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

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KADIMA REHABILITATION & NURSING AT LUZERNE
Inspection Results For:

There are  78 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 survey completed on December 28, 2023, it was determined that Kadima Rehabilitation and Nursing at Luzerne corrected the federal deficiencies cited during the survey ending October 26, 2023, 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. :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 nurse staffing schedules, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for six shifts out of 63 shifts reviewed.

Findings include:

A review of the facility's daily employee staffing sheets from December 7, 2023, to December 27, 2023, revealed that the facility failed to provide minimum nurse aide staff of 1:12 residents during the day and evening shifts and 1:20 during the night shift, as per the facility's census.

December 13, 2023: 1 nurse aide on the night shift, versus the 2 required for a census of 33 residents.
December 20, 2023: 2 nurse aides on the evening shift, versus the 3 required for a census of 32 residents.
December 23, 2023: 1 nurse aide on the night shift, versus the 2 required for a census of 33 residents.
December 24, 2023: 2 nurse aides on the day shift, versus the 3 required for a census of 32 residents
December 24, 2023: 1 nurse aide on the evening shift, versus the 3 required for a census of 32 residents.
December 25, 2023: 2 nurse aides on the evening shift, versus the 3 required for a census of 32 residents.

The facility failed to meet the required nurse aide to resident ratios on the above six shifts.



 Plan of Correction - To be completed: 01/31/2024

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 was re-educated on ensuring that the nursing care ratios are provided, and that the facility is actively recruiting CNAs.
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. :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 nurse staffing schedules it was determined that the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for 20 shifts out of the 63 shifts reviewed.

Findings include:

A review of the facility's daily employee staffing sheets from December 7, 2023, to December 27, 2023, revealed that the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:30 during the evening shift and 1:40 during the night shift, as per the facility's census.

December 7, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 30 residents.
December 8, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 31 residents.
December 9, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 33 residents.
December 10, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 33 residents.
December 11, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 33 residents.
December 12, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 33 residents.
December 13, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 33 residents.
December 14, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents.
December 15, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents.
December 18, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents.
December 19, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents.
December 20, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents.
December 21, 2023 - 1 LPNs during the evening shift, versus the required 2 for a census of 33 residents.
December 21, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 33 residents.
December 22, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 33 residents.
December 23, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 33 residents.
December 24, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents.
December 25, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents.
December 26, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents.
December 27, 2023 - 0 LPNs during the night shift, versus the required 1 for a census of 32 residents.


During an interview on December 28, 2023, at approximately 10:30 AM, the Director of Nursing confirmed that the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on the above shifts.








 Plan of Correction - To be completed: 01/31/2024

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.
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.


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