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

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KADIMA REHABILITATION & NURSING AT CAMPBELLTOWN
Inspection Results For:

There are  136 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
KADIMA REHABILITATION & NURSING AT CAMPBELLTOWN - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated survey in response to a complaint completed on April 8, 2024, it was determined that Kadima Rehabilitation and Nursing at Campbelltown was not in 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)(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 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 18 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from March 17, 2024, through April 6, 2024, revealed the following:

The facility failed to meet the minimum ratio of one NA for 12 residents on the day (7:00 a.m. to 3:00 p.m.) shift on March 17, 19, 20, 21, 22, 23, 24, 25, 26, 28, and 30, 2024, and April 1, 3, and 6, 2024.

The facility failed to meet the minimum ratio of one NA for 12 residents on the evening (3:00 p.m. to 11:00 p.m.) shift on March 17, 18, 21, 22, 24, 25, 26, 28, and 29, 2024, and April 1, 2, 5, and 6, 2024.

The facility failed to meet the minimum ratio of one NA for 20 residents on the night (11:00 p.m. to 7:00 a.m.) shift on March 18, 19, and 22, 2024, and April 3 and 5, 2024.


 Plan of Correction - To be completed: 05/15/2024

Step 1) Facility cannot retroactively correct

Step2 ) Facility will conduct audit of last 4 weeks of CNA staffing ratios to assess compliance

Step3) DON/Designee will educate DON / Scheduler on CNA staffing ratio regulation of 1:12 dayshift, 1:12 evening shift and 1:20 night shift per regulation. Facility will conduct daily staffing meeting to ensure ongoing compliance and systemic change

Step 4) DON / Designee will conduct 3 audits a week x 4 weeks to ensure CNA staffing ratios are met per compliance and regulation. Results will be conducted at QAPI
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 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 15 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from March 17, 2024, through April 6, 2024, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on day (7:00 a.m. to 3:00 p.m.) shift on March 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27, 2024, and April 6, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 30 residents on evening (3:00 p.m. to 11:00 p.m.) shift on March 17, 24, and 28, 2024, and April 6, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night (11:00 p.m. to 7:00 a.m.) shift on March 18, 23, 24, 30, and 31, 2024.




 Plan of Correction - To be completed: 05/17/2024

Step 1) Facility cannot retroactively correct

Step2 ) Facility will conduct audit of last 4 weeks of LPN staffing ratios to assess compliance

Step3) DON/Designee will educate DON / Scheduler on LPN staffing ratio regulation of 1:25 dayshift, 1:30 evening shift and 1:40 night shift per regulation. Facility will conduct daily staffing meeting to ensure ongoing compliance and systemic change

Step 4) DON / Designee will conduct 3 audits a week x 4 weeks to ensure LPN staffing ratios are met per compliance and regulation. Results will be conducted at QAPI
211.12(f.1)(5) LICENSURE Nursing services. :State only Deficiency.
(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.
Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum Registered Nurse (RN) to resident ratio for 13 of 21 days reviewed.

Findings include:

A review of nursing schedules for 21 days from March 17, 2024, through April 6, 2024, revealed the following:

The facility failed to meet the minimum RN to resident ratio of one RN for 250 residents on the night (11:00 p.m. to 7:00 a.m.) shift on March 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 30, 2024, and April 1, 2, 2024.


 Plan of Correction - To be completed: 05/17/2024

Step 1) Facility cannot retroactively correct

Step2 ) Facility will conduct audit of last 4 weeks of RN staffing ratios to assess compliance

Step3) DON/Designee will educate DON / Scheduler on RN staffing ratio regulation of 1:250 dayshift, 1:250 evening shift and 1:250 night shift per regulation. Facility will conduct daily staffing meeting to ensure ongoing compliance and systemic change

Step 4) DON / Designee will conduct 3 audits a week x 4 weeks to ensure RN staffing ratios are met per compliance and regulation. Results will be conducted at QAPI
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 on a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 2.87 hours of direct care for each resident for 12 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from March 17, 2024, through April 6, 2024, revealed the following total nursing care hours below minimum requirements:

March 17, 2024: 2.31 care hours per resident.
March 18, 2024: 2.54 care hours per resident.
March 22, 2024: 2.64 care hours per resident.
March 23, 2024: 2.71 care hours per resident.
March 24, 2024: 2.22 care hours per resident.
March 25, 2024: 2.66 care hours per resident.
March 26, 2024: 2.71 care hours per resident.
March 28, 2024: 2.67 care hours per resident.
March 30, 2024: 2.84 care hours per resident.
April 1, 2024: 2.69 care hours per resident.
April 5, 2024: 2.86 care hours per resident.
April 6, 2024: 2.23 care hours per resident.



 Plan of Correction - To be completed: 05/17/2024

Step 1) Facility cannot retroactively correct

Step2 ) Facility will conduct audit of last 4 weeks of PPD to assess compliance

Step3) DON/Designee will educate DON / Scheduler on PPD of 2.87 hours/ each day per regulation. Facility will conduct daily staffing meeting to ensure ongoing compliance and systemic change

Step 4) DON / Designee will conduct 3 audits a week x 4 weeks to ensure PPD hours are met per compliance and regulation. Results will be conducted at QAPI

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