Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT LITITZ
Patient Care Inspection Results

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KADIMA REHABILITATION & NURSING AT LITITZ
Inspection Results For:

There are  130 surveys for this facility. Please select a date to view the survey results.

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KADIMA REHABILITATION & NURSING AT LITITZ - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to three complaints, completed on February 6, 2024, it was determined that Kadima Rehabilitation and Nursing at Lititz, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.









 Plan of Correction:


§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:
Based upon review of staffing schedules and records, it was determined the facility failed to meet the State minimum ratio requirement for nurse aides for 3 staffing weeks reviewed.

Findings include:

Review of facility staffing schedules and records dated January 7, 2024 through January 27, 2024 revealed the facility did not meet the State minimum ratio requirement for nurse aides on the following dates: January 7, 2024 - 7-3, 3-11 and 11-7 shifts; January 8, 2024 - 11-7 shift; January 9, 2024 - 3-11 shift; January 10, 2024 - 7-3 and 3-11 shift; January 11, 2024 - 7-3, 3-11 and 11-7 shifts; January 12, 2024 - 7-3 and 3-11 shifts; January 13, 2024 - 3-11 and 11-7 shifts; January 14, 2024 - 7-3 and 3-11 shifts; January 15, 2024 - 3-11 shift; January 16, 2024 - 3-11 shift; January 17, 2024 - 11-7 shift no aides; January 18, 2024 - 3-11 shift; January 19, 2024 - 7-3, 3-11 and 11-7 shifts; January 20, 2024 - 7-3, 3-11 and 11-7 shifts; January 21, 2024 - 7-3 and 3-11 shifts; January 22, 2024 - 3-11 and 11-7 shifts; January 23, 2024 - 3-11 shift; January 24, 2024 - 7 -3 and 11-7 shifts; January 25, 2024 - 7-3, 3-11 and 11-7 shifts; January 26, 2024 - 7-3, 3-11 and 11-7 shifts and January 27, 2024 - 7-3, 3-11 and 11-7 shifts.

Interview with Nursing Home Administrator on February 6, 2024, at 11:00 a.m. confirmed the above information.




 Plan of Correction - To be completed: 04/24/2024

1. Facility can not retroactively correct.

2. All residents had the potential to be affected; however, there were no adverse resident outcomes as a result of this deficient practice.

3. Licensed staff have been re-educated on staffing requirements by the DON and/or designee. An ongoing systemic change put in place is the review of staffing in daily meeting.

4. The Administrator or designee will audit the schedule for four weeks and then monthly for two months to ensure appropriate coverage.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based upon review of staffing schedules and records, it was determined the facility failed to meet the State minimum ratio requirement for LPNs for 3 staffing weeks reviewed.

Findings include:

Review of facility staffing schedules and records dated January 7, 2024 through January 27, 2024 revealed the facility did not meet the State minimum ratio requirement for LPNs on the following dates: January 8, 2024 - 11-7 shift; January 9, 2024 - 3-11 shift; January 11, 2024 - 11-7 shift; January 12, 2024 - 7-3 shift; January 17, 2024 - 3-11 shift; January 19, 2024 - 7-3 shift; January 21, 2024 - 7-3 shift; January 22, 2024 - 11-7 shift; January 23, 2024 - 7-3 shift and January 24, 2024 - 11-7 shift.

Interview with Nursing Home Administrator on February 6, 2024, at 11:00 a.m. confirmed the above information.


 Plan of Correction - To be completed: 04/24/2024

1. Facility can not retroactively correct.

2. All residents had the potential to be affected; however, there were no adverse resident outcomes as a result of this deficient practice.

3. License staff have been re-educated on staffing requirements by the DON or designee. An ongoing systemic change put in place is the review of staffing in daily meeting.

4. The Administrator or designee will audit the schedule weekly for four weeks and then monthly for two months to ensure appropriate coverage is on place. Results of the audits will be reported to the QAPI committee for review and analysis of need for ongoing monitoring.
§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:
Based upon review of staffing schedules and records, it was determined the facility failed to meet the State minimum requirement of 2.87 PPD for 3 staffing weeks reviewed.

Findings include:

Review of facility staffing schedules and records dated January 7, 2024 through January 27, 2024 revealed the facility did not meet the State minimum requirement of 2.87 PPD for the following dates: January 11, 2024 - 2.83 PPD; January 12, 2024 - 2.83 PPD; January 13, 2024 - 2.74 PPD; January 19, 2024 - 2.65 PPD; January 21, 2024 - 2.23 PPD; January 22, 2024 - 2.71 PPD; January 24, 2024 - 2.83 PPD; January 26, 2024 - 2.84 PPD and January 27, 2024 - 2.84 PPD.

Interview with Nursing Home Administrator on February 6, 2024, at 11:00 a.m. confirmed the above information.





 Plan of Correction - To be completed: 04/24/2024

1. Facility can not retroactively correct.

2. All residents had the potential to be affected; however, there were no adverse resident outcomes as a result of this deficient practice.

3. Licensed staff have been re-educated on staffing requirements by the DON or designee. An ongoing systemic change put in place is the review of staffing in daily meeting.

4. The Administrator or designee will audit the schedule for four weeks and then monthly for two months to ensure appropriate coverage is in place. Results of the audits will be reported to the QAPI committee for review and analysis of need for ongoing monitoring.

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