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:

There are 88 surveys for this facility. Please select a date to view the survey results.

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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 completed on March 12, 2025, it was determined that Kadima Nursing Rehabilitation and Nursing at Luzerne corrected the federal deficiencies cited during the survey of January 16, 2025, under the requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care, but continued to be out of compliance with the following requirements of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 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: 04/04/2025

5520

1. The facility is unable to retroactively ensure NA to resident ratios are met on the cited dates.
2. The facility will maintain NA to resident ratios. The NHA and staff recruiter met and formed an action plan to meet with nursing students during one of their final classes as well as new nursing graduates at job fairs and open houses. The recruiter is also on site at the facility to expedite any new hire paperwork.
3. The DON was re-educated on ensuring NA to resident ratios are met. There will be a daily staffing meeting to review the current day and future dates NA ratios.
4. The NHA or designee will complete an audit of NA to resident ratios daily x 7 days then weekly x 4 weeks to ensure ratios are met. Results will be submitted to the QAPI Committee for review and analysis of need for 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.

Plan of Correction - To be completed: 04/04/2025

5530

1. The facility is unable to retroactively ensure LPN to resident ratios are met on the cited dates.
2. The facility will maintain LPN to resident ratios. The NHA and staff recruiter met and formed an action plan to meet with nursing students during one of their final classes as well as new nursing graduates at job fairs and open houses. The recruiter is also on site at the facility to expedite any new hire paperwork.
3. The DON was re-educated on ensuring LPN to resident ratios are met. There will be a daily staffing meeting to review the current day and future dates LPN ratios.
4. The NHA or designee will complete an audit of LPN to resident ratios daily x 7 days then weekly x 4 weeks to ensure ratios are met. Results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.

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

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

Observations:

Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum registered nurse to resident ratio was provided on each shift for 7 shifts out of 63 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following date the facility failed to provide minimum registered nurse (RN) staff of 1:250 on the night shift, based on the facility's census:

February 17, 2025, 0 RNs on the night shift, versus the required 1, for a census of 35
February 26, 2025, 0 RNs on the night shift, versus the required 1, for a census of 34
February 28, 2025, 0 RNs on the night shift, versus the required 1, for a census of 34
March 4, 2025, 0 RNs on the night shift, versus the required 1, for a census of 34
March 6, 2025, 0 RNs on the night shift, versus the required 1, for a census of 34
March 7, 2025, 0 RNs on the night shift, versus the required 1, for a census of 34
March 8, 2025, 0 RNs on the night shift, versus the required 1, for a census of 34

An interview with the Director of Nursing, on March 12, 2025, at approximately 1:30 PM, confirmed the facility had not met the required RN to resident ratios on the above dates.

Plan of Correction - To be completed: 04/04/2025

5540
1. The facility is unable to retroactively ensure RN to resident ratios are met on the cited dates.
2. The facility will maintain RN to resident ratios. The NHA and staff recruiter met and formed an action plan to meet with nursing students during one of their final classes as well as new nursing graduates at job fairs and open houses. The recruiter is also on site at the facility to expedite any new hire paperwork.
3. The DON was re-educated on ensuring RN to resident ratios are met. There will be a daily staffing meeting to review the current day and future dates RN ratios.
4. The NHA or designee will complete an audit of RN to resident ratios daily x 7 days then weekly x 4 weeks to ensure ratios are met. Results will be submitted to the QAPI Committee for review and analysis of need for 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.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined the facility failed to consistently provide minimum general nursing care hours to each resident daily on one out of the 21 days reviewed.

Findings include:

A review of the facility's staffing levels revealed that on the following date the facility failed to provide minimum nurse staffing of 3.2 hours of general nursing care to each resident:

February 25, 2025 - 3.19 direct care nursing hours per resident.

The facility's general nursing hours were below minimum required levels on the date noted above.

An interview with the Director of Nursing on March 12, 2025, at approximately 1:30 PM, confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Plan of Correction - To be completed: 04/08/2025

5640

5640
1. The facility is unable to retroactively ensure minimum PPD hours of Direct Care are met on the cited dates.
2. The facility will maintain minimum PPD hours of direct care. The NHA and staff recruiter met and formed an action plan to meet with nursing students during one of their final classes as well as new nursing graduates at job fairs and open houses. The recruiter is also on site at the facility to expedite any new hire paperwork.
3. The DON was re-educated on ensuring minimum PPD hours of direct care. There will be a daily staffing meeting to review the current day and future dates PPD hours of direct care.
4. The NHA or designee will complete an audit of PPD hours of direct care daily x 7 days then weekly x 4 weeks to ensure ratios are met. Results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.

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