Kadima Rehabilitation & Nursing at Luzerne

Inspectors wroteBased on a review of facility policies, observations, and staff and resident interviews, it was determined that the facility failed to provide meals in accordance with resident needs and preferences to ensure adequate nutrition and hydration and failed to consistently provide bedtime snacks as required for 3 of 36 residents. This deficient practice resulted in a lack of nutritionally adequate meals for 36 of 36 residents in the facility, created the potential for nutritional deficiencies, and placed all residents in Immediate Jeopardy to their health and safety.

Inspectors wroteBased on a review of facility policies, manufacturer instructions for use, staff interviews, and observations, it was determined that the facility failed to follow safe and sanitary food handling practices during the washing, sanitizing, and preparation of cooking equipment, dishware, tableware, and utensils in the facility's kitchen. This failure resulted in the improper sanitization of food-contact surfaces, created an increased potential for foodborne illness, and placed 36 out of 36 residents in a condition of Immediate Jeopardy to their health and safety.

Inspectors wroteBased on staff interview and a review of employee credentials, it was determined the facility failed to ensure the registered dietitian (RD) provided the required on-site oversight of the food and nutrition services department.

Inspectors wroteBased on a review of the facility's planned cycle menus, staff interviews, and observations, it was determined the facility failed to ensure meals were prepared and served in accordance with planned menus to meet the nutritional needs and specialized dietary requirements for 14 residents. Specifically, the facility failed to follow planned menus for 4 of 4 residents requiring a pureed diet (Residents 11, 12, 4, and 5), 9 of 9 residents requiring a mechanical ground diet (Residents 13, 14, 15, 16, 17, 18, 19, 20, and 21), and 1 of 1 resident requiring a gluten-free diet (Resident 2).

Inspectors wroteBased on observations, test tray evaluation, review of resident concern forms, and resident and staff interviews, it was determined the facility failed to ensure foods were served at safe and palatable temperatures for residents consuming regular diets identified for 1 test tray and 7 of 7 residents (Residents 1, 3, 6, 7,8, 9, and 10) who voiced concerns related to food temperature, palatability, or meal service timeliness.

Inspectors wroteBased on review of clinical records, written notices of facility-initiated transfers, and staff interviews, it was determined that the facility failed to provide sufficiently detailed written notices of facility-initiated hospital transfers to the resident and the resident's representative for one of five residents sampled (Resident 1), by failing to identify the reason for the move in writing.

Inspectors wroteBased on a review of clinical records and the facility's bed hold policy and staff interview it was determined the facility failed to provide written notice of the specifics of the facility's bed hold policy to the resident, responsible party or legal representative at the time of the transfer, to include the duration and reserve bed payment for one resident out of five sampled (Resident 1).

Inspectors wroteBased on review of clinical records, facility policy provided to residents upon transfer from the facility, and interview with facility staff revealed the facility failed to demonstrate the implementation of specifically delineated procedures for Medicaid payor source bed holds and the provision of notices of the facility's bed hold policy in an understandable language that allow a resident to return to the facility after a transfer to the emergency room for one resident out of five reviewed. (Resident 1).

Inspectors wroteBased on staff interview, a review of personnel files and employee credentials, it was determined the facility failed to provide sufficient staff with the necessary skill set and competencies to ensure appropriate nutritional oversight for residents in the facility and failed to ensure the full-time director of food and nutrition services, who was not a qualified dietitian or other clinically qualified nutrition professional, received frequently scheduled consultations from a qualified dietitian or other clinically qualified nutritional professional.

Inspectors wroteBased 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.

Inspectors wroteBased on review of clinical records, select facility policy, and staff interview it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medication for one of 15 sampled residents. (Resident 29).

Inspectors wrotedetermined the facility failed to assess, evaluate, monitor nutritional parameters, and develop and implement individualized nutritional interventions to maintain nutritional parameters and deter weight loss for three residents (Residents 18, 12, and 29) out of 15 residents sampled.

Inspectors wroteBased on a review of clinical records, resident and staff interview it was determined the facility failed to develop and implement effective safety measures to prevent the ingestion of an illegal substance for one resident out of 15 residents sampled. (Resident 25).

Inspectors wroteBased on review of clinical records, select facility policy, observation, and staff interview, it was determined the facility failed to maintain oxygen equipment in a functional and sanitary manner for two residents out of 15 sampled (Residents 13 and 24).

Inspectors wroteBased on review of select facility policy and clinical records, and staff interview, it was determined the facility 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).

Inspectors wroteBased 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.

Inspectors wroteBased on review of employee personnel files and select facility policy and interviews with facility staff, it was determined the facility failed to demonstrate that licensed nurses possess the necessary competencies and skills to accurately prepare and administer prescribed medications to residents for 1 out of 5 residents reviewed. (Resident A1)

Inspectors wroteBased on observations and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment.

