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

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KADIMA REHABILITATION & NURSING AT LAKESIDE
Inspection Results For:

There are  87 surveys for this facility. Please select a date to view the survey results.

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KADIMA REHABILITATION & NURSING AT LAKESIDE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a revisit completed on Janaury 5, 2024, it was determined that Kadima Rehabilitation & Nursing at Lakeside failed to correct the deficiencies cited during the survey of December 7, 2024, and continued to have a deficiency with the potential for no more than minimal harm to residents under the requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and was not in compliance with the the following requirements of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.24(c)(2)(i)(ii)(A)-(D) REQUIREMENT Qualifications of Activity Professional:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
§483.24(c)(2) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who-
(i) Is licensed or registered, if applicable, by the State in which practicing; and
(ii) Is:
(A) Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or
(B) Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or
(C) Is a qualified occupational therapist or occupational therapy assistant; or
(D) Has completed a training course approved by the State.
Observations:

Based on staff interviews and a review of employee personnel records it was determined the facility's activities program was not directed by a qualified professional.

Findings included:

Interview with the nursing home administrator (NHA) and review of staff personnel records on January 5, 2024, at approximately 11:30 AM revealed that Employee 2 was hired by the facility on December 11, 2023, and did not possess the regulatory required qualifications for an activities director in long term care.

A review of Employee 2's personnel record confirmed that the employee did not possess the regulatory required qualifications for the position of director of activities

During this interview with the nursing home administrator it was determined that Employee 2 was hired by the facility on January 4, 2023 and was also not a qualified therapeutic recreation specialist or an activities professional.

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28 Pa. Code 201.3 Definitions.

28 Pa. Code 201.18(e)(6) Management












 Plan of Correction - To be completed: 02/06/2024

0680
1. Employee 2 is enrolled in a course to become a qualified activities professional.
2. Employee 2 is being overseen by an Occupational Therapist who works in the facility. The activities calendars, programming, care plans and MDS assessments are being reviewed.
3. The NHA was re-educated on ensuring a qualified activities professional is placed in charge of the activities program of the facility. This was an isolated incident due to a necessary employee termination.
4. The NHA or designee will complete an audit of course progress weekly x until the activities certification course is completed to ensure adequate progress is made each week. The 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. :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 and staff interview, it was determined that the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for one shift out of three shifts reviewed.

Findings include:

A review of the facility's nurse staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:25 on the day shift and 1:30 on the evening shift and 1:40 on the night shift based on the facility's census.

January 4, 2024 - 1 LPN on day shift versus, the required 1.25 full time equivalent for a census of 26 residents.

Interview with the Direcor of Nursing (DON) on January 5, 2023, at approximately 3:30 PM, confirmed that the facility failed to meet the required LPN to resident ratio on the date and shift indicated above.






 Plan of Correction - To be completed: 02/06/2024

5530
1. There were no ill effects suffered by any resident due to the facility's failure to meet the ratio for resident to LPN for 31 shifts.
2. The facility uses agency staffing and has continuous open position advertising on employment sites in order to attract additional staff. We also offer incentives to current employees to work extra hours and shifts.
3. Nursing staff will be educated to the importance of good work attendance and how this is very important to meeting the required ratio and ppd.
4. A weekly audit of nursing call-off will be completed x 4 weeks and then monthly x 2 months with a report to 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 nurse staffing and staff interview, 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 three shifts reviewed.

Findings include:

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

January 4, 2024 - 0 RN on night shift versus, the required 1 for a census of 26.

An interview with the Director of Nursing (DON) on January 5, 2024, at approximately 3:31 PM, confirmed that the facility had not met the required RN to resident ratios on the above shift.




 Plan of Correction - To be completed: 02/06/2024


5540
1. There were no ill effects suffered by any resident due to the facility's failure to meet the ratio for resident to RN for 21 shifts.
2. The facility uses agency staffing and has continuous open position advertising on employment sites in order to attract additional staff. We also offer incentives to current employees to work extra hours and shifts.
3. Nursing staff will be educated to the importance of good work attendance and how this is very important to meeting the required ratio and ppd.
4. A weekly audit of nursing call-off will be completed x 4 weeks and then monthly x 2 months with a report to QAPI.


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