Health inspection·August 2, 2024

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to make certain that weight loss was identified and addressed and identify needs for increased nutrition for eight of eleven residents (Resident R1, R2, R3, R4, R5, R6, R7, and R8). Residents Affected - Some Findings include: Review of the facility job description for the Registered Dietitian indicated the primary purpose of the job position is to implement, coordinate, and evaluate the medication nutrition therapy for the residents, provide resident and family education, provide nutritional assessment and consultation to assist in planning, organizing, and directing the food and nutritional services of the facility. Included in the list of duties and responsibilities were: assist in developing a written dietary plan of care and to review nurse's notes to determine if the care plan is being followed. Review of the facility policy, Weight Monitoring and Weight Loss Intervention last reviewed 11/30/23, indicated 'All residents will be weighed on admission, readmission and at least monthly. More frequent weights may be obtained as per facility policy. Review of the Centers for Disease Control's Adult BMI (body mass index) Categories dated 3/19/24, indicated for adults ages 20 and over, the following distributions: Underweight: Less than 18.5 Health weight: 18.5 - less than 25 Overweight: 25 - less than 30 Obesity: 30 or greater Review of the Code of Federal Regulations, §483.25(g) Quality of Care Guidance indicated: Page 1 of 12 395382 395382 08/02/2024 Kadima Rehabilitation & Nursing at Irwin 249 Maus Drive North Huntingdon, PA 15642

F 0692 Parameters for significant weight loss is defined as: Level of Harm - Minimal harm or potential for actual harm -5% or greater in one month -7.5% or greater in three months Residents Affected - Some -10% or greater in six months Review of Resident R1's admission record indicated he was originally admitted to the facility on [DATE]. Review of the facility diagnosis list included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), the presence of a Stage IV pressure wound (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer), anemia (too little iron in the body causing fatigue), and severe protein-calorie malnutrition (PCM, refers to a nutritional status where reduced availability of nutrients leads to changes in body composition and function. Review of Resident R1's most recently captured weight was 109.3 pounds, and height of 5 feet 11 inches. Resident R1's ideal body weight is documented to be 172 - 208 pounds. Review of a physician's order dated 5/20/24, with an order end date of 5/22/24, indicated for Resident R1 to be weighed each evening shift for two days. Review of Resident R1's weight record for 5/20/24 - 5/22/24, revealed no weights captured. Review of census information indicated Resident R1 was present in the facility. Review of a physician's order dated 5/28/24, indicated for Resident R1 to be weighed weekly for four weeks. Review of census information indicated Resident R1 was present in the facility during the above time from 5/28/24, through 6/14/24, and between 6/22/24, through 6/25/24. Review of Resident R1's weight record revealed one weight captured on 5/30/24 (120.0 pounds), and one weight captured on 6/12/24 (109.3 pounds), revealing an 8.9% weight loss in 13 days. Review of a physician's order dated 6/30/24, with an order end date of 7/3/24, indicated for Resident R1 to be weighed each day shift for two days. Review of Resident R1's weight record for 6/30/24 - 7/3/24, revealed no weights captured. Review of census information indicated Resident R1 was present in the facility. Review of a physician's order dated 6/30/24, with an order end date of 7/25/24, indicated for Resident R1 to be weighed weekly for four weeks. Review of census information indicated Resident R1 was present in the facility during the above order time from 6/30/24, through 7/6/24, and between 7/10/24, through 7/16/24. Review of Resident R1's weight record revealed that no weights captured during the time that Resident R1 was present in the facility. 395382 Page 2 of 12 395382 08/02/2024 Kadima Rehabilitation & Nursing at Irwin 249 Maus Drive North Huntingdon, PA 15642

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of a physician's order dated 7/10/24, with an order end date of 8/7/24, indicated for Resident R1 to be weighed weekly for four weeks. Review of census information indicated Resident R1 was present in the facility during the above order time from 7/10/24, through 7/16/24. and between 7/24/24, through 7/31/24. Review of Resident R1's weight record revealed that no weights captured during the time that Resident R1 was present in the facility. Review of a physician's order dated 5/24/24, indicated Resident R1 was to receive 30 milliliters (mL) of liquid protein supplement three times daily. This order was renewed in 6/23/24, upon readmission from the hospital on 6/22/24. The order was discontinued on 6/30/24, upon readmission to the hospital. Review of the physician orders revealed that the order was not renewed upon Resident R1's return from the hospital on 7/6/24, and only renewed on 7/17/24, related to a later hospital return on 7/16/24. Review of dietician progress notes dated 6/4/24, 6/18/24 (during resident hospitalization), and 7/18/24, all indicated Resident R1 should be receiving a liquid protein supplement. Review of Resident R2's admission record indicated she was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 7/4/24, included diagnoses of alcoholic cardiomyopathy (disease in which the long-term consumption of alcohol leads to heart failure) and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of nurse practitioner new patient assessment completed on 6/28/24, included in the listing of active medical problems moderate protein energy malnutrition. ' Review of Resident R2's most recently captured weight was 105.3 pounds, and height of 5 feet, 6 inches. Resident R2's ideal body weight is documented to be 149 - 180 pounds. Review of a physician's order dated 7/5/24, with an order end date of 8/2/24, indicated for Resident R2 to be weighed weekly for four weeks. Review of Resident R2's weight record for 7/5/24 - 7/31/24, revealed an initial weight was captured on 7/5/24, and no additional weights captured until 7/26/24. Review of census information revealed that Resident R2 was in the facility during the above time. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of anemia, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and age-related physical debility. Review of Resident R3's most recently captured weight was 134.4 pounds, and height of 5 feet, 3 inches. Resident R3's ideal body weight is documented to be 135 - 164 pounds. 395382 Page 3 of 12 395382 08/02/2024 Kadima Rehabilitation & Nursing at Irwin 249 Maus Drive North Huntingdon, PA 15642

