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:

Findings of an abbreviated complaint survey completed on April 17, 2026, at Kadima Rehabilitation and Nursing at Luzerne identified no new deficient practice related to the reported complaint allegations, under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities as they relate to the Health portion of the survey process, however deficient practice was identified under the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.\~

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 05/04/2026

1. The facility is unable to retroactively correct the staffing requirements.
2. An audit will be conducted, on the past 14 days, to ensure the nursing assistant's ratios have been met.
3. Education will be provided to the administrative assistant on the importance of ensuring the Nurse Aide to resident ratios are met.Job posting updated to reflect new bonus structure for recruitment and retention
4. An audit will be completed, weekly x 4 then monthly x 2, to ensure the nurse's aide to resident ratios are met. The results of the audits will be reviewed at QAPI for trends and for the need to be reeducated.

§ 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.

Observations:

Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum licensed practical nurse ratio to resident ratio was provided on each shift for 3 shifts out of 42 shifts reviewed.

Findings include:

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

March 25, 2026- 1.03 LPNs on the evening shift, versus the required 1.17, for a census of 35.

March 26, 2026- 1.03 LPNs on the evening shift, versus the required 1.17 for a census of 35.

April 11. 2026- 1.03 LPNs on the day shift, versus the required 1.44 for a census of 36.

On the above dates mentioned, no additional excess higher-level staff were available to compensate for this deficiency.

An interview with the Nursing Home Administrator, on April 17, 2026, at 1:15 PM, reviewed the aforementioned findings.

Plan of Correction - To be completed: 05/04/2026

1. The facility is unable to retroactively correct the staffing requirements.
2. An audit will be conducted, on the past 14 days, to ensure the Licensed Nurses ratios have been met.
3. Education will be provided to the administrative assistant on the importance of ensuring the LPN to resident ratios are met.Job postings updated to reflect new bonus structure for recruitment and retention
4. An audit will be completed, weekly x 4 then monthly x 2, to ensure the Licensed practical nurse to resident ratios are met. The results of the audits will be reviewed at QAPI for trends and for the need to be reeducated.

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Plan of Correction - To be completed: 05/04/2026

The facility is unable to retroactively correct the staffing requirements.
2. An audit will be conducted, on the past 14 days, to ensure the Registered Nurses ratios have been met.
3. Education will be provided to the administrative assistant on the importance of ensuring the RN to resident ratios are met.Job postings updated to reflect new bonus structure for recruitment and retention
4. An audit will be completed, weekly x 4 then monthly x 2, to ensure the RN to resident ratios are met. The results of the audits will be reviewed at QAPI for trends and for the need to be reeducated.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, 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 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 3.2 hours of general nursing care to each resident per the regulation effective July 1, 2024:

March 23, 2026- 3.05 direct care nursing hours per resident.

March 24, 2026- 3.16 direct care nursing hours per resident.

March 25, 2026- 3.05 direct care nursing hours per resident.

April 11, 2026- 3.03 direct care nursing hours per resident.

The facility's general nursing hours were below minimum required levels on the dates noted above.

An interview with the Nursing Home Administrator on April 17, 2026, at 1:15 PM reviewed the findings that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Plan of Correction - To be completed: 05/04/2026

1.The facility is unable to retroactively correct PPD for dates cited.
2. A wide audit of the facility was completed to ensure the minimum PPD of 3.2 hours are met daily for each resident
3. The DON/ Designee were reeducated on the total number of hours of general nursing care provided in each 24-hour period be a minimum of 3.2 hours. The DON will review the census daily to ensure 3.2 hours of nursing care are being provided within a 24-hour period. If staffing levels are not being met, DON will instruct the scheduler to adjust the schedule by filling any gaps with per diem staff. The facility continues all effort to recruit and hire licensed staff.
4. The DON/ Designee will conduct an audit of daily staffing sheets weekly x 4 weeks and then monthly x 2 months to ensure facility meets the minimum daily 3.2 nursing hours for each resident. The results will be submitted to the QAPI committee for review and analysis of need of ongoing monitoring

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