Kadima Rehabilitation & Nursing At Luzerne

F-F801

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18 (b)(1)(3)(e)(1)(3) Management

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 19 395484 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48277 potential for actual harm Based on review of select facility policy and clinical records, and staff interview, it was determined the facility Residents Affected - Few failed to offer and/or provide the pneumococcal immunization, unless the immunization was medically contraindicated or the resident has already been immunized, to one resident out of five residents reviewed (Residents 29).

Findings include:

A review of facility policy titled Influenza and Pneumococcal Pneumonia Vaccination and Immunization Program last reviewed September 16, 2024, revealed that each resident is offered a pneumococcal immunization unless the immunization is medically contraindicated. Nursing staff will provide education information to the resident/authorized representative prior to the administration of each vaccine. Once education has been completed, a signed consent form is to be obtained prior to administration of the vaccine.

A review of the clinical record revealed that Resident 29 was admitted to the facility on [DATE REDACTED], with diagnoses to include atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and

on the artery walls which causes obstruction of blood flow), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and diabetes (body has trouble controlling blood sugar and using it for energy).

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 19 395484 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21738

Residents Affected - Some Based on observations and space measurements provided by the facility, it was determined the facility failed to provide the regulatory required minimum square footage in nine of 21 resident rooms.

Findings include:

Observations made on Janaury 14, 2025, at 9:30 AM, revealed square footage was not adequate in the following resident rooms:

room [ROOM NUMBER] is a single-bedded resident room, which requires a minimum of 100 square feet.

The square footage of this room measured 85 square feet.

Resident rooms 15, 16, 17, 18, 19, 20, 21, and 23 are two- bedded resident rooms with square footage measurements of only 143 square feet.

These multi-bed rooms failed to provide the minimum square footage requirement of 80 square feet per bed, or a total of 160 square feet in a semi-private room.

CFR 483.90(d)(1)(ii) Bedrooms

28 Pa. Code: 205.20 (d)(f) Resident bedrooms

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 19 395484

F-F838

28 Pa Code 201.18(e)(1)(6) Management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 19 395484 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm 21738

Residents Affected - Many Based on a review of professional literature, the facility's assessment, facility documentation, a review of the medical and nutritional needs of the resident census, and staff interview it was determined the facility failed to conduct and document a facility-wide assessment, using evidence-based methods, which identified and accurately reflected the specific resources necessary and available to care for its specific resident population.

Findings include:

Review of the Centers for Medicare and Medicaid Services Memorandum, Revised Guidance for Long-Term Care Facility Assessment Requirements (QSO-24-13-NH) dated June 18, 2024, revealed the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions), and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. Further review revealed the assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess to deliver the necessary care required by the residents being served.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 19 395484 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 An interview with the NHA on November 20, 2024, at 9:30 AM confirmed the current part-time registered dietitian who also works for sister facilities works remotely and completes nutritional assessments and Level of Harm - Minimal harm or nutritional progress notes offsite, without face-to-face interaction with the residents. potential for actual harm

The facility failed to conduct and document a comprehensive facility-wide assessment, which is required to Residents Affected - Many identify the specific resources necessary to meet the unique needs of its resident population. This deficient practice has the potential to negatively affect the quality of care and quality of life for all residents.

During an interview on January 16, 2025, at 9:00 AM the Nursing Home Administrator confirmed that the Facility Assessment did not contain all the required information.

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