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 May 14, 2024, it was determined that Kadima Rehabilitation and Nursing at Luzerne corrected the federal deficiencies cited during the survey ending February 29, 2024, 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 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. :

(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 on a review of nurse staffing data and staff interviews, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 9 shifts out of 42 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates, the facility failed to provide minimum nurse aide staff of 1:12 on the day and evening shifts and 1:10 on the night shifts, based on the facility's census.

April 29, 2024: 3.0 nurse aides on the day shift, versus the required 3.08 for a census of 37.
April 29, 2024: 2.53 nurses aide the evening shift, versus the required 3.08 for a census of 37.
April 30, 2024: 3.0 nurse aides on the day shift, versus the required 3.08 for a census of 37.
May 2, 2024: 2.33 nurse aides on the evening shift, versus the required 3.0 for a census of 36.
May 4, 2024: 2.5 nurse aides on the day shift, versus the required 2.92 for a census of 35.
May 4, 2024: 1.5 nurse aides on the night shift versus the required 1.75 for a census of 35.
May 11, 2024: 2.5 nurse aides on the evening shift versus the required 3.0 for a census of 36.
May 12, 2024: 2.93 nurse aides on the day shift versus the required 3.0 for a census of 36.
May 12, 2024: 2.5 nurse aides on the evening shift versus the required 3.0 for a census of 36.

An interview with the Director of Nursing and Nursing Home Administrator on May 14, 2024, at approximately 1:00 PM confirmed the facility had not met the required nurse-aide-to-resident ratios on the above dates.

Plan of Correction - To be completed: 07/01/2024

1. The facility in 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 was re-educated on ensuring that the nursing care ratios are provided, and that the facility is actively recruiting CNAs. A daily staffing meeting with DON and NHA has been implemented to review census and staffing to ensure we are meeting required ratio.
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.

Plan of Correction - To be completed: 07/01/2024

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 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. A daily staffing meeting with DON and NHA has been implemented to review census and staffing to ensure we are meeting required ratio.
4.The DON or designee will conduct an audit of the LPN 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)(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 schedules, provided nursing time, and resident census, it was determined that the facility failed to ensure the minimum registered nurse staff to resident ratio was provided on each shift for one shift out of 42 reviewed.

Findings include:

A review of the facility's staffing records revealed that for the weeks of April 29, 2024, through May 12, 2024, the facility failed to provide a minimum registered nurse (RN) staff of 1:250 on the following date:

May 5, 2024: 0.85 RNs on the day shift, versus the required one (1) for a census of 35.

An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 14, 2024, at approximately 1:00 PM, confirmed that the facility had not met the required RN-to-resident ratios on the above shift.

Plan of Correction - To be completed: 07/01/2024

1. The facility is unable to retroactively provide a minimum RN 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 and Recruitment were re-educated on ensuring that the nursing care ratios are provided, and that the facility is actively recruiting RN's. A daily staffing meeting with DON and NHA has been implemented to review census and staffing to ensure we are meeting required ratio.
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(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.

Observations:

Based on a review of nurse staffing schedules and the daily resident census, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident for 3 out of 14 dates reviewed.

Findings include:
A
review of the facility's weekly staffing records for the weeks of April 29, 2024, through May 12, 2024 revealed that on the following dates, the facility failed to provide a minimum nurse staffing of 2.87 hours of general nursing care to each resident:

April 29, 2024: 2.72 nursing hours per resident per 24 hours
May 4, 2024: 2.64 nursing hours per resident per 24 hours
May 5, 2024: 2.86 nursing hours per resident per 24 hours

On the above dates, the facility failed to provide the minimum of 2.87 hours of direct nursing care daily for each resident.

Plan of Correction - To be completed: 07/01/2024

1. The facility is unable to retroactively provide a minimum PPD hours for cited dates.
2.A facility wide audit was completed to ensure PPD was met. Recruitment increased RN, LPN, and CNA 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 RN's, LPN's and CNA's. A daily staffing meeting with DON and NHA has been implemented to review census and staffing to ensure we are meeting required PPD for nursing.
4.The DON or designee will conduct an audit of the nursing PPD 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.

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