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

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KADIMA REHABILITATION & NURSING AT POTTSTOWN
Inspection Results For:

There are  99 surveys for this facility. Please select a date to view the survey results.

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KADIMA REHABILITATION & NURSING AT POTTSTOWN - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a revisit survey completed on January 18, 2024 it was determined that Kadima Rehabilitation and Nursing at Pottstown failed to correct the deficiencies identified during the survey of November 6, 2023 and continued to be out of compliance with the following requirements of 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 review of facility staffing data, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents on day and evening shift for ten of thirteen days of facility staffing reviewed.

Findings include:

Review of the staffing for the days of January 5, 2024 through January 17, 2024, revealed the following dates and shifts did not meet the requirement of one nurse aide per 12 residents:

January 5, 2024 3-11 shift
January 6, 2024 7-3 and 3-11 shifts
January 7, 2024 7-3 and 3-11 shifts
January 10, 2024 3-11 shift
January 11, 2024 7-3 and 3-11 shift
January 12, 2024 7-3 and 3-11 shift
January 13, 2024 7-3 shift
January 14, 2024 7-3 and 3-11 shift
January 15, 2024 7-3 and 3-11 shift
January 16, 2024 7-3 and 3-11 shift

Interview with the Nursing Home Administrator on January 18, 2024 at 12:30 p.m. confirmed that the aide staffing ratios were not met on the above days and shifts.





 Plan of Correction - To be completed: 04/01/2024

1. The facility is unable to retroactively provide minimum CNA ratio for 1/18/2024.
2. A facility wide audit was completed to ensure ratios were met. Continue to recruit with increased CNA sign on bonuses, and wages are competitive with surrounding areas. Agency to assist with staffing ratios while hiring.

3. The DON and recruitment were 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 X2 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 review of facility staffing data, it was determined that the facility failed to ensure a minimum of one LPN per 30 residents on evening shift for five of thirteen days of facility staffing reviewed.

Findings include:

Review of the staffing for the days of January 5, 2024 through January 17, 2024, revealed the following dates and shifts did not meet the requirement of a minimum of 1 LPN per 30 residents on evening shift for the following dates.

January 8, 2024
January 11, 2024
January 13, 2024
January 16, 2024
January 17, 2024

Interview with the Nursing Home Administrator on January 18, 2024 at 12:30 p.m. confirmed that the LPN staffing ratios were not met on the above days and shifts.


 Plan of Correction - To be completed: 04/01/2024

1. The facility is unable to retroactively provide minimum LPN ratio for 1/18/2024.
2. A facility wide audit was completed to ensure ratios were met. Continue to recruit with increased LPN sign on bonuses, and wages are competitive with surrounding areas. Agency to assist with staffing ratios while hiring.

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 X2 months. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.


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