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Health Inspection

Kadima Rehabilitation & Nursing At Luzerne

January 16, 2025 · Drums, PA · 463 North Hunter Hwy
Citations 2
CMS Rating 1/5
Beds 37
Provider ID 395484
Healthcare Facility
Kadima Rehabilitation & Nursing At Luzerne
Drums, PA  ·  View full profile →
Inspection Summary

KADIMA REHABILITATION & NURSING AT LUZERNE in DRUMS, PA — inspection on January 16, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF801
TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48277 Few failed to offer and/or provide the pneumococcal immunization, unless the immunization was medically affected

Review of Resident 29's Informed Consent for Pneumococcal Vaccine signed by Resident 29's resident representative on July 18, 2024, indicated permission for the facility to administer the pneumococcal vaccine.

Further review of the clinical record revealed no documented evidence the facility administered the pneumococcal vaccine as requested per the signed consent.

Interview with the Director of Nursing on January 16, 2025, at 12:08 PM confirmed the facility failed to provide pneumococcal immunizations to Residents 29.

28 Pa.

Code 201.14(a) Responsibility of licensee.

28 Pa.

Code 201.18(b)(1) Management.

28 Pa Code 211.5 (f)(i) Medical records

28 Pa.

Code 211.10(a)(d) Resident care policies

28 Pa code 211.12 (c)(d)(1)(5) Nursing Services

395484

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 395484 B.

Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222

Review of the Facility Assessment, last reviewed by the facility on November 29, 2024, indicated the number of resident beds in the facility is 37 and the average daily census of the facility is 36 residents.

There was no further information specific to the facility, the facility's population, and facility resources necessary to care for its residents competently during both day-to-day operations and emergencies.

The Facility Assessment failed to accurately reflect the current staff employed in the facility to ensure a sufficient and competent number of qualified staff are available to meet each resident's needs.

Review of the facility's Resident Matrix (list of all residents in the facility), dated January 14, 2025, revealed a total census of 35 residents. Of the 35 residents, the Matrix identified one resident (Resident 18) receiving enteral feeding (method of feeding that delivers food and fluid via a tube inserted into the stomach or small intestine) who would require services of a qualified dietitian.

During an interview on January 14, 2025, at approximately 9:30 AM the full-time foodservice director (FSD) confirmed she was a Certified Dietary Manager but does not meet the minimum qualifications to be the qualified dietitian or clinically qualified nutrition professional.

The FSD stated that the facility does employ a part-time registered dietitian who works remotely.

The FSD stated that she interacts with the registered dietitian via e-mail and telephone to provide/receive updates on residents.

The FSD stated that she does visit residents to obtain food preferences which are added to each resident's meal ticket and documented in the clinical record.

The FSD also noted that she attends plan of care meetings for residents.

395484

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 395484 B.

Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DRUMS, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from KADIMA REHABILITATION & NURSING AT LUZERNE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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