophrenia, major depressive disorder, and vascular dementia, required partial/moderate assistance with bathing and transfers according to their care plan. Despite this, the resident was left unattended in the tub room by a Physical Therapist Assistant (PTA), leading to a fall and a comminuted fracture of the right shoulder. The incident occurred when the PTA allowed the resident into the shower room unsupervised, believing the resident demonstrated good safety with setup. However, the resident's care plan indicated a need for assistance during bathing. The resident was later found on the floor by a Nurse Aide, who was unaware that the resident had been left unattended in the tub room. The resident was assisted into a chair using a Hoyer lift after the fall. Interviews with various staff members, including Nurse Aides, Registered Nurses, and the Director of Nursing, confirmed that it was not the facility's practice to leave residents unattended in the shower or tub room. Staff were expected to monitor residents closely for safety during bathing. The investigation revealed that the resident's care plan required assistance, and the failure to provide this led to the resident's fall and subsequent injury.
Failure to Implement ADL Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident, identified as Resident R41, who required assistance with activities of daily living (ADL), specifically bathing and showering. The resident's clinical record indicated a need for partial/moderate assistance with self-care tasks, including showering and tub transfers. Despite this, an incident occurred where the resident was left unattended in the tub/shower area, resulting in a fall and injury. This incident was inconsistent with the care plan, which required the assistance of one staff member during bathing/showering. The resident's medical history included schizophrenia, major depressive disorder, a history of seizures, vascular dementia, transient ischemic attacks, cerebral infarction, altered mental status, gait and mobility abnormalities, and type one diabetes mellitus. The inconsistency in the implementation of the care plan was confirmed during an interview with the Director of Nursing and the Nursing Home Administrator. Staff interviews revealed that the care plan for ADLs should be reviewed before showering residents to ensure proper transfer and assistance levels for resident safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New Castle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edison Manor Nursing & Rehabilitation Center | 0.5 mi | ★★★★★ | 9 | 1 |
| Quality Life Services - New Castle | 1.7 mi | ★★★★★ | 2 | 0 |
| Avalon Care Center | 1.9 mi | ★★★★★ | 3 | 0 |
| Haven Convalescent Home, Inc | 2.1 mi | ★★★★★ | 2 | 0 |
| Jameson Nursing And Rehab Center | 3 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.