Inspection·April 20, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide written notice of facility initiated transfer to the hospital identifying the reason for the transfer in a language and manner easily understand by one resident (Resident 9) and failed to provide written notice of the facility initiated transfer to the hospital to the resident's representative for one resident out of six sampled (Resident 34). Findings include: A review of Resident 9's clinical record revealed that the resident was transferred to the hospital on March 2, 2023, and returned to the facility on March 30, 2023. The identified reason for the resident's transfer was noted as low hemoglobin (A hemoglobin test measures the amount of hemoglobin in your blood. Hemoglobin is a protein in your red blood cells that carries oxygen to your body's organs and tissues and transports carbon dioxide from your organs and tissues back to your lungs. If a hemoglobin test reveals that your hemoglobin level is lower than normal, it means you have a low red blood cell count {anemia}). A review of Resident 34's clinical record revealed that the resident was admitted to the facility on [DATE], and was severely cognitively impaired. The resident was transferred to the hospital on April 11, 2023, and returned to the facility on April 15, 2023. There was no indication that the resident's representative was provided written notice of the resident's transfer to the hospital. Interview with the Administrator on April 19, 2023, at approximately 10:30 a.m. confirmed that Resident 9's reason for the transfer was not written in a language and manner easily understood. The NHA also verified that the facility was unable to provide evidence that written notice was provided to Resident 34's representative. The NHA stated that the facility did not have a mailing address for Resident 34's representative, although the resident had resided in the facility since March 17, 2023, and was severely cognitively impaired. 28 Pa. Code 201.29(h) Resident rights 28 Pa. Code 201.14(a) Responsibility of Licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 2 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of three resident out of 14 sampled (Resident 9, 34, and 12). Residents Affected - Some Findings include: The Significant change MDS Assessment of Resident 9, dated October 7, 2022, revealed that Section A 1500 was coded as 0 indicating that the resident was not considered by the State to require a Level II PASRR admission screening process, to have serious mental illness, and/or intellectual disability or mental retardation or a related condition. (Preadmission Screening and Resident Review {PASARR} is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings). However, a review of Resident 9's clinical record revealed a Level I PASRR was completed on June 28, 2021, which indicated that the resident did not meet the criteria for a Level II PASRR, However, an appeal of the decision and a determination made by the Pennsylvania Department of Human Services, Office of Developmental Programs on July 7, 2021, indicated Resident 9 needed special services for Intellectual Disabilities (ID). A review of Resident 34's admission MDS assessment dated [DATE], indicated in Section N0410 Medications Received that Insulin injections were received seven times in the last seven days. Review of the Resident 34's March 2023 Medication Administration Record (MAR) revealed that Resident 34 was hospitalized [DATE], and March 19, 2023, and not present in the facility. According to the MAR the resident received Insulin injections on only five days during the look back period. A review of Resident 12's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a mental condition with episodes of mood swings ranging from depressive lows to manic highs). A review of Resident 12's admission MDS assessment dated [DATE], indicated Section A 1500 was coded as 0 indicating that the resident was not considered by the State to require a Level II PASRR process, to have serious mental illness, and/or intellectual disability or mental retardation or a related condition. However, a review of Resident 12's clinical record revealed a Level I PASRR was completed on March 17, 2023, which indicated that the resident did meet the criteria for a Level II PASRR. A determination letter dated March 21, 2023 from the Pennsylvania Department of Health Office of Mental Health and Substance Abuse confirmed Resident 12's need for specialized services due to a mental condition. Interview with the Director of Nursing on April 19, 2023, at approximately 11:50 a.m. confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 3 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm that Resident 9's Significant change MDS assessment dated [DATE], was inaccurate, with respect to completion of Section A 1500 related to the PASRR, Resident 34's admission MDS assessment dated [DATE] was inaccurate with respect to completion of Section N0410 Medications Received related to Insulin injections, and Resident 12's admission MDS assessment dated [DATE], was inaccurate with respect to completion of Section A 1500 related