DRUMS, PA - Federal inspectors found significant deficiencies at Kadima Rehabilitation & Nursing at Luzerne during a January 2025 survey, including failure to provide required immunizations to residents and rooms that fell below minimum space requirements.
Immunization Program Failures Put Vulnerable Residents at Risk
The most concerning violation involved the facility's failure to administer a pneumococcal vaccine to a resident despite having written consent from the resident's representative. Resident 29, who was admitted with multiple serious health conditions including atherosclerotic heart disease, dementia, and diabetes, never received the pneumococcal immunization even though their representative had signed consent forms in July 2024.
The facility's own policy, last reviewed in September 2024, clearly states that each resident should be offered pneumococcal immunization unless medically contraindicated. The policy requires nursing staff to provide educational information to residents or their representatives before obtaining signed consent forms prior to vaccine administration.
When investigators reviewed Resident 29's medical records, they found the signed consent form but no documentation that the vaccine was ever administered. The Director of Nursing confirmed during a January 16, 2025 interview that the facility had failed to provide the pneumococcal immunization to Resident 29.
This vaccination failure is particularly concerning given Resident 29's underlying health conditions. Pneumococcal disease poses serious risks to elderly individuals and those with compromised immune systems. The bacteria can cause pneumonia, bloodstream infections, and meningitis - all potentially fatal complications in nursing home residents who already face elevated health risks due to their age and medical conditions.
Medical Significance of Pneumococcal Vaccination
Pneumococcal vaccination represents a critical preventive measure for nursing home residents. The vaccine protects against Streptococcus pneumoniae bacteria, which causes one of the most common and serious types of pneumonia in elderly adults. For residents with existing cardiovascular disease like atherosclerotic heart disease, pneumococcal infections can trigger additional cardiac complications.
Residents with diabetes face particular vulnerability to pneumococcal disease because elevated blood sugar levels can impair immune system function. Those with dementia may be unable to communicate symptoms effectively, potentially delaying treatment if they contract the infection. The combination of these conditions in Resident 29 made timely vaccination especially important for preventing serious illness.
The Centers for Disease Control and Prevention recommends pneumococcal vaccination for all adults aged 65 and older, as well as younger adults with certain chronic conditions including diabetes and heart disease. In nursing home settings, where residents live in close proximity and may have compromised immune systems, vaccination programs become even more crucial for preventing outbreaks.
Inadequate Living Space Compromises Resident Comfort
Inspectors also identified significant problems with room sizes that failed to meet federal space requirements. Nine of the 21 resident rooms examined did not provide adequate square footage for residents' basic needs and comfort.
One single-occupancy room measured only 85 square feet, falling 15 square feet short of the required 100 square feet minimum. Eight semi-private rooms each measured 143 square feet, providing only about 71.5 square feet per resident - well below the required 80 square feet per bed in shared accommodations.
These space deficiencies affect residents' quality of life and ability to maintain personal belongings, receive visitors comfortably, and move safely around their living areas. Adequate room size supports residents' dignity and allows space for necessary medical equipment, mobility aids, and personal furnishings that help create a homelike environment.
The space requirements exist to ensure residents have sufficient room for their beds, personal belongings, and safe movement within their living areas. Inadequate space can increase fall risks, limit privacy, and create challenges for staff providing care. When residents share rooms that are too small, it can lead to conflicts over personal space and difficulty maintaining personal belongings.
Industry Standards and Best Practices
Federal regulations establish minimum space requirements to protect residents' quality of life and ensure facilities can provide appropriate care. The 80 square feet per resident requirement in shared rooms and 100 square feet for private rooms represent basic standards that facilities must meet to maintain their Medicare and Medicaid certification.
For vaccination programs, nursing homes are required to have comprehensive policies that ensure all eligible residents receive recommended immunizations unless medically contraindicated. These programs should include staff education, resident and family education, proper documentation systems, and regular monitoring to ensure compliance.
Effective immunization programs require coordination between nursing staff, physicians, and pharmacy services. Facilities typically maintain vaccination schedules, track which residents have received which vaccines, and ensure proper storage and handling of vaccines to maintain their effectiveness.
Additional Issues Identified
The inspection narrative indicates these violations occurred alongside other deficiencies, though the specific details of additional violations were not included in the provided documentation. The facility received citations under multiple sections of Pennsylvania health codes related to licensee responsibilities, management practices, medical records, resident care policies, and nursing services.
The violations suggest broader systemic issues with the facility's quality assurance programs and compliance monitoring. When facilities fail to follow their own written policies, as occurred with the vaccination program, it raises questions about staff training, supervision, and accountability systems.
Both violations represent areas where the facility's actual practices fell short of established standards and their own written policies. The space deficiencies indicate long-standing infrastructure problems that would require significant investment to correct, while the vaccination failure suggests gaps in clinical care coordination and follow-through.
These findings highlight the importance of regular monitoring and quality improvement efforts in nursing home operations. Facilities must maintain robust systems to ensure they comply with both their own policies and regulatory requirements that protect resident health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kadima Rehabilitation & Nursing At Luzerne from 2025-01-16 including all violations, facility responses, and corrective action plans.
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