Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Wilmington during CMS and state inspections, most recent first.
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Outdated and undated meds were found on multiple med carts, including a Serevent Diskus without an open date, three Trelegy Ellipta Diskus without open dates, and additional Trelegy, Fluticasone Propionate/Furoate Diskus, and a Humalog insulin pen that were beyond use or lacked required dating. An LPN confirmed staff could not determine discard dates for several items and acknowledged the meds should have been discarded.
The facility lacked evidence that non-pharmacological interventions were attempted before giving PRN psychotropic meds to two residents. One resident with anxiety, COPD, and diabetes received repeated PRN Ativan doses, and another resident with anxiety, dysphagia, and HTN received repeated PRN Vistaril doses. The DON confirmed the records did not show non-pharmacological interventions before these administrations.
Failure to Communicate Clinical Information During Hospital Transfers: The facility did not ensure that required clinical information was sent with two residents when they were transferred to the hospital. One resident had HF, anxiety disorder, and hyperlipidemia, and the other had COPD, MS, and GERD. The DON confirmed the records lacked evidence that the receiving provider was given the necessary clinical information at the time of transfer.
A resident with a g-tube, anorexia, an eating disorder, and anxiety had tube feeding and tubing hanging without dates showing when they were started. A piston syringe used for water flushes was also observed with an outdated date, and the DON confirmed the feeding, tubing, and syringe were not dated or changed per order.
Improper Oxygen Administration and Equipment Care: The facility failed to provide ordered oxygen and maintain respiratory equipment for two residents. One resident with respiratory failure and COPD had oxygen set below the ordered flow rate, an undated nasal cannula, and an empty humidification bottle. Another resident with COPD and respiratory failure had an oxygen concentrator filter covered with a large amount of fluffy white substance. The DON confirmed the equipment issues and that the oxygen flow rate was not in accordance with the physician's order.
An LPN preparing meds touched a pill without sanitizing or washing hands or using gloves, then picked up pills that had fallen on the floor and placed them into a med cup. Separately, a resident receiving nebulizer tx had a mouthpiece lying on the floor next to the bed and lacking a date; the DON confirmed the mouthpiece was on the floor and should have been dated.
Surveyors found that staff failed to consistently document ADL care and ordered turning/repositioning in resident clinical records. One resident with a hip fracture, COPD, and HTN had multiple days with no recorded oral hygiene, personal hygiene, toileting hygiene, or dressing, and no evidence that a physician-ordered every-two-hour turning and repositioning was carried out. Two other residents, one with heart failure and another with anxiety and respiratory failure, also had numerous days without documentation that oral care, personal care, toileting hygiene, and dressing were completed. The NHA and DON confirmed that the records were incomplete and that such care should be documented after it is provided.
The facility did not maintain a fully functional call bell system in one nursing unit, resulting in the lack of visual alerts when residents activated their call bells. Multiple residents reported long wait times for assistance, with some stating that staff were unaware of their calls and that delays had worsened since the original system failed. The temporary system in place did not provide adequate notification to staff, leading to missed calls and prolonged response times.
The facility did not label a multi-dose vial of Aplisol-tuberculin PPD with the date it was opened and the use-by date in the North Two Nurse Station medication room. The manufacturer's instructions require vials in use for more than 30 days to be discarded due to potential potency issues. The Assistant DON confirmed the vial was in use without proper labeling.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Outdated and Undated Medications Found on Multiple Medication Carts
Penalty
Summary
Drugs and biologicals in the facility were not appropriately labeled and stored because outdated or undated medications were found on three of four medication carts reviewed: the North two cart, the South cart, and the [NAME] cart. Facility policy stated that medications and biologicals are to be stored according to manufacturer recommendations and that outdated, contaminated, or deteriorated medications are to be immediately removed from stock and disposed of. Manufacturer guidance reviewed by surveyors stated that an open Humalog insulin pen must be used within 28 days after opening, Trelegy Ellipta must be discarded six weeks after opening the foil tray or when the counter reads 0, Serevent Diskus must be discarded six weeks after opening the foil tray or when the counter reads 0, and Fluticasone Propionate/Furoate Diskus must be discarded six weeks or two months after opening the foil pouch or when the counter reads 0, whichever comes first. On the North two medication cart, surveyors observed a Serevent Diskus out of its foil package without an open date, and an LPN confirmed staff could not determine the discard date and that it should have been discarded. On the South cart, three Trelegy Ellipta Diskus were found out of their foil packages without open dates, and an LPN confirmed staff could not determine the discard dates and that they should have been discarded. On the [NAME] cart, surveyors found two Trelegy Ellipta Diskus in use, one with an open date of 12/1/25 and one without an open date; two Fluticasone Propionate Diskus in use with open dates of 12/12/25; a Fluticasone Furoate Diskus in use without an open date; and an open Humalog insulin pen with an expiration date of 2/26/26. The LPN confirmed one Trelegy was beyond its use-by date, the other lacked an open date, both Fluticasone Propionate Diskus were beyond their use-by dates, the Fluticasone Furoate Diskus lacked an open date, and the Humalog insulin pen should have been discarded.