to the PASRR. Residents Affected - Some 28 Pa. Code 211.5(g)(h) Clinical records 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 4 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on clinical record review and staff interview, it was determined that the facility failed to incorporate the recommendations from the Pre-admission Screening and Resident Review (PASARR) level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for two of three residents reviewed (Residents 12 and 4). Findings include: Review of clinical record of Resident 12 revealed diagnoses to include schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a mental condition with episodes of mood swings ranging from depressive lows to manic highs). Further review of Resident 12's clinical record revealed a PASARR Level I (federally required assessment to help ensure that all individuals with serious mental disorders and/or intellectual disabilities are not inappropriately placed in nursing homes for long term care) dated March 17, 2023, with the following outcome: Individual has a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition; requires further evaluation (Level II). A PASARR Level II determination letter dated March 21, 2023, indicated that, You do have evidence of a Mental Health condition that meets the criteria for review by the Office of Mental Health and Substance Abuse Services (OMHSAS). You may benefit from specialized mental health services. The County Mental Health office shall assist the nursing facility in accessing mental health services for you in accordance with OMHSAS Bulletin-16-11. The treatment must be provided by qualified mental health professionals, and treatment can include partial psychiatric hospitalization, peer support services, psychiatric outpatient clinic services, mobile mental health treatment, crisis intervention services, targeted mental health care management, and outpatient drug and alcohol services. Residents who reside in the Nursing Facility may receive specialized mental health services either in the facility or in the community. Review of Resident 12's current care plan conducted during the survey ending April 20, 2023, revealed no care plan developed in relationship to the PASARR II determination. The care plan failed to identify the individual and specific referrals made, or services recommended and/or provided to the resident as the result of the resident's mental health condition and PASARR II. Review of clinical record of Resident 4 revealed diagnoses to include schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a mental condition with episodes of mood swings ranging from depressive lows to manic highs). Further review of Resident 4's clinical record revealed a PASARR Level I (federally required assessment to help ensure that all individuals with serious mental disorders and/or intellectual disabilities are not inappropriately placed in nursing homes for long term care) dated November 15, 2022, with the following outcome: Individual has a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition; requires further evaluation (Level II). A PASARR Level II determination letter dated February 8, 2023, indicated that, You do have evidence of a Mental Health condition that meets the criteria for review by the Office of Mental Health and Substance Abuse Services (OMHSAS). You may benefit from specialized mental health services. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 5 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some County Mental Health office shall assist the nursing facility in accessing mental health services for you in accordance with OMHSAS Bulletin-16-11. The treatment must be provided by qualified mental health professionals, and treatment can include partial psychiatric hospitalization, peer support services, psychiatric outpatient clinic services, mobile mental health treatment, crisis intervention services, targeted mental health care management, and outpatient drug and alcohol services. Residents who reside in the Nursing Facility may receive specialized mental health services either in the facility or in the community. Review of Resident 4's current care plan conducted during the survey ending April 20, 2023, revealed no care plan developed in relationship to the PASARR II determination. The care plan failed to identify the individual and specific referrals made, or services recommended and/or provided to the resident as the result of the resident's mental health condition and PASARR II. An interview with the Director of Nursing on April 20, 2023 at 10:00 AM confirmed that the PA-PASARR-ID II form completed had identified Residents 12 and 4 as target residents and were unable to provide evidence of coordination of services including care planning. There was no evidence at the time of the survey that the facility had timely identified and coordinated the provision of specialized services for Residents 12 and 4. Refer F745 28 Pa. Code 211.16(a)(b) Social Services 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services 28 Pa. Code 211.5(f) Clinical Records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 6 