Kadima Rehabilitation & Nursing At Luzerne
KADIMA REHABILITATION & NURSING AT LUZERNE in DRUMS, PA — inspection on January 16, 2025.
Found 10 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.
Inspection Findings
During an interview on January 15, 2025, at 12:10 PM the Director of Nursing (DON) confirmed that nursing staff failed to follow acceptable standards of nursing practice during medication administration resulting in multiple medication errors. 28 Pa.
Code 211.9 (a)(1)(d) Pharmacy services 28 Pa.
Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa.
Code 211.10(c) Resident care policies.
395484 01/16/2025
Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222
During an interview on January 16, 2025, at 1:30 PM, the Director of Nursing confirmed that the facility had not implemented interventions to prevent the resident from being provided with or consuming nonprescribed medications.
The Director also confirmed that no education regarding the risks of consuming nonprescribed substances had been provided to Resident #25. 28 Pa.
Code 201.14(a) Responsibility of licensee. 28 Pa.
Code 201.18(e)(1) Management. 28 Pa.
Code 211.12 (d)(5) Nursing services
395484 01/16/2025
Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222
Review of a dietary note dated September 11, 2024, indicated the resident's current weight was 127.4 lbs., -1.8 lbs. x 30 days, -13lbs. /-10.2 lbs. x 180 days.
Height is 63, BMI 21.9 which is below her ideal body weight of 140-169 lbs.
Weight monitoring continued to show ongoing weight loss, but no updated nutritional assessments or individualized interventions were documented between the resident's admission in October 2023 and September 2024 Interview with the Director of Nursing (DON) on January 16, 2025, at approximately 12:15 PM confirmed the facility failed to obtain and record Resident 29's reweights and failed to timely notify the physician and dietician of the residents significant weight loss that occurred on June 8, 2024, to provide the necessary information to accurately assess the resident's nutritional status and needs and evaluate the adequacy of the resident's nutritional intake and plan nutritional support as necessary.
Refer F-F801, F-F838 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services.
395484 01/16/2025
Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222
395484 01/16/2025
Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222
review meal intakes, complete meal rounds, document food intake, participate in care conferences
medically related nutritional therapy or to make recommendations regarding medications or supplementation.
The facility's FSD had limited scope of practice and lacked necessary credentials/qualifications to provide the operational and nutritional oversight of a RD or clinically qualified nutrition professional.
A review of a facility provided job description for the RD indicated that the primary purpose of the job description is to implement, coordinate, and evaluate the medical nutrition therapy for the residents, provide resident, and family education, provide nutritional assessment and consultation to assist planning, organizing, and directing the food and nutritional services of the facility.
Functions of the RD included to perform administrative duties such as completing necessary forms, reports, evaluations, studies, etc., to assure control of the Food Service Department, inspect food storage rooms, utility/janitorial closets, etc., for upkeep and supply control, participate in facility surveys (inspections) made by authorized government agencies, assist in developing methods for determining quality and quantity of food served, and participate in Quality Assurance programs, and any facility committee or program, which seeks to improve the performance or accuracy of resident care.
However, the RD's part time remote status limited her ability to fulfill these responsibilities effectively.
Interview with the nursing home administrator (NHA) on January 16, 2025, at 9:00 AM failed to provide documentation confirming the RD's role included on site consultation or oversight, or that the FSD received frequently scheduled consultations from the RD.
Interview with the part-time RD on January 16, 2025, at 1:30 PM revealed that she works remotely and has worked with the facility on-and-off since December 18, 2020.
The RD confirmed that she completes all job tasks including nutritional assessments remotely with input from the interdisciplinary team including nursing and the FSD.
The RD confirmed that she accesses residents' clinical records remotely.
The RD stated that she does not contact residents on the phone before completing nutritional assessments and had not been in the facility to observe the residents' ability to eat, interview residents and provide nutritional consultation or observe the residents for signs and symptoms of nutritional and hydration inadequacies/deficiencies and provide oversight of the operations of the food and nutritional services department.
Refer F-F692, F-F838 28 Pa Code 201.18(e)(1)(6) Management.
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Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222
required to identify the specific resources necessary to meet the unique needs of its resident
the Facility Assessment did not contain all the required information.
Refer F-F692, F-F801 28 Pa.
Code 201.14(a) Responsibility of licensee 28 Pa.
Code 201.18 (b)(1)(3)(e)(1)(3) Management
395484 01/16/2025
Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222
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
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Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222
single resident rooms.
minimal harm NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and space measurements provided by the facility, it was determined the facility failed to
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
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.