F 0692 Review of a physician's order dated 6/10/24, with a start date of 6/19/24, and an order discontinuation date of 7/5/24, indicated for Resident R3 to be weighed weekly on Wednesdays, for four weeks. Level of Harm - Minimal harm or potential for actual harm Wednesday 6/19/24: Not documented. Residents Affected - Some Wednesday 6/26/24: 146.4 pounds. Wednesday 7/3/24: hospitalized . Review of a physician's order dated 6/24/24, with a start date of 6/25/24, and an order end date of 7/2/24, indicated for Resident R3 to be weighed weekly on daily, for seven days. 6/25/24: 151.6 6/26/24: 146.4 6/27/24: 147.1 6/28/24: Not documented. 6/29/24: 147.4 6/30/24: 147.4 7/01/24: Not documented. Review of a physician's order dated 7/12/24, with an order end date of 8/9/24, indicated for Resident R3 to be weighed weekly on Fridays, for four weeks. Friday 7/12/24: 143.0 pounds. Friday 7/19/24: 134.4 pounds. Friday 7/26/24: Not assessed. Review of Resident R3's weight record indicated: 6/11/24: 174.0 pounds. 6/15/24: 146.2 pounds. Review of a dietician progress note dated 7/30/24, at 4:11 p.m. indicated that Resident R3 had a 17 pound loss due to inaccurate weight documentation, and that her BMI was 23.8 (classified as a healthy weight), documented as indicating obesity. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of COPD, anemia, and chronic kidney disease. 395382 Page 4 of 12 395382 08/02/2024 Kadima Rehabilitation & Nursing at Irwin 249 Maus Drive North Huntingdon, PA 15642

F 0692 Review of a physician's order dated 4/29/24, with a start date of 5/8/24 and an order end date of 6/5/24, indicated for Resident R4 to be weighed weekly on Wednesdays, for four weeks. Level of Harm - Minimal harm or potential for actual harm Wednesday 5/08/24: Not assessed. Residents Affected - Some Wednesday 5/15/24: Not assessed. Wednesday 5/22/24: Not assessed. Wednesday 5/29/24: Not assessed. Review of Resident R4's weight record revealed two weights captured; 4/30/24 - 341.0 pounds, and the exact same weight captured approximately six weeks later - 341.0 pounds. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes, multiple sclerosis (a disease that affects central nervous system), and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Resident R5's plan of care dated 5/30/23, for nutrition risk indicated for staff to record and monitor weights. Review of a physician's order dated 1/2/24, indicated for Resident R5 to be weighed monthly. Review of Resident R5's weight record indicated: February: 160.2 pounds. March: 169.8 pounds. April: Not documented. May: Not documented. June: 168.6 pounds. July: Not documented. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of anemia, chronic kidney disease, and malnutrition. Review of a physician's order dated 1/9/24, with a start date of 1/11/24 and an order end date of 2/8/24, indicated for Resident R6 to be weighed weekly on Thursdays, for four weeks. Thursday 1/11/24: Not documented 395382 Page 5 of 12 395382 08/02/2024 Kadima Rehabilitation & Nursing at Irwin 249 Maus Drive North Huntingdon, PA 15642