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm Based on a review of clinical records and resident and staff interview it was determined that the facility failed to develop and implement an individualized discharge plan for one of two residents reviewed for discharge planning (Resident 6). Residents Affected - Few Findings Include: A review of Resident 6's clinical record revealed admission to the facility on August 19, 2022, with diagnoses including congestive heart failure (chronic condition in which the heart does not pump as well as it should) and depression. During interview with Resident 6 on April 18, 2023, at 10:00 AM the resident stated that he was satisfied at the facility, but if possible, would like to transfer to a facility, which allowed smoking. There was no evidence of the resident's discharge plans or assessment of the resident's potential for discharge to lesser level of care, identification of the resident's discharge goals or if the resident's placement was long term. Review of Resident 6's current plan of care, in effect at the time of the survey ending April 20, 2023, revealed no documented evidence of the resident's discharge goals or the development of a discharge plan to meet this resident's goals for discharge. The resident's care plan did not identify that the resident was to remain in the facility for continuing long term care. Interview with the administrator on April 20, 2023, at approximately 10:00 AM failed to provide documented evidence that a functioning discharge planning process, that begins on admission, and involves identifying each resident's discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure a successful discharge had been developed for Resident 6. Refer F745 28 Pa. Code 211.11 (d)(e) Resident care plan 28 Pa. Code 211.16 (a)(b) Social Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 7 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and interviews with staff and resident it was determined that the facility failed to consistently provide a functional communication system to maintain the resident's ability to communicate for one resident with communication needs out of 14 sampled residents (Resident 32). Residents Affected - Few Findings included: An admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan a resident's care) dated March 10, 2023, revealed Resident 32 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact) and that the resident's preferred language was Spanish. A review of clinical record revealed that Resident 32 was admitted to the facility on [DATE], with diagnoses to include diabetes, anxiety, acute respiratory failure with hypoxia, tracheostomy, and gastro-esophageal reflux disease (GERD). A nurses' note dated March 3, 2023, at 2:17 PM, indicated the resident was admitted to facility at this time. The resident's daughter was present at bedside at this time. The entry noted that the resident speaks Spanish and a translator was at the resident's bedside. Interview with Resident 32, on April 19, 2023, at approximately 8:05 AM, revealed that the resident was lying in bed. After knocking, and obtaining visual acknowledgment of entrance, the surveyor entered the resident's room. There was no communication binder-book or communication board visibly present in the resident's room to allow the survey or to communicate with the resident. An attempt was made to communicate with the alert and oriented resident in English, but the resident did not appear to understand. A second observation of Resident 32, on April 19, 2023, at approximately 9:55 AM, in the presence of the Director of Nursing (DON), revealed the resident was sitting up in bed. During this the DON confirmed that there was no communication binder-book , communication or other communication tool present in the resident's room to communicate with the resident A review of Resident 32's comprehensive plan of care in effect during the survey ending April 20, 2023, revealed that the resident's care plan did not address that the resident's primary spoken language was Spanish and failed to address the resident's communication needs and the measures planned to maintain the resident's communication abilities and methods for staff to effectively communicate with the resident in the absence of an interpreter. Interview with the Nursing Home Administrator (NHA) on April 19, 2023, at approximately 1:45 PM, confirmed that the facility failed to develop and implement a functional system to maintain this resident's communication abilities Refer F745 28 Pa. Code 211.11 (d)(e) Resident care plan FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 8 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to provide restorative nursing services planned to maintain the functional abilities and declines in range of motion for one of three sampled residents (Resident 22). Findings include: A review of the clinical record revealed that Resident 22 was admitted to the facility on [DATE], with diagnoses that included Hemiplegia (in its most severe form, complete paralysis of half of the body) and Hemiparesis (unilateral paresis, is weakness of one entire side of the body) following cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood) affecting the left non dominant side. An occupational therapy Discharge summary dated [DATE], indicated that Resident 22 was to wear a left had orthotic (splint or brace) at bedtime to prevent further contracture and manage tone. A Restorative Nursing Program (RNP) was to be established for the splint. There was no documented evidence that the resident was participating in a restorative nursing program following discharge from OT on February 3, 2023, through April 19, 2023, the time of surveyor inquiry. Interview with the Director of Therapy on April 19, 2023, at 10:30 AM confirmed that the facility failed to provide the restorative nursing program planned for Resident 22's splint use following discharge from OT on February 3, 2023. 28 Pa. Code: 211.5(f) Clinical records 28 Pa Code 211.12 (a)(c)(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 9 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select incident reports and resident and staff interviews it was determined that the facility failed to ensure the provision of necessary supervision during meals to promote resident safety while eating as required by one resident out of 14 residents sampled Findings include: A review of Resident 7's clinical record revealed that she was admitted to the facility February 12, 2020, with diagnoses to include dementia, anxiety, protein - calorie malnutrition, dysphagia (difficulty swallowing), and malignant neoplasm of the larynx, and tongue. A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated January 31, 2023, revealed that the resident was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact), and required staff supervision with eating, with one person physical assistance. A review of the resident's care plan initially dated, February 19, 2020, revealed a focus area that the resident is nutritionally at risk related to malignant neoplasm of tongue and larynx, and dysphagia. The planned interventions to assist the resident included regular diet with puree texture and thin consistency liquids. Allow mechanical soft snacks of choice, including graham crackers with milk, cheese puffs and cakes/cupcakes, with staff supervision during activities, dated as resolved March 31, 2023. The resident had a physician order December 23, 2022, for a regular diet, puree texture, thin consistency, double portions per resident request and a divided plate with all meals. The order also noted to allow mechanical soft snacks of choice with supervision. Nursing documentation dated March 30, 2023, at 3:34 PM, indicated that Resident 23 (Resident 7's roommate) was heard calling for help. A licensed practical nurse (LPN) responded to the residents' room and observed that Resident 7 was unable to talk or cough. Resident 7 nodded and grabbed at her neck to indicate that she was choking. The LPN immediately began abdominal thrusts x 2, less than 30 seconds later the resident was able to clear on own with cough. Registered Nurse (RN) in to assess RT. No acute distress noted. The resident was speaking and coughing. Lungs clear to auscultation. O2 saturation 94%. The resident stated that she was eating an egg salad sandwich and began choking. The physician was noted and ordered an x-ray. A dietary note, dated March 31, 2023, at 9:14 AM, as a late entry, indicated that speech therapy (ST) evaluated patient for safe oral (PO) intake. Discussed with her the difficulty that she had with the soft sandwich. Following the evaluation, informed her that she is going to stay on a puree diet only. She was agreeable. Nursing noted on March 31, 2023, at 1:52 PM, indicated Left lower lobe pneumonia noted. Pt with decreased breath sounds at this time with slight non - productive cough, afebrile. A review of facility provided Incident Report (IR) entitled choking, dated March 30, 2023, 3:00 PM, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 10 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 indicating Resident 7 was eating an egg salad sandwich and began choking. Level of Harm - Minimal harm or potential for actual harm An employee witness statement dated March 30, 2023, from Employee 4, Licensed Practical Nurse (LPN), revealed that she was documenting on the computer standing by resident room [ROOM NUMBER]. Then had heard roommate (Resident 23), calling help. Employee 4, LPN, promptly ran into the room and found the Resident 7 holding her neck and egg salad sandwich in front of her. Residents Affected - Few Interview with alert and oriented Resident 7, on April 19, 2023, at approximately 8:50 AM, revealed she was eating an egg salad sandwich, but was not able to recall if staff was present in the room, or in the hallway. Interview with alert and oriented Resident 23, (roommate) on April 19, 2023, at approximately 8:55 AM, revealed that staff was not present in the room, however, was not able to state where staff was located outside the room. Interview (telephone) with Employee 4, LPN on April 18, 2023, at approximately 11:33 AM, indicated she had been outside Resident 7's room, going up and down the hallway, documenting on the computer, which was positioned