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 89 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 an abbreviated complaint survey completed on April 17, 2025, it was determined that Kadima Rehabilitation and Nursing at Luzerne was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(k).

Observations:

Based on review of clinical records, written notices of facility-initiated transfers, and staff interviews, it was determined that the facility failed to provide sufficiently detailed written notices of facility-initiated hospital transfers to the resident and the resident's representative for one of five residents sampled (Resident 1), by failing to identify the reason for the move in writing.

Findings include:

A review of the clinical record for Resident 1 revealed the following facility-initiated hospital transfers:
On February 3, 2025, Resident 1 was transferred to the hospital and returned to the facility on February 10, 2025.
On February 10, 2025, the resident was again transferred to the hospital and returned to the facility on February 12, 2025.
On February 24, 2025, the resident was transferred to the hospital and was discharged from the facility at the time of the survey.

A review of the clinical record and facility documentation revealed no evidence that written notices were provided to Resident 1 or the resident's representative for the above transfer dates.

Specifically, the notices failed to include:
The reason(s) for the transfer.
The contact information for the Office of the State Long-Term Care Ombudsman.
If applicable, the contact information for the agency responsible for the protection and advocacy of individuals with developmental disabilities or mental illness.

An interview conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 17, 2025, at approximately 1:00 PM confirmed the facility was unable to produce documentation showing that a written notice, as required by regulation, had been provided to either Resident 1 or the resident's representative for the transfers noted above.

28 Pa. Code 201.14(a) Responsibility of license

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 05/13/2025

1. The facility has provided a notice of transfer to Resident 1's guardian via certified mail.
2. An audit of discharges in the past 2 weeks was completed to ensure that the resident / resident representative was notified of the transfer and the reason for the transfer in writing.
3. The Transfer Policy was revised and licensed nurses were re educated on importance of proper notification of a resident discharge in writing, which includes the reason for the transfer in layman's terms.
4. The NHA/ designee will audit resident transferred out of facility to ensure the resident/ resident representative was notified of transfer in writing weekly x 4 then monthly x 2. Results of the audits will be reviewed at QAPI to determine if further education if needed.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

Observations:

Based on a review of clinical records and the facility's bed hold policy and staff interview it was determined the facility failed to provide written notice of the specifics of the facility's bed hold policy to the resident, responsible party or legal representative at the time of the transfer, to include the duration and reserve bed payment for one resident out of five sampled (Resident 1).

Findings include:

A review of a facility policy for "bed hold" (no policy review date available at the time of the survey) revealed, for Medicaid residents, the bed will be held while a resident is in the hospital or on therapeutic leave. Medicaid pays for hospitalization of 15 days and therapeutic leave of 30 days. The resident is allowed to return to the facility in this time frame. If there is no bed available at the facility, on the date of hospital discharge, the facility will make every effort to place the resident in a local facility.

A review of Resident 1's clinical record revealed the resident was admitted to the facility on April 22, 2024. A review of an admission Minimum Data Set assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) indicated that the resident was severely cognitively impaired with a BIMS score of 3 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 0 to 7 indicating severe, cognitive impairment) and a diagnosis of dementia and a history of alcohol abuse.

Further review of the record revealed that Resident 1 had been adjudicated incapacitated by the court on April 4, 2023, with a guardian appointed to oversee both medical and financial decisions. At the time of the survey, only the first page of the four-page guardianship order was present in the clinical record. During an interview with the Director of Social Services on April 17, 2025, at 11:00 AM, she acknowledged the complete guardianship order was not on file and confirmed she had to contact the guardian during the survey to obtain the remaining pages, which were subsequently placed in the record.

Review of the admission agreement including decisions for care and treatment provided by the facility, dated April 22, 2024, revealed it included information regarding resident transfers and the facility's bed-hold policy. The agreement was signed by Resident 1; however, there was no documented evidence that the court-appointed guardian had reviewed or signed the agreement, nor that a copy of the agreement and the facility's bed-hold policy had been provided to the guardian upon admission.

Resident 1 was transferred to the hospital on three occasions: February 3, 2025; February 10, 2025; and February 24, 2025. There was no documented evidence that the resident's guardian was provided written notice at the time of transfer or within 24 hours of transfer, detailing the facility's bed-hold policy, including the duration of the bed-hold, if any; any associated reserve bed payment agreement; or the resident's right to return to the next available bed.