Inspectors wroteBased on observations and resident and staff interviews, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment and ready availability of clean bath linens, to at least three of the five residents sampled (Residents 1, 2, and 22) and on two of the two nursing halls.

Inspectors wroteBased on a review of clinical records and resident and staff interviews, it was determined that the facility failed to develop and implement individualized plans to manage residents' dementia-related behavioral symptoms to promote resident safety and the residents' highest practicable physical and mental well-being for one resident out of five sampled (Resident 26).

Inspectors wroteBased on a review of clinical records and staff and resident interviews, it was determined that the facility failed to provide medically related social services for one resident out of the five sampled (Resident 22).

Inspectors wroteBased on a review of clinical records, select facility policy, and investigation reports, and observation, and staff and resident interviews, it was determined that the facility failed to provide timely and consistent care, according to professional standards of practice, to prevent multiple facility acquired, unstageable pressure sores for one out of the 13 residents sampled (Resident 10).

Inspectors wroteBased on review of clinical records and staff interview it was determined that the facility failed to provide sufficient staff with the necessary skill set and competencies to ensure appropriate nutritional oversight for residents in the facility and nutritional assessment for one (Resident 2) out of 13 residents reviewed.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to properly maintain garbage and refuse containers in garbage storage area in a sanitary manner.

Inspectors wroteBased on observation, review of the facility's infection control tracking logs and policy, and staff interviews it was determined that the facility failed to maintain a comprehensive program to monitor the development and spread of infections within the facility and plan preventative measures accordingly and failed to ensure the consistent implementation of infection control procedures designed to prevent the potential for the spread of infection during the medication administration for two out of two medication carts (North and South).

Inspectors wroteBased on a review of select facility policy and staff interview, it was determined that the facility did not have one or more individuals serving as the Infection Preventionist (IP) responsible for the facility's infection prevention plan.

Inspectors wroteBased on a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to demonstrate that it had ascertained if a resident had an advance directive upon admission and whether the resident would like information to formulate an advance directive for three of 13 sampled residents (Residents 2, 13, and 21).

Inspectors wroteBased on observations, a review of facility policy, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a clean and homelike resident environment on two of two nursing units (North and South nursing units) and failed to ensure comfortable water temperatures including three residents out of the 13 sampled (Residents 13, 21, and 25), and three out of the six residents interviewed during a resident group interview (Residents 5, 23, and 28). Findings Include: An observation of resident room [ROOM NUMBER] on February 27, 2024, at 8:45 AM revealed the white window blinds were bent and missing fins. A dirt buildup was visible on the window sill between the window and the screen. [...]

Inspectors wroteBased on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of three residents out of 13 sampled (Residents 3, 22, and 12).

Inspectors wroteBased on review of select facility policy and controlled drug records and observation and staff interview, it was determined that the facility failed to implement pharmacy procedures to promote accurate administration, and records accounting for controlled drugs for five of eight residents sampled (Resident 13, 7, 24, 19, and 8), and reconciliation of controlled drugs on one of two medication carts (North).

Inspectors wroteBased on a review of the facility's abuse policy, select facility investigation reports, and clinical records, and staff interview, it was determined that the facility failed to ensure one resident out of 13 sampled was free from misappropriation of resident property, medication (Resident 13).

Inspectors wroteBased on a review of clinical records and select facility investigations, and staff interviews, it was determined that the facility failed to timely develop a person-centered care plan to address a resident's high risk for falls and meet the safety needs of one resident out of 13 sampled (Resident 10).

Inspectors wroteBased on clinical record and select facility policy review, and staff interview it was revealed that the facility failed to monitor weight and evaluate nutritional and hydration requirements to ensure acceptable parameters of nutritional status are maintained to the extent possible for one resident out of 13 sampled (Resident 2).

Inspectors wroteBased on review of select facility policy and clinical records, observation and staff interview, it was determined that the facility failed to ensure that medications were labeled according to accepted labeling requirements for one of five residents sampled (Resident 8).

Inspectors wroteBased on a review of clinical records and facility documentation, and an interview with staff, it was determined that the facility failed to provide the required advance notice, through a Notice of Medicare Non-Coverage (CMS 10123-NOMNC), regarding the termination of Medicare services for one of the three residents sampled (Resident 26).

Inspectors wroteBased on a review of clinical records and written transfer notices, and staff interview, it was determined that the facility failed to ensure that a written notice of a facility initiated hospital transfer of the resident was provided to the resident and the resident's representative for one resident out of five residents sampled (Resident 12).

Inspectors wroteBased on observations and space measurements provided by the facility, it was determined that the facility failed to provide the regulatory required minimum square footage in nine of 21 resident rooms.

Inspectors wroteBased on a review of select facility policy and staff interview, it was determined that the facility did not have one or more individuals serving as the Infection Preventionist (IP) responsible for the facility's infection prevention plan.

Inspectors wroteBased on review of grievances lodged with the facility, the schedule of the facility's activities staff and activities programming and interviews with staff, it was determined that the facility failed to provide an ongoing program of activities designed to meet the needs, interests, and preferences of two out of 8 sampled residents (Residents 18 and 21)

Inspectors wroteBased on a review of grievances lodged with the facility and the schedules of the employees of the facility's activities department and staff interviews it was determined that the facility was not administered in a manner that enables it to uses it staff resources to maintain the highest practicable mental and psychosocial well-being of each residents causing emotional upset to two of eight residents sampled (Resident 21 and 18).

Inspectors wroteBased on a review of clinical records and staff interview it was determined that the facility failed to provide person-centered quality care by failing to follow physician orders for medication administration and accurately monitor bowel activity and administration of the bowel protocol as prescribed for one resident out of seven 7 sampled (Resident 11).

Inspectors wroteBased on observations and staff interview it was determined that the facility failed to demonstrate an effective maintenance program of regular inspection of all bed frames, mattresses, and bed rails to assure that the mattress fit the bed frames properly limiting entrapment zones and promoting resident comfort and safety for 21 resident beds with side rails and further failed to ensure the availability of a functioning bed for all current licensed and certified resident beds (Resident rooms [ROOM NUMBER]).

Inspectors wroteBased on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of three resident out of 14 sampled (Resident 9, 34, and 12).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to incorporate the recommendations from the Pre-admission Screening and Resident Review (PASARR) level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for two of three residents reviewed (Residents 12 and 4).

Inspectors wroteBased on observation, a review of select facility policy and clinical records and staff interviews it was determined that the facility failed to assess a resident's potential need for bed rails, including the risk for entrapment and a review of the risks versus benefits with the resident and/or the resident's representative for one of four sampled residents (Resident 36).

Inspectors wroteBased on review of clinical records and interviews with staff, it was determined the facility failed to provide therapeutic and medically related social services to promote the psychosocial well-being of one of two residents reviewed for discharge planning (Resident 6), coordination of required mental health services for two of three residents (Resident 12 and 4) and assisting and arranging to meet a resident's communication needs for one resident out of 14 sampled (Resident 32).

Inspectors wroteBased on a review of clinical records and facility documentation and staff interviews, it was determined the facility failed to provide a Notice of Medicare Provider Non-Coverage and for the appeal process for one of three records reviewed. (Resident 19).

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to provide written notice of facility initiated transfer to the hospital identifying the reason for the transfer in a language and manner easily understand by one resident (Resident 9) and failed to provide written notice of the facility initiated transfer to the hospital to the resident's representative for one resident out of six sampled (Resident 34).

Inspectors wroteBased on a review of clinical records and resident and staff interview it was determined that the facility failed to develop and implement an individualized discharge plan for one of two residents reviewed for discharge planning (Resident 6). Findings Include: A review of Resident 6's clinical record revealed admission to the facility on August 19, 2022, with diagnoses including congestive heart failure (chronic condition in which the heart does not pump as well as it should) and depression. During interview with Resident 6 on April 18, 2023, at 10:00 AM the resident stated that he was satisfied at the facility, but if possible, would like to transfer to a facility, which allowed smoking. [...]

Inspectors wroteBased on a review of clinical records and interviews with staff and resident it was determined that the facility failed to consistently provide a functional communication system to maintain the resident's ability to communicate for one resident with communication needs out of 14 sampled residents (Resident 32).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide restorative nursing services planned to maintain the functional abilities and declines in range of motion for one of three sampled residents (Resident 22).

Inspectors wroteBased on a review of clinical records and select incident reports and resident and staff interviews it was determined that the facility failed to ensure the provision of necessary supervision during meals to promote resident safety while eating as required by one resident out of 14 residents sampled

Inspectors wroteBased on review of select facility policies and procedures and clinical records, observation, and resident and staff interviews, it was determined that the facility failed to provide supplemental oxygen administration care consistent with professional standards of practice for one of five residents reviewed (Resident 31).

Inspectors wroteBased on a review of select facility policy and clinical records and staff interview, it was determined that the facility failed to ensure the provision of consistent and timely physician services for one of 14 sampled residents (Resident 19).

Inspectors wroteBased on review of clinical records, observations and staff and resident interviews it was determined that the facility failed to provide, or secure, dental services for one resident out of 14 sampled (Resident 4).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed timely ascertain a resident's eligibility to receive the influenza and pneumococcal immunizations and provide immunization if eligible as desired by one of five residents reviewed (Resident 15).

Inspectors wroteBased on observations and space measurements provided by the facility, it was determined that the facility failed to provide the regulatory required minimum square footage in nine of 21 resident rooms.