Kadima Rehabilitation & Nursing at Washington

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for two of two nursing units (North and South units).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to store medications properly, for two of three two medication carts (North Hall and Middle Hall medication carts).

Inspectors wroteBased on facility policy, manufacturers recommendations, observation, clinical record review and staff interview, it was determined that the facility failed to reorder medications timely for one of three residents (Resident R1).

Inspectors wroteBased on review of facility documents, observations and resident and staff interviews, it was determined that the facility failed to follow physician's orders for five of seven residents (Resident R1, R2, R3, R4, and R5).

Inspectors wroteBased on review of facility policy, resident observations, resident interviews and confidential staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of five of eight residents (Resident R1, R3, R6, R7, and R8). Findings Include: Review of the facility policy Nursing Department Staff dated 1/7/26, indicated the facility will provide services by sufficient numbers of personnel on a 24-hour basis to provide nursing care to all resident sin accordance with resident care plans. Review of the facility policy Call Light Response dated 1/7/26, indicated, Staff will respond to the call light and the resident's requests and needs in a timely manner. During an interview on 3/27/26, at approximately 11:25 a. [...]

Inspectors wroteBased on review of facility documents, clinical records and staff interviews, it was determined that the facility failed to schedule a follow-up appointment for one of four residents (Resident R1).

Inspectors wroteBased on review of the facility's facility assessment, staff interview, professional standards, and facility documentation, it was determined the facility failed to conduct and document a comprehensive, evidence-based facility assessment to ensure licensed nursing staff possessed the required training and competencies necessary to provide care and services for residents and Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care as required.

Inspectors wroteBased on review of facility policy, documentation, staff interview and review of Centers for Disease Control (CDC) guidelines for Legionella (bacteria that causes disease found in contaminated water) control, and staff interviews it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for twelve of twelve months (January 2025 through January 2026).

Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Infection Control for ten of ten staff members (Employee E9, E10, E11, E12, E13, E14, E15, E16, E17 and E18).

Inspectors wroteBased on observations and a staff interview, it was determined the facility failed to post contact information, Adult Protective Services (APS), State Agency, and a statement the resident may file a complaint with the State Agency as required, in the building in one of one location where postings are (first floor nursing unit).

Inspectors wroteBased on observations, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing units (North and South Nursing Units).

Inspectors wroteBased on resident and staff interviews, and review of facility documents (grievances, resident council, and staffing) review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for ten of sixteen residents (Residents R200, R500, R501, R502, R503, R504, R505, R506, R507, and 508).

Inspectors wroteBased on review of personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for five of five nurse aides (NA Employee E13, E15, E16, E17 and E18).

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to properly store food products in the walk-in cooler and freezer which created the potential for cross contamination (Main Kitchen).

Inspectors wroteBased on review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for four of four quarterly meetings (2/12/25, 3/19/25, 4/23/25, 5/28/25, 6/25/25 ,7/30/25, 8/27/25, 9/24/25,10/28/25, 11/18/25, and 12/16/25). Findings Include:Review of Quality assurance and Performance Improvement sign in sheets and attendance records for 2/12/25, 3/19/25, 4/23/25, 5/28/25, 6/25/25 ,7/30/25, 8/27/25, 9/24/25,10/28/25, 11/18/25, and 12/16/25, failed to reveal the Lab Representative and Community Member, one of whom must be the facility's administrator, owner, board member, or other individual in a leadership role who has knowledge of facility systems and the authority to change those systems. During an interview on 1/30/26, at 10:20 a. [...]

Inspectors wroteBased on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on resident rights for three of ten staff members (Employees E9, E10 and E15).

Inspectors wroteBased on review of personnel records, and staff interview it was determined that the facility failed to ensure that five of five sampled Nurse Aides (NA) received a minimum of 12 hours of in-service education per year (NA Employees E13, E15, E16, E17 and E18).

Inspectors wroteBased on review of the facility policy and clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions for when the individual is incapacitated) or conduct periodic review of instructions, for two of six residents reviewed (Resident R8, and R36). Findings Include: A review of the facility policy Advance Directives last reviewed 17/26 with a prior review date of 1/9/25, indicated procedures for periodic review of DNROrders will occur at least annually. This facility will allow revocations or amending DNR orders by the resident, the attorney in fact, the representative or treating physician. Such changes will be documented in the medical record. [...]

Inspectors wroteBased on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make certain, residents who voice grievances can do so without fear of discrimination or reprisal for twelve of sixteen residents (R77, R200, R201, R500, R501, R502, R503, R504, R505, R506, R507, and 508).

Inspectors wroteBased on review of the facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for potential abuse for one of three residents (Residents R400).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for one of two residents (Resident R18).

Inspectors wroteBased on review of facility assessment, facility policy, employee file and staff interview, it was determined that the facility failed Prevention of Abuse and Neglect in-service education for two of ten employees (Employees E9and E15)

Inspectors wroteBased on review of the facility assessment, facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for ten of ten staff members (Employee E9, E10, E11, E12, E13, E14, E15, E16, E17 and E18).

Inspectors wroteBased on review of facility assessment, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for ten of ten staff members (Employee E9, E10, E11, E12, E13, E14, E15, E16, E17and E18).

Inspectors wroteBased on review of regulatory requirements, facility policy, facility documents, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Effective Communication for two of ten employees (E9 and E15).

Inspectors wroteBased on review of the grievance policy, facility documents, and staff interviews it was determined that the facility policy does not include all required elements and that the facility failed to document, resolve, and provide response to residents and/or their responsible parties for eleven of thirteen residents (Resident R2, R3, R4, R5, R6, R7, R8, R9, R10, and R11).