The facility failed to provide written bed-hold information to the representative of a resident who had a documented diagnosis of dementia, was severely cognitively impaired, and had been legally declared incapacitated. This information is critical to ensuring the resident's representative can make informed decisions regarding the resident's care and potential return to the facility.

During an interview with the Nursing Home Administrator (NHA) on April 17, 2025, at approximately 11:15 AM, the NHA stated that the business office manager (BOM) was responsible for issuing bed-hold information. She further reported the facility had not had a BOM "for a long time" and was unable to provide the previous BOM's dates of employment. The NHA confirmed the facility did not issue any written notice of its bed-hold policy to the resident's representative at the time of Resident 1's hospital transfers on the dates noted above.

28 Pa Code 201.18 (b)(1) Management

28 Pa Code 201.29 (b)Resident rights

Plan of Correction - To be completed: 05/13/2025

1. The facility has provided a Bed Hold Notification Letter and Bed Hold Policy to Resident 1's Guardian via certified mail.
2. An audit of discharges/transfers in the past 2 weeks was completed to ensure that the resident/ resident representative received a "Bed Hold Notification Letter".
3. The Licensed nurses and BOM were reeducated on the Bed Hold Notification Policy.
4. The NHA/ designee will audit transfers/ discharges weekly x 4 then monthly x 2 to ensure that the resident/ resident representative was notified of the Bed Hold Policy. Results of the audits will be reviewed at QAPI to determine if further education is needed.

483.15(e)(1)(2) REQUIREMENT Permitting Residents to Return to Facility:

§483.15(e)(1) Permitting residents to return to facility.
A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following.
(i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident-
(A) Requires the services provided by the facility; and
(B) Is eligible for Medicare skilled nursing facility services or Medicaid
nursing facility services.
(ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.

§483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.

Observations:

Based on review of clinical records, facility policy provided to residents upon transfer from the facility, and interview with facility staff revealed the facility failed to demonstrate the implementation of specifically delineated procedures for Medicaid payor source bed holds and the provision of notices of the facility's bed hold policy in an understandable language that allow a resident to return to the facility after a transfer to the emergency room for one resident out of five reviewed. (Resident 1).

Findings include:

A review of the facility's policy titled "Bed Reservations for Medicaid Covered Residents" (no policy revision date noted) indicated that Medicaid residents are permitted a maximum of 15 consecutive bed-hold days per hospitalization. The policy further states that residents shall be allowed to return to the nursing facility immediately upon the first availability of a bed in a semi-private room, provided the resident continues to require the facility's services.

A review of Resident 1's clinical record revealed the resident was covered under a Medicaid managed care plan and was transferred to the hospital on February 24, 2025, for behavioral concerns, including physical aggression toward staff. Nursing documentation on that date described the resident as increasingly agitated, unresponsive to redirection, and having physically assaulted a nurse. The physician and emergency services were contacted, and the resident was sent to the emergency department at 7:51 AM.

Despite the facility's policy and the resident's Medicaid status, there was no documented evidence that a written notice of the facility's bed-hold or readmission policy, specifically regarding the 15-day Medicaid bed-hold entitlement, was provided to the resident or the resident's representative at the time of transfer. There was no evidence the resident or responsible party was informed in writing about their rights to return, nor any indication that they accepted or declined a bed hold.

Social service notes dated February 26 and 27, 2025, documented that attempts were made to place Resident 1 in other facilities due to his behaviors. All contacted facilities declined to accept the resident. The clinical record from February 28 through March 10, 2025, indicated the resident remained hospitalized, with no documented discharge plan from the facility.

Documentation submitted during the survey included multiple emails from hospital staff between February 25 and March 11, 2025, requesting that Resident 1 be readmitted. On February 25, 2025, the facility's corporate admissions representative stated the resident would not be accepted back until specific conditions were met: no need for one-to-one supervision or video monitoring, no use of PRN (as needed) medications or restraints, and a minimum of 72 hours free from behavioral interventions. Despite continued requests from the hospital through March 11, 2025, the facility did not permit the resident's return.