F 0692 Thursday 1/18/24: 181.0 pounds. Level of Harm - Minimal harm or potential for actual harm Thursday 1/28/24: Not documented Thursday 2/01/24: 181.0 pounds. Residents Affected - Some Review of Resident R6's plan of care dated 3/12/24, for nutrition risk indicated for staff to record and monitor weights. Review of Resident R6's physician orders failed to include any further orders for weight monitoring. Review of Resident R6's weight record indicated: 2/1/24: 181.0. 3/7/24: 161.0, a loss of 20 pounds (11%) in 5 weeks. 4/2/24: 173.6, a gain of 12.6 pounds (7.8%) in 4 weeks. 5/2/24: 142.0, a loss of 31.6 pounds (22.8%) in approximately 4 weeks. 5/24/24: 155.0, a gain of 13 pounds (9.2%) in 3 weeks. No June weight completed. 7/2/24: 147.2, a loss of 7.8 pounds (5.0%) in approximately 6 weeks. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes, history of a stroke, and malnutrition. Review of Resident R7's most recently captured weight was 103.2 pounds, and height of 5 feet, 7 inches. Resident R7's ideal body weight is documented to be 153 - 185 pounds. Review of a physician's order dated 12/13/24, with a start date of 12/23/24, and an order end date of 1/20/24, indicated for Resident R7 to be weighed weekly on Saturdays, for four weeks. Review of census information revealed Resident R7 was present in the facility between 12/23/24, through 01/20/24. Saturday 12/23/23: Not documented. Saturday 12/30/23: Not documented. Saturday 01/06/24: Not documented. Saturday 01/13/24: Not documented. 395382 Page 6 of 12 395382 08/02/2024 Kadima Rehabilitation & Nursing at Irwin 249 Maus Drive North Huntingdon, PA 15642

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of a physician's order dated 2/8/24, with a start date of 2/9/24, and an order end date of 3/8/24, indicated for Resident R7 to be weighed every seven days for four weeks, Due to resident's inconsistent weights. Resident R7 was present in the facility between 2/9/24, through 6/28/24. Review of Resident R7's weight record from 2/9/24, through 6/28/24, revealed the following: 2/09/24: 143.8 pounds. 2/16/24: Not documented. 2/23/24: 157.8 pounds. 3/01/24: 103.2 pounds. 6/02/24: 103.2 pounds. Review of Resident R7's progress notes revealed a nutrition note on 3/12/24, and no further nutrition notes until 6/18/24. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of multiple sclerosis (a disease that affects central nervous system), rheumatoid arthritis (chronic, painful inflammatory disorder affecting many joints, including those in the hands and feet), and a seizure disorder. During an interview on 7/30/24, at 3:20 p.m. Resident R8 stated that she goes to an outside facility to get a monthly infusion for her rheumatoid arthritis. Resident R8 stated that outside facility staff ask her weight, but she has to guess. Resident R8 stated that her dosage of this medication is dependent upon her weight. Review of Resident R8's physician's orders revealed one physician order dated 4/17/24, for Resident R8 to receive an Orencia (intravenous infusion to treat rheumatoid arthritis) on 5/15/24. Review of documents uploaded to the electronic medical record indicated Resident R8 received an Orencia injection on 6/12/24, and was scheduled to receive another on 7/10/24. Review of Resident R8's progress notes revealed that she also had received an Orencia infusions on 3/20/24. Further review of Resident R8's progress notes indicated in the physician notes dating back to 1/19/23, that Resident R8 was receiving Orencia infusions. Review of a physician's order dated 2/1/24, indicated Resident R8 was to be weighed monthly. Resident R7 was present in the facility between 1/16/24, through 7/31/24, without any leaves of absence. Review of Resident R7's weight record from 2/1/24, through 7/31/24, revealed the following: 2/9/24: 167.4 pounds. 3/7/24: 167.2 pounds. 395382 Page 7 of 12 395382 08/02/2024 Kadima Rehabilitation & Nursing at Irwin 249 Maus Drive North Huntingdon, PA 15642

F 0692 April: Level of Harm - Minimal harm or potential for actual harm Not Documented. May: Residents Affected - Some Not Documented. June: Not Documented. 6/2/24: 167.2 pounds. During an interview on 7/30/24, at 3:30 p.m., the Nursing Home Administrator confirmed that the facility failed to make certain weight loss was identified and addressing a timely manner and to identify needs for increased nutrition for eight of eleven residents. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. 395382 Page 8 of 12 395382 08/02/2024 Kadima Rehabilitation & Nursing at Irwin 249 Maus Drive North Huntingdon, PA 15642