Inspectors wroteBased on review of federal and state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures to report allegations of abuse and neglect for five of twelve residents (Resident R1, R3, R8, R9 and R10).

Inspectors wroteBased on review of facility documents, observations, and resident and staff interviews it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for eight of 16 residents (Residents R1, R3, R5, R8, R9, R10, R12, and R13).

Inspectors wroteBased on a review of facility policy, federal regulation, and staff interview, it was determined that the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for 12 of 12 months (January 2024 through December 2024).

Inspectors wroteBased on review of facility policies, job descriptions, clinical records, and staff interviews, it was determined that the facility failed to adhere to acceptable standards of practice related to participation in interdisciplinary meetings, monitoring of Food Service operations, resident interviews, and participation in the Quality Assurance and Performance Improvement (QAPI), by the Registered Dietitian.

Inspectors wroteBased on policy review, documentation and review of Centers for Disease Control (CDC) guidelines for Legionella (bacteria that causes disease found in contaminated water) control, and staff interviews it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for twelve of twelve months (December 2023 through December 2024).

Inspectors wroteBased on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to provide concern forms and grievance boxes to residents and visitors on the nursing units and failed to provide an opportunity for anonymous grievances (Resident group).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels for five of seven residents reviewed (Residents R13, R26, R28, R29, and R46).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess a resident for safe smoking for three of five residents reviewed (Residents R4, R10, and R54).

Inspectors wroteBased on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to ensure that residents were protected from potential for abuse by failing to perform criminal history background checks prior to hire for two of five personnel files reviewed (Employee E7 and E12). Findings Include: Review of facility policy Abuse: Protection From Abuse reviewed 1/31/24 and 1/9/25, revealed the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. The facility conducts background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. [...]

Inspectors wroteBased on review of facility policy, observations, manufacturers recommendations, clinical records, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of two residents observed (Resident R3).

Inspectors wroteBased on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of four residents (Resident R1). Review of the facility policy Resident Elopement dated 1/31/24, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the physical structure of the facility without knowledge of facility staff. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: [...]

Inspectors wroteBased on review of facility documentation and staff interviews, it was determined that the facility failed to provide documentation of an effective training program, that included training topics based on the resident population for one of four residents (Resident R1).

Inspectors wroteBased on review of facility policy, observations, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information in one area (storage shed).

Inspectors wroteBased on observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, homelike environment on one of two nursing units(North Wing), and in the main dining room.

Inspectors wroteBased on review of facility policy, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from neglect for one of two residents (Resident R8), by failing to follow physicians orders during incontinence pad change and linen change. This was identified as past non-compliance.

Inspectors wroteBased on review of facility policy, clinical records, facility documentation, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision and implement effective bed mobility interventions as per physician order to promote resident safety, for one of two residents (Resident R8). This deficiency is cited as past non-compliance.

Inspectors wroteBased on review of facility policy, water testing logs and staff interview, it was determined that the facility failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia). That the facility failed failed to provide surveillance data and analysis and provide documentation of the I/C program must include, at a minimum, a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, and visitors for three of eleven months (Mar, April, and May 2023).

Inspectors wroteBased on review of facility records and staff interview, it was determined that the facility failed to ensure the designated Infection Preventionist was qualified with specialized training in infection prevention and control.

Inspectors wroteBased on observations, and resident and staff interviews, it was determined that the facility failed to maintain a clean, homelike environment on three of three nursing units (South, North, and Middle Nursing Units).

Inspectors wroteBased on review of personnel records and staff interview it was determined that the facility failed to provide nursing staff annual performance evaluations based on the date of hire for four of four nurse aides (NA Employee E3, E4, E5, and E6).

Inspectors wroteBased on review of facility policy, observation and staff interview, it was determined that the facility failed to make certain that refrigerated medications are stored at proper temperatures and failed to monitor the medication refrigerator temperatures daily in one of one medication rooms.

Inspectors wroteBased on review of the facility's admission agreement and staff interviews, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator.

Inspectors wroteBased on review of facility documentation and interviews with staff, it was determined that the facility failed to develop, implement, and maintain an effective training program that was sufficient to meet the requirement for facility-provided annual nurse aide education.

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide training on abuse, neglect, and exploitation for four of ten staff members (Employees E4, E6, E8, and E9).

Inspectors wroteBased on review of facility documents, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for four of four nurse aides (Employees E3, E4, E5, and E6).

Inspectors wroteBased on review of state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of staff to resident abuse or neglect for two of five residents reviewed (Resident R44 and R46).

Inspectors wroteBased on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for three of twelve residents (Resident R43, R48, and R61).

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide Communication training to direct care facility staff.

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to facility staff.

Inspectors wroteBased on observations, facility document reviews, and staff interviews it was determined that the facility failed to make certain that equipment was in safe operating condition for one of one crash carts and one of one AEDs (Automatic External Defibrillators).

Inspectors wroteBased on review of facility policy, observations, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information for two of two areas accessible to all staff (nutrition room and basement storage area).

Inspectors wroteBased on observations and resident and staff interviews, it was determined that the facility failed to provide a clean, sanitary, and homelike environment for two of two nursing units (North Wing and South Wing).

Inspectors wroteBased on review of resident clinical records and staff interviews it was determined that the facility failed to make certain that appropriate treatment and services were ordered and/or provided for two of three residents with a urinary catheter (Resident R1 and R2).

Inspectors wroteBased on review of observations and staff interviews, it was determined that the facility failed to properly dispose of expired and/or opened medical supplies in one of one medication rooms and one of one basement storage areas.