There was no evidence of clinical reassessment or documented evaluation by the facility regarding its ability to meet Resident 1's care needs. The facility did not demonstrate efforts to coordinate with the hospital to plan for the resident's return. Furthermore, there were no transfer or discharge planning documents completed by the facility, and the resident's record did not include documentation of the decision to decline or accept a bed-hold.

During an interview on April 17, 2025, the Nursing Home Administrator and Director of Nursing confirmed that the resident was initially admitted per corporate directive. Both acknowledged the resident had a history of aggressive behaviors and stated that due to concerns for the safety of staff and other residents, the facility determined it could not meet his needs. However, there was no documented evidence that the facility conducted a formal review of its ability to accommodate the resident's behavioral health needs upon potential readmission.

28 Pa Code 201.18 (b)(1) Management

28 Pa Code 201.29 (b)Resident rights

Plan of Correction - To be completed: 05/13/2025

1. The facility is unable to retroactively correct.
2. An audit of residents transferred to an acute care facility in the past 2 weeks was completed to ensure that a discharge plan is documented, if applicable.
3. Residents will be readmitted according to the resident assessment and physician recommendations. The residents' medical chart will contain required documentation by the IDT and the resident physician. The IDT members will be re-educated on the importance of documentation of assessment and discharge/readmission plans in the medical records.
4. The NHA/ designee will audit transfers to acute care for accurate documentation in the medical record regarding a readmission plan or a discharge plan is complete, weekly x 4 weeks then monthly x 2 months. The audits will be reviewed at QAPI to ensure compliance and the need for further education is needed,

§ 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.

Observations:

Based on a review of nurse staffing data and staff interview, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 5 shifts out of 21 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following date the facility failed to provide minimum nurse aide staff of 1:11 on the evening shift, and 1:15 on the night shift based on the facility's census:

April 11, 2025, 2.6 NAs on the evening shift, versus the required 3.18, for a census of 35
April 14, 2025, 2.27 NAs on the evening shift, versus the required 3.18, for a census of 35
April 14, 2025, 2 NAs on the night shift, versus the required 2.33, for a census of 35
April 15, 2025, 3 NAs on the evening shift, versus the required 3.18, for a census of 35
April 16, 2025, 2 NAs on the night shift, versus the required 2.33, for a census of 35

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

An interview with the Director of Nursing, on April 17, 2025, at approximately 1:30 PM, confirmed the facility had not met the required NA to resident ratios on the above dates.

Plan of Correction - To be completed: 05/13/2025

1 The facility is unable to retroactively provide a minimum CNA ratio for cited dates.
2.An audit was completed to ensure ratios were met. Recruitment offers 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 CNAs.
4.The DON or designee will conduct an audit of the CNA 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. :

(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 data and staff interview, it was determined the facility failed to ensure the minimum licensed practical nurse ratio to resident was provided on each shift for 1 shift out of 21 reviewed.

Findings include:

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

April 16, 2025, 0 LPNs on the night shift, versus the required 1, for a census of 35

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

An interview with the Director of Nursing, on April 17, 2025 at approximately 1:30:PM, confirmed the facility had not met the required LPN to resident ratios on the above dates.

Plan of Correction - To be completed: 05/13/2025

1.The facility is unable to retroactively provide a minimum LPN ratio for cited dates.
2.An audit was completed to ensure LPN ratios were met. Recruitment offers sign on bonuses for new hires 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 LPN 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)(5) LICENSURE Nursing services. :

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

Observations:

Based on a review of nurse staffing data and staff interview, it was determined the facility failed to ensure the minimum registered nurse staff to resident ratio was provided on each shift for 3 shifts out of 21 reviewed.

Findings include:

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

April 11, 2025, 0 RNs on the night shift, versus the required 1, for a census of 35
April 14, 2025, 0 RNs on the night shift, versus the required 1, for a census of 35
April 15, 2025, 0 RNs on the night shift, versus the required 1, for a census of 35

An interview with the Director of Nursing, on March 17, 2025, at approximately 1:30 PM, confirmed the facility had not met the required RN to resident ratios on the above dates.

Plan of Correction - To be completed: 05/13/2025

The facility is unable to retroactively provide a minimum RN ratio for cited dates.
2.An audit was completed to ensure RN ratios were met. Recruitment offers sign on bonuses to new hires 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 RN's.
4.The DON or designee will conduct an audit of the RN 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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