on top the cart. Employee 4 indicated she was not able to stay in one position because of the physical layout (width-distance) of the hallway and needed to move position when residents were being transported and or self - propelling in their wheelchairs. She further stated her back was turned when she heard Resident 23, (roommate) calling for help, when she quickly turned and entered the room. Interview with the Director of Nursing (DON) on April 18, 2023, at approximately 12:10 PM, confirmed that the facility was unable to determine the staff member who had been assigned to supervise Resident 7, while eating on that date as required. The DON was also unable to state the type of activity in which the resident had participated on March 30, 2023, at 3:00 PM, in the resident's room while eating the sandwich to ensure that the resident's care plan was followed to allow the mechanical soft snacks with supervision during activities. Interview with the Nursing Home Administrator (NHA) on April 19, 2023, at approximately 9:40 AM, confirmed the above, and was unable to provide any additional information. She further acknowledged the facility failed to provide necessary staff supervision while the resident was eating to deter choking episodes. 28 Pa. Code 211.12 (a)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.11(d) Resident care plan FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 11 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policies and procedures and clinical records, observation, and resident and staff interviews, it was determined that the facility failed to provide supplemental oxygen administration care consistent with professional standards of practice for one of five residents reviewed (Resident 31). Residents Affected - Few Findings include: The facility policy entitled, Oxygen Administration, last reviewed December 19, 2022, revealed that the first step in the procedure for oxygen administration is to verify the physician's order. Observation of Resident 31 on April 18, 2023, at 11:12 a.m. revealed the resident was in his room with supplemental oxygen in place via an oxygen concentrator (bedside machine that concentrates ambient air to supply an oxygen-rich gas stream) with the liter flow set at 2.0 liters per minute (l/m). Observation of Resident 31 on April 19, 2023, at 9:00 a.m. revealed the resident was in his room with supplemental oxygen in place via an oxygen concentrator with liter flow set at 5.0 liters per minute (l/m). Clinical record review for Resident 31 revealed physician's order for supplemental oxygen administration, dated October 2, 2022, stated Supplemental oxygen via nasal cannula (flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen) @ 2 LPM, every night shift related to Chronic Obstructive Pulmonary Disease with acute exacerbation (COPD-term used to describe progressive lung diseases characterized by increasing breathlessness). Interview with Resident 31 on April 19, 2023, at 9:05 a.m. revealed he wears the oxygen all the time except when walking to the bathroom. Resident 31 reported he feels the need to wear oxygen all the time and has increased shortness of breath after returning from using the bathroom. He stated he turns the oxygen concentrator up all the way. Interview with Employee 2 (Registered Nurse) on April 19, 2023, at 9:10 a.m. confirmed Resident 31 was prescribed 2 liters of oxygen every night shift. Employee 2 added he often turns it up when he comes back from the bathroom. Employee 2 confirmed that the resident's Medication Administration Record also indicated Resident 31's physician order was for 2 liters of oxygen every night shift. Interview with Nursing Home Administrator on April 19, 2023, at 1:30 p.m. confirmed the facility failed to follow physician orders for the application of oxygen. In addition, the facility was unable to provide documented evidence that Resident 31 was educated on physician directed orders for oxygen therapy. 28 Pa. Code 211.12 (a)(d)(1)(5) Nursing services 28 Pa. Code 211.10(c) Resident Care Policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 12 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of select facility policy and clinical records and staff interviews it was determined that the facility failed to assess a resident's potential need for bed rails, including the risk for entrapment and a review of the risks versus benefits with the resident and/or the resident's representative for one of four sampled residents (Resident 36). Findings include: A review of the facility policy Use of Side Rails reviewed by the facility December 19, 2022, indicated Side rails may be used as resident mobility aids and the use of side rails as restraints will not be used unless necessary to treat a resident's medical symptom. Residents must be assessed for entrapment risk from bed rails prior to use of side rails. Guidelines for the policy included: Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: the side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances.) The use of side rails as restraints is prohibited unless they are necessary to treat a resident's medical symptoms. Quarter