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on a review of facility policy, resident observations and interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 11 of 18 residents (Resident R5, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17). Findings include: Review of the facility policy, Nursing Department Staffing dated 11/30/23, indicated The facility will provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: -Licensed nurses -Other nursing personnel During an observation on 7/30/24, at 2:12 p.m., Resident R9, when asked if there was sufficient nursing staff stated, Some days yes. Sometimes they have three, and that's not enough. Resident R9 confirmed that he has been left in bed in urine soiled clothing and linen for an extended period of time. During an interview on 7/30/24, at 2:13 p.m., Resident R10 stated he was in agreement with Resident R9, pertaining to a lack of nursing staff. Resident R10 further stated Every light can be lit up and down the hall, no one answers. During an interview and observation on 7/30/24, at 2:52 p.m., Resident R12's call light was alarming. Resident R12 stated she would like to get back into bed. Observation at this time revealed four staff seated at the nurses station. During call lights observations on 7/30/24, beginning at 2:58 p.m. revealed: 2:58 p.m. - Residents R13/R14's room light alarming; Resident R15/R16's room alarming. Unknown start time. 3:02 p.m. - Resident R8/R10's room began alarming. 3:05 p.m. - Resident R5/R17's room began alarming. 3:11 p.m. - All four rooms remain alarming. 3:16 p.m. - Resident R5/R17's room responded to (11 minute duration). Residents R13/R14's and Resident R15/R16's room still alarming (observed time 18 minutes). Resident R8/R10's still alarming (14 minutes). During an interview on 7/30/24, at 3:20 p.m., when asked about call light response, Resident R8 stated that she waits over an hour at times. Resident R8 further stated that she has been told that she cannot have her scheduled shower due to a lack of staff. 395382 Page 9 of 12 395382 08/02/2024 Kadima Rehabilitation & Nursing at Irwin 249 Maus Drive North Huntingdon, PA 15642

F 0725 Level of Harm - Minimal harm or potential for actual harm During an interview on 7/30/24, at 3:22 p.m., Resident R11 stated that she waits a long time for call light response and for pain medication after she asks for it. During the above interviews with Resident R8 and Resident R11, a nurse aide responded to the alarming call light at 3:31 p.m., a 29 minute response time. Residents Affected - Some During an interview on 7/30/24, at approximately 3:30 p.m. the Nursing Home Administrator confirmed the facility failed to have sufficient nursing staff to provide nursing and related services to 13 of 16 residents. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(6) Management. 28 Pa. Code: 201.20(a) Staff development. 28 Pa. Code: 211.12(a) (c)(d)(1)(2)(3)(4)(5) Nursing services. 395382 Page 10 of 12 395382 08/02/2024 Kadima Rehabilitation & Nursing at Irwin 249 Maus Drive North Huntingdon, PA 15642

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on staff interviews and review of the Food Service Director's Job description, it was determined that the facility failed to employ a full-time qualified Food Service Director for six of six weeks (6/18/24 7/30/24). Finding include: Review of the facility's Food Service Director's Job Description indicated that the Food Service Director: · Must be a graduate of an accredited course in dietetic training approved by the American Dietetic Association. · Must be registered as a Food Service Director in Pennsylvania. · Must provide documentation of registry/certificate upon application for the position. During an interview on 7/30/24, at approximately 12:30 p.m. Food Service Director (FSD) Employee E1, stated that while she is currently enrolled in classes to be a Certified Dietary Manager (CDM), she currently is not certified. During an interview on 7/30/24, at 1:55 p.m. Registered Dietician Employee E2 stated that she works only one day per week, will be leaving the facility in two weeks, and further stated that she does not take any part in the operation and/or management of the dietary department, and has never done so. During an interview on 7/30/2024, at 3:30 p.m. Nursing Home Administrator (NHA) confirmed that Food Service Director Employee E1 did not possess the appropriate qualifications as required. 28 Pa. Code: 211.6(c)(d) Dietary services. 395382 Page 11 of 12 395382 08/02/2024 Kadima Rehabilitation & Nursing at Irwin 249 Maus Drive North Huntingdon, PA 15642

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of facility documents, staff interviews, and the results of the previous and current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to implement a good faith attempt to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively six of six weeks (6/18/24 - 7/30/24). Findings include: Review of the facility's Food Service Director's Job Description indicated that the Food Service Director: · Must be a graduate of an accredited course in dietetic training approved by the American Dietetic Association. · Must be registered as a Food Service Director in Pennsylvania. · Must provide documentation of registry/certificate upon application for the position. During an interview on 7/30/24, at approximately 12:30 p.m. Food Service Director (FSD) Employee E1, stated that while she is currently enrolled in classes to be a Certified Dietary Manager (CDM), she currently is not certified. Review of the facility survey ending 6/18/24, included a citation for the lack of a qualified Food Service Director. Review of the facility's plan of correction submitted for this citation included as a corrective measure the availability of a Registered Dietician to provide dietary department oversight. This facility also employs a part-time qualified dietician who is available to assist with monitoring the dietary department. During an interview on 7/30/24, at 1:55 p.m. Registered Dietician Employee E2 stated that she works only one day per week, will be leaving the facility in two weeks, and further stated that she does not take any part in the operation and/or management of the dietary department, and has never done so. During an interview on 7/30/2024, at 3:30 p.m. the Nursing Home Administrator confirmed the facility's QAPI committee failed to implement a good faith attempt to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively six of six weeks 42 CFR 483.75(a)(2)(h)(i) QAPI Program/Plan, Disclosure/Good Faith Attempt. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.18(e)(2)(3)(4) Management. 395382 Page 12 of 12