Lack of documented non-pharmacological interventions before PRN psychotropic use
Penalty
Summary
The facility failed to provide evidence that non-pharmacological interventions were attempted before administering PRN psychotropic medications to two residents. Facility policy titled "Use of Psychotropic Medication" dated 2/24/26 stated that non-pharmacological approaches must be attempted unless clinically contraindicated to minimize the need for psychotropic medications. Review of one resident's record showed diagnoses including anxiety, COPD, and diabetes, with an order for Lorazepam 0.5 ml by mouth every four hours PRN for anxiety. The resident received PRN Ativan multiple times across January, February, and March 2026, and the clinical record lacked evidence that non-pharmacological interventions were attempted before those administrations. Review of a second resident's record showed diagnoses including dysphagia, hypertension, and anxiety, with an order dated 1/22/26 for Vistaril 50 mg by mouth every eight hours PRN for anxiety. The resident received PRN Vistaril multiple times across January, February, and March 2026, and the clinical record also lacked evidence that non-pharmacological interventions were attempted before those administrations. During interview, the DON confirmed that the records lacked evidence of non-pharmacological interventions prior to the PRN psychotropic administrations and stated that such interventions should be attempted and documented in the clinical record.
Failure to Communicate Clinical Information During Hospital Transfers
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. Facility policy titled Transfer Form Instructions stated that when a resident is transferred, a transfer form is to be completed and forwarded with current medical findings, diagnosis, summary of the course of treatment followed, pertinent administrative and social information, and other information as necessary and appropriate. Resident R67, admitted with diagnoses including heart failure, anxiety disorder, and hyperlipidemia, had progress notes showing hospital transfers on 11/18/25 and 12/17/25, but the clinical record lacked evidence that necessary clinical information was communicated to the receiving provider. Resident R71, admitted with diagnoses including COPD, multiple sclerosis, and GERD, had progress notes showing multiple hospital transfers on 1/7/26, 1/11/26, 1/16/26, 1/27/26, 2/2/26, and 2/6/26, and the record also lacked evidence that necessary clinical information was provided to the receiving health care provider. During interview, the DON confirmed that the records lacked evidence of this communication and stated that clinical information should have been provided at the time of transfer.
G-tube Feeding and Syringe Not Dated or Changed per Order
Penalty
Summary
Appropriate treatment was not provided to prevent potential complications related to a gastrostomy tube for one resident. The resident had diagnoses including anorexia, an eating disorder, and anxiety, and had physician orders for Jevity 1.5 at 75 ml per hour and for the piston syringe used for tube feed water flushes to be changed every day on the midnight shift. Facility policy stated that enteral feeding tubing must be changed every 24 hours and that feeding bags must be labeled with the date and time they are hung. During observations, the resident’s feeding was hanging on an IV pole and connected to the g-tube, but the feeding and tubing had no dates showing when they were initiated. A piston syringe was also observed hanging on the IV pole with a date of 2/22/26. The DON confirmed that the feeding and tubing lacked initiation dates and that the piston syringe should have been changed per physician order.
Improper Oxygen Administration and Equipment Care
Penalty
Summary
The facility failed to maintain proper care of respiratory equipment and failed to provide oxygen according to physician's orders for two residents. Resident R18 had diagnoses including respiratory failure, COPD, and anxiety, and had physician's orders for supplemental oxygen via nasal cannula at 2 liters/minute every shift. During observations, R18 was lying in bed with oxygen in place, but the oxygen concentrator was set at 1.5 liters/minute instead of the ordered rate, the nasal cannula lacked a date, and the humidification water bottle was empty. The DON confirmed that the humidification bottle was empty, the cannula lacked a date, and the oxygen flow rate was not in accordance with the physician's orders. Resident R23 had diagnoses including COPD, respiratory failure, and diabetes, and had an order for oxygen to keep SpO2 at or above 90 percent. Observations showed an oxygen concentrator next to the resident's bed with a filter on the back covered by a large amount of fluffy white substance. The resident's care plan included ensuring oxygen equipment care and tubing were changed per physician's orders. The DON confirmed that the oxygen concentrator filter was covered with a large amount of fluffy white substance and should be clean.