or half side rails, or enabler bars may be used to assist in mobility and transfer of residents. An assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: bed mobility and ability to transfer between positions, to and from bed or chair, to stand and toilet. The use of quarter or half side rails, as an assistive device will be addressed in the resident care plan. Informed consent for the use of less restrictive devices will be obtained from the resident or legal representative per facility protocol. Less restrictive interventions will be incorporated in care planning include: Providing restorative care to enhance abilities to stand safely and walk; a trapeze to increase bed mobility; placing the bed lower to the floor and surrounding the bed with a soft mat; equipping the resident with a device that monitors attempts to rise; providing frequent staff monitoring at night with periodic assisted toileting for residents attempting to arise to use the bathroom; and/or furnishing visual and verbal reminders to use the call bell for residents who are able to comprehend the information. Documentation will indicate if less restrictive approaches are not successful and orders to apply and monitor the use of side rails for a specific time will be obtained. The use of siderails will be evaluated in terms of risks and benefits for each individual resident. Informed consent for the side rail will be obtained from the resident and/or legal representative. Signed consent forms do not alleviate the facility from meeting the requirements for restraint use, including proper assessment and care planning. The resident or family representative may request a restraint; however, the facility is responsible for evaluating the appropriateness of the request.) The resident will be checked frequently for safety. If side rails are associated with decline in function, the resident's needs will be reassessed. When side rail use is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment. Side rails with padding may be used to prevent resident injury in situations of uncontrollable movement disorders but are still restraints if they meet the definition of a restraint. Designated facility staff will use judgement when assessing the resident's risk for injury due to neurological disorders. For resident who have been restrained by side rails, the process to reduce the use of side rails as restraints will be systematic and gradual (e.g. lessening the time the bed rail is used while increasing visual and verbal reminders to use the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 13 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 call bell using ½ side rails, ¼ side rails, etc.) Level of Harm - Minimal harm or potential for actual harm Clinical record revealed that Resident 11 was admitted [DATE], with diagnoses to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Residents Affected - Some Observation on April 18, 2023, at approximately 1:15 PM revealed Resident 11 was in bed with bilateral side rails (approximately 27 inch in length) raised. A quarterly MDS assessment dated [DATE] (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) revealed that Resident 36 was severely, cognitively impaired with a BIMS score (BIMS stands for Brief Interview for Mental Status. It is a screen used to assist with identifying a resident's current cognition) of 3 (0 to 7 indicates severe cognitive impairment) and required extensive assistance of two staff for activities of daily living including bed mobility, transfers and toileting, was non-ambulatory, and a physical restraint of a bed rail was being used daily in bed. Review of Resident 11's Side Rail Evaluation dated September 9, 2021, indicated bilateral side rails or grab bars are indicated for the resident's use to serve as an enabler to promote independence with bed mobility and positioning and that informed consent was obtained for side rail and/or restraint use, a physician order was in place, and a review has been performed to determine that the mattress does not shift or slide allowing for an increased gap between the bed and the side rail(s)/grab bars. There was no documented evidence that a comprehensive side rail assessment had been conducted to include an evaluation of the specific side rail (1/4 side rail, ½ side rail, grab bar, etc.) or alternatives to the use of a bed rail that were attempted and how these alternatives failed to meet the resident's assessed needs. Although the assessment noted that informed consent was obtained there was no documented evidence of signed informed consent for the use of the siderails in the resident's clinical record. Review of Resident 11's care plan initially dated September 14, 2021, and last revised December 22, 2022, indicated the resident's use of bilateral enablers to increase independence with rolling during activities of daily living. Interventions included to re-evaluate the use of bilateral enablers quarterly and as needed. There was no documented evidence in the clinical record of a quarterly reassessment for the use of the bilateral enablers. There was no documented evidence the facility assessed the bilateral enablers,which was inconsistent with the MDS assessment noting that these devices were a physical restraint according to the quarterly MDS dated [DATE]. During an interview conducted on April 20, 2023 at approximately 9:30 AM the director of nursing (DON) stated that Resident 11's bilateral side rails were not considered a physical restraint, but were considered an enabler. However, the DON failed to provide documented evidence that a comprehensive side rail assessment (other than the initial Side Rail Evaluation dated September 9, 2021), to include documented evidence of consent for the use of the side rails was obtained. