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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

KADIMA REHABILITATION & NURSING AT LUZERNE
Inspection Results For:

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

Initial comments:

Based on a revisit and abbreviated complaint survey completed on July 23, 2024, it was determined that Kadima Rehabilitation and Nursing at Luzerne failed to correct the deficiencies cited during the survey of June 18, 2024, and continued to be out of compliance with the following requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.70(a)-(c) REQUIREMENT License/Comply w/ Fed/State/Locl Law/Prof Std:

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.

§483.70(a) Licensure.
A facility must be licensed under applicable State and local law.

§483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards.
The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.

§483.70(c) Relationship to Other HHS Regulations.
In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.

Plan of Correction - To be completed: 08/18/2024

1. The facility is unable to retroactively meet requirements for state mandated staffing ratios and PPD requirements.
2. The recruitment department has expanded services to ensure adequate staffing levels. Sign on bonuses, referral bonuses, tuition reimbursement and competitive wages are being offered.
3. The DON was re-educated maintaining nursing schedules consistent with state requirements. A daily staffing meeting will be held to ensure ratios and PPDs are met.
4. The NHA or designee will conduct an audit of the nursing schedules weekly x 4 weeks then monthly x 2 months to ensure state minimum PPD and ratios are met. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based 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.

Findings include:

An observation on July 23, 2024, at 9:09 AM revealed dirt and debris was on the floors throughout the hallway of the south side nursing unit.

Observation in the common resident bathroom on this hall revealed hair and a dried yellow-urine like substance on the toilet.

Observation in resident Room 9 revealed dried feces on the toilet and toilet seat. Dirt and debris was observed on the bathroom floor.

Dirt, debris and a dried red substance was observed on the floor of resident Room 7. Brown streaks were observed on the wall next to the door.

Observation in resident Room 12 revealed dried stain streaks on the wall next to the resident's dresser. There was an accummulation of dust and dirt stuck to these streaks on the wall.

Observation in the resident shower room on the north hall revealed a black and brown mold like substance coating the caulking extending the perimeter of the floor of the shower.

Observation in resident Room 14 revealed a dried brown substance on the floor along with food crumbs scattered about the floor. Observation in the resident's bathroom, revealed black streaks extending down the base of the toiled and dried fecal-like brown spots on the toilet seat.

Observation of the resident shower room in the middle hall revealed cracked floor tiles.

Observation in resident Room 21 revealed dried liquid spots on the floor and dried brown drips on the wall.

An accummulation of dust and dirt was observed behind the ice machine in the resident dining room.

Interview with the Director of Nursing on July 23, 2024, at approximately 2:15 PM confirmed that the facility is to be maintained daily to provide a clean and sanitary environment for the residents.

28 Pa. Code 201.18 (e)(2.1) Management

Plan of Correction - To be completed: 08/18/2024

1. The facility floors were swept and mopped. Facility toilets were cleaned. The spills on the walls were cleaned. The facility shower room has dark gray grout that turns black when wet. The area was dried and checked for a black substance. Cracked tiles were replaced.
2. A facility wide environmental services audit was completed. Areas identified were addressed.
3. The Environmental Services department was re-educated on providing a clean and sanitary environment. The Environmental Services Director and NHA will conduct regular environmental rounds.
4. The NHA or designee will conduct an environmental services audit weekly x 4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(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.

Plan of Correction - To be completed: 08/18/2024

1. The facility is unable to retroactively provide minimum nurse aide ratio for cited dates.
2.A facility wide audit was completed to ensure ratios were met. Recruitment increased, CNA sign on bonuses, and wages are competitive with surrounding areas.

3.The DON and scheduler were re-educated on ensuring that the nursing care ratios are provided, and that the facility is actively recruiting CNAs. DON will review census and schedule daily to ensure we have adequate staffing levels of CNA's daily.

4.The DON or designee will conduct an audit of the nursing care ratios to ensure it is provided weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need of 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.

Plan of Correction - To be completed: 08/18/2024

1. The facility is unable to retroactively provide a minimum LPN ratio for cited dates.
2. A facility wide audit was completed to ensure ratios were met. Recruitment initiatives were increased, LPN sign on bonuses, and wages are competitive with surrounding areas.

3. The DON and Recruitment were re-educated on ensuring that the nursing care ratios are provided, and that the facility is actively recruiting LPNs. The DON will review census and schedule daily to ensure adequate staffing of LPN's.

4. The DON or designee will conduct an audit of the nursing care ratios to ensure it is provided weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.

§ 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.

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Plan of Correction - To be completed: 08/18/2024

1. The facility is unable to retroactively provide minimum registered nurse ratio for cited dates.
2.A facility wide audit was completed to ensure ratios were met. Recruitment increased, RN sign on bonuses, and wages are competitive with surrounding areas.

3.The DON was re-educated on ensuring that the nursing care ratios are provided, and that the facility is actively recruiting RNs. The DON will review census and schedule daily to ensure adequate staffing of RN's each day.

4.The DON or designee will conduct an audit of the registered nurse ratios to ensure it is provided weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.

§ 211.12(i)(1) LICENSURE Nursing services.:

(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.

Plan of Correction - To be completed: 08/18/2024

1. The facility is unable to retroactively correct PPD for dates cited.
2. A facility wide audit was completed to ensure the minimum PPD of 2.87 hours are met daily for each resident.

3. The DON /designee were re-educated on the total number of hours of general nursing care provided in each 24-hour period be a minimum of 2.87 hours. The DON will review the census daily to ensure 2.87 hours of nursing care are being provided within a 24-hour period. If staffing levels are not being met, DON will instruct the scheduler to make adjustments to the schedule by filling any gaps with per diem staff. The facility continues recruit licensed and non-licensed nursing staff.

4. The DON / designee will conduct an audit of daily staffing sheets weekly x 4 weeks, then monthly x 2 to ensure facility meets the minimum daily 2.87 nursing hours for each resident. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, 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 3.2 hours of direct resident care for each resident.

Plan of Correction - To be completed: 08/18/2024

1. The facility is unable to retroactively correct PPD for dates cited.
2. A facility wide audit was completed to ensure the minimum PPD of 3.2 hours are met daily for each resident.

3. The DON /designee were re-educated on the total number of hours of general nursing care provided in each 24-hour period be a minimum of 3.2 hours. The DON will review the census daily to ensure 3.2 hours of nursing care are being provided within a 24-hour period. If staffing levels are not being met, DON will instruct the scheduler to make adjustments to the schedule by filling any gaps with per diem staff. The facility continues recruit licensed and non-licensed nursing staff.

4. The DON / designee will conduct an audit of daily staffing sheets weekly x 4 weeks, then monthly x 2 to ensure facility meets the minimum daily 3.2 nursing hours for each resident. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.

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