Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

KADIMA REHABILITATION & NURSING AT LAKESIDE

DALLAS, PA · 31 certified beds · Last Life Safety survey September 4, 2025

CMS Certification Number 395730 · first certified June 1987

Ownership

Operated by KADIMA HEALTHCARE GROUP · For profit - Partnership

  • Ownership changed August 29, 2018 (change of ownership)from MAYBROOK P LAKESIDE OPCO LLC
18
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
5
Tags cited more than once
Across separate surveys
16
Inspection & testing records
Of the citations on file

Position within PA

18 citations — more than 78% of the 656 certified nursing homes in PA. Compared within PA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 4 citations; the earlier surveys in the window averaged 7. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Past the typical window (July 2026 to September 2026). Most PA facilities have been surveyed by October 2026. This facility’s last Life Safety survey was September 2025. Facilities in PA are typically surveyed 10–12 months after the last one (median 11), measured over 1,113 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

1 of the 18 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 18 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in PA, and nationally. Surveyors differ markedly between states, so the PA figure is the meaningful one.

This facility18PA median10National median11
Citations on file over three years, compared
MeasureCitations
This facility18
Median facility in PA10
Median facility nationally11

Survey history

Citations at each Life Safety survey
82023-1262024-1142025-09
Citations at each Life Safety survey
Survey dateCitations
December 7, 20238
November 21, 20246
September 4, 20254

Most-cited tags

Most-cited tags at this facility
K-03533K-03453K-07122K-03632K-09182K-02911K-03551K-07611
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0353Inspect, test, and maintain automatic sprinkler systems.32025-09-04
K-0345Have approved installation, maintenance and testing program for fire alarm systems.32025-09-04
K-0712Have simulated fire drills held at unexpected times.22024-11-21
K-0363Install corridor and hallway doors that block smoke.22024-11-21
K-0918Have generator or other power source capable of supplying service within 10 seconds.22025-09-04
K-0291Install emergency lighting that can last at least 1 1/2 hours.12023-12-07
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.12024-11-21
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.12025-09-04

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 10
  • Miscellaneous Deficiencies 3
  • Gas, Vacuum, and Electrical Systems Deficiencies 2
  • Construction Deficiencies 1
  • Other 2
Citations by CMS category
CategoryCitations
Smoke Deficiencies10
Miscellaneous Deficiencies3
Gas, Vacuum, and Electrical Systems Deficiencies2
Construction Deficiencies1
Emergency Preparedness Deficiencies1
Egress Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

September 4, 2025 — 4 citations

Citations issued on September 4, 2025
TagWhat the surveyor checksStatus
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (October 1, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (October 1, 2025)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (October 1, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (October 1, 2025)

November 21, 2024 — 6 citations

Citations issued on November 21, 2024
TagWhat the surveyor checksStatus
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (December 26, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (December 26, 2024)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (December 26, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (December 26, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (December 26, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (December 26, 2024)

December 7, 2023 — 8 citations

Citations issued on December 7, 2023
TagWhat the surveyor checksStatus
E-0001Establish an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (January 26, 2024)
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (January 26, 2024)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (January 26, 2024)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (January 26, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (January 26, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (January 26, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (January 26, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (January 26, 2024)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.