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 14 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 28 Pa. Code 211.10(a)(d) Resident care policies Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.8 (d)(e) Use of restraints Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 15 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0713 Provide or arrange emergency care by a doctor 24 hours a day. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policy and clinical records and staff interview, it was determined that the facility failed to ensure the provision of consistent and timely physician services for one of 14 sampled residents (Resident 19). Residents Affected - Few Findings include: A review of facility policy entitled Protocol - when to call the physician or physician extender, last reviewed by the facility December 19, 2022, the physicians caring for residents in your facility want to respond in an appropriate and timely manner to changes in condition. Types of situations which frequently arise which require physician notification includes pain. The nursing staff is expected to notify the physician based on the urgency of the situation as outlined in the accompanying chart and in the following time frame: Emergency - Notify the physician at the time of the event. The physician is expected to respond within 30 minutes. A review of the clinical record revealed that Resident 19 was most recently admitted to the facility on [DATE], with diagnoses to have include major depression, dementia, chronic kidney disease, Chronic Obstructive Pulmonary Disease (COPD), osteoporosis, gastro-esophageal reflux disease (GERD), and constipation. A nurse's note dated December 24, 2022, at 8:35 PM, revealed that the resident complained of stomach pains and had refused dinner. The resident's last bowel movement was the prior day, December 23 (12/23). Nursing noted that the resident was guarding abdomen and expressing intense pain. The entry indicated that nursing notified the physician's office regarding the matter and were awaiting a return call. The resident's vital signs were within normal parameters. and further orders were pending. A nurse's note dated December 24, 2022, at 10:38 PM, revealed that the physician had not yet returned the call to the facility and nursing contacted the physician's office again. Nursing noted that a report was to be given to oncoming nurse for continuation of the resident's care during the night shift of nursing duty. A nurse's note dated December 25, 2022, at 12:05 AM, revealed that the resident was calling out in pain. The resident had complaints of pain rated a 10 out of 10 (scale of 1-10 with 10 being the most severe) in the resident's lower abdomen. The resident described the pain as an intermittent stabbing pain. Vital signs: 145/101 blood pressure, 114 pulse, 22 respirations. Nursing noted that a call was placed to the on-call physician and nursing was awaiting a return call. A nurse's note dated December 25, 2022, at 12:43 AM, revealed that a second call was placed to the on-call provider and the facility was awaiting a return call. A nurse's note dated December 25, 2022, at 1:34 AM, revealed that a third call was placed to the physician on-call service. At this time an order was received to send the resident to the emergency room (ER), 911 called. Nursing noted that the resident was transferred to the hospital on December 25, 2022, at 1:51 AM. The resident returned to the facility on December 28, 2022, at 10:02 PM. A review of hospital (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 16 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0713 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documentation, a Discharge summary, dated [DATE], revealed that the resident was admitted to the hospital with diagnoses of Urinary tract infection (UTI), generalized abdominal pain, acute cystitis without hematuria, and pneumonia. Interview with the Director of Nursing (DON) on April 18, 2023, at approximately 12:10 PM, confirmed that approximately 5 hours (December 24, 2022, 8:35 PM - December 25, 2022, 1:34 AM), had passed before a physician responded to the facility's repeated calls. The DON also confirmed that a resident expressing symptoms of guarding abdomen and complaining of intense pain, a 10 out of 10, and agreed that the resident's need appeared to be emergent. Interview with the Nursing Home Administrator (NHA) on April 19, 2023, at approximately 9:40 AM, acknowledged that the physician failed to respond timