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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

KADIMA REHABILITATION & NURSING AT PALMYRA
Inspection Results For:

There are 148 surveys for this facility. Please select a date to view the survey results.

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KADIMA REHABILITATION & NURSING AT PALMYRA - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Revisit survey completed on September 29, 2024, it was determined that Kadima Rehabilitation and Nursing at Palmyra 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.

Plan of Correction:

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e)

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

Observations:

Based on staff interview, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian.

Findings include:

During an interview on September 29, 2024, at 10:35 a.m., the Director of Nursing (DON) stated that the facility did not employ a certified dietary manager. The DON also stated that there was not a full-time registered dietitian at the facility. There was no evidence that the facility employed a certified dietary manager in the absence of a full-time qualified dietitian.

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

Plan of Correction - To be completed: 10/30/2024

1 The facility has an advertisement placed on local job boards, with a competitive salary, to attract a Certified Dietary Manager candidate.
The current Dietary Manager is enrolled in certification classes and is overseen by another Certified Dietary Manager in the company. A qualified dietary manager in accordance with the regulation will be employed/on staff by the correction date.
2 The facility has an advertisement placed on local job boards, with a competitive salary, to attract a full-time Registered Dietitian candidate if a Certified Dietary Manager cannot be found.
3 The Recruiter was re-educated on ensuring a full-time Certified Dietary Manager is present at the facility. The NHA will send open position postings to the recruiter weekly and as needed.
4 The NHA or designee will complete a credential audit of the candidate before hire to ensure the Certified Dietary Manager credential is present. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:

Based on observation, it was determined that the facility failed to ensure that a dignified environment and services were provided to promote quality of life on the nursing unit.

Findings include:

Observation on the nursing unit revealed a bulletin board outside of the dining room displaying the menus for breakfast, lunch, and dinner. On Sunday, September 29, 2024, the menus posted were labeled "Friday" and incorrectly identified what was to be served at each meal.

Plan of Correction - To be completed: 10/30/2024

1.Menus were replaced with the correct date's menu.
2 A menu with the correct meals listed will be posted daily.
3 The Dietary Manager was re-educated on posting daily menus. The NHA will conduct daily rounds to ensure postings are updated daily.
4 The NHA or designee will complete an audit of the menu posting and weekly x 4 weeks then monthly x 2 months to ensure accurate postings . The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for two fo three days reviewed.

Findings include:

Review of nursing schedules for seven days from September 26 to 28, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for ten residents on day shift (7:00 a.m. to 3:00 p.m.) on September 26, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 11 residents on evening shift (3:00 p.m. to 11:00 p.m.) on September 26 and 27, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on September 27, 2024.

Plan of Correction - To be completed: 10/30/2024

) Facility cannot retroactively correct
2) Facility will conduct audit of CNA staffing ratios for last 4 weeks to ensure compliance with regulation
3) NHA will reeducate DON and Staff scheduler on CNA staffing ratio per regulation to ensure ongoing compliance. Facility will conduct daily staffing meeting to ensure compliance with regulation
4) NHA/ Designee will conduct audit 3 times a week x 4 weeks and once a month x 2 months to ensure adequate CNA Ratios per regulation. Results will be reviewed at QAPI.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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 on a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for three of three days reviewed.

Findings include:

Review of nursing schedules for seven days from September 26 to 28, 2024, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on day shift (7:00 a.m. to 3:00 p.m.) on September 28, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 30 residents on evening shift (3:00 p.m. to 11:00 p.m.) on September 26, 27, and 28, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11:00 p.m. to 7:00 a.m.) on September 28, 2024.

Plan of Correction - To be completed: 10/30/2024

1) Facility cannot retroactively correct
2) Facility will conduct audit of LPN staffing ratios for last 4 weeks to ensure compliance with regulation
3) NHA will re educate DON and Staff scheduler on LPN staffing ratio per regulation to ensure ongoing compliance. Facility will conduct daily staffing meeting to ensure compliance with regulation
4) NHA/ Designee will conduct audit 3 times a week x 4 weeks and once a month x 2 months to ensure adequate LPN Ratios per regulation. Results will be reviewed at QAPI.

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