Cross-Contamination During Medication Administration and Nebulizer Equipment Handling
Penalty
Summary
The facility failed to prevent potential cross-contamination during medication administration on the West Wing medication cart. During observation, an LPN preparing medications touched a pill from a bottle without sanitizing or washing hands and without applying gloves, then placed the pill into a medication cup with other pills. The LPN also dropped pills onto the floor and picked them up from the floor before placing them into the medication cup. During interview, the LPN confirmed not sanitizing or washing hands or applying gloves before touching the pill and confirmed picking pills up off the floor and placing them into the medication cup. The facility also failed to prevent cross-contamination for Resident R122 during nebulizer treatment equipment management. Resident R122 was admitted with diagnoses including coronary artery bypass graft, diabetes, and hypertension, and had an order for Ipratropium Albuterol solution every four hours. Observations showed a nebulizer machine sitting on the bedside stand next to the resident's bed with a hand held mouthpiece lying on the floor and lacking a date. The DON confirmed that the mouthpiece was lying on the floor and lacked a date, and stated that it should not have been on the floor and should have had a date indicating when it was placed.
Incomplete Documentation of ADL Care and Turning/Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical documentation for multiple residents regarding personal hygiene, oral care, toileting, dressing, and, for one resident, turning and repositioning. Facility policy titled "Flow of Care" dated 3/27/25 requires that targeted care needs be documented on Care Tracker/Point of Care/ADL flow records. For one resident admitted on 12/12/25 with diagnoses including a left femur neck fracture, COPD, and hypertension, review of the tasks section for December 2025 showed missing documentation on multiple dates for oral hygiene, personal hygiene, toileting hygiene, and upper and lower body dressing. The same resident had a physician’s order dated 12/14/25 for turning and repositioning every two hours, but the clinical record lacked evidence that this turning and repositioning was completed as ordered. Two additional residents also had incomplete documentation of ADL care. One resident admitted on 11/15/25 with heart failure, hypertension, and a need for assistance with personal care had numerous days in December 2025 with no documented evidence that oral hygiene, personal hygiene, toileting hygiene, and upper and lower body dressing were completed. Another resident admitted on 11/26/25 with anxiety, respiratory failure, and hypertension similarly had multiple dates in December 2025 without documentation of these same ADL tasks. In an interview on 1/23/26 at 10:15 a.m., the Nursing Home Administrator and the Director of Nursing confirmed that the clinical records for these three residents did not contain complete documentation for turning and repositioning, personal hygiene, oral hygiene, toileting, and dressing, and acknowledged that such care should be documented in the clinical record after completion.
Failure to Maintain Functional Call Bell System in Resident Areas
Penalty
Summary
The facility failed to ensure that the call bell system was adequately working for one of its nursing units, specifically the West Hall Nursing Unit. According to facility policy, a call bell or alternative device should be within reach of each resident in their room, toilet, or bathing area, and staff should be alerted to calls by visual and auditory signals. However, observations revealed that the call bell system in the corridors did not illuminate when resident call bells were activated. Maintenance records confirmed that the original call bell system had not been functioning since 4/22/25, and a temporary system installed on 4/29/25 did not provide a visible overhead light. Instead, calls were only displayed on a central screen, and if multiple calls were made before staff responded, earlier calls would not be visible and could be missed. Interviews with residents indicated consistent and prolonged wait times for assistance after using the call bell system, with reports of waiting from thirty minutes to several hours. Residents expressed concerns that staff were often unaware of their calls, especially since the original system stopped working. Some residents reported that due to long wait times, they would attempt to get up by themselves if they could not wait any longer for help. The Nursing Home Administrator confirmed that the central call bell system was not fully functioning to provide visual communication of which room the call bell activation was coming from.
Failure to Label Multi-Dose Vial of Aplisol
Penalty
Summary
The facility failed to properly label a multi-dose vial of Aplisol-tuberculin purified protein derivative (PPD) injection with the date it was opened and the date it should be used by. This deficiency was identified in one of the three medication storage rooms observed, specifically the North Two Nurse Station medication room. According to the manufacturer's instructions, vials in use for more than 30 days should be discarded due to potential oxidation and degradation affecting potency. The facility's policy on medication storage, reviewed on 3/26/24, mandates that medications be stored safely and securely, with no outdated or deteriorated medications available for use. During an observation on 3/12/25, it was noted that the vial was opened and in use without the required labeling. The Assistant Director of Nursing confirmed the oversight, acknowledging that the vial was in daily use and should have been labeled appropriately.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 472 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near New Wilmington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shenango Presbyterian Seniorcare | 0.3 mi | ★★★★★ | 12 | 0 |
| Jameson Nursing And Rehab Center | 4.6 mi | ★★★★★ | 4 | 0 |
| Edison Manor Nursing & Rehabilitation Center | 7.3 mi | ★★★★★ | 9 | 1 |
| Kadima Rehabilitation & Nursing At New Castle | 7.6 mi | ★★★★★ | 19 | 0 |
| Haven Convalescent Home, Inc | 8.5 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Kadima Rehabilitation & Nursing At New Wilmington.
100% money-back within 48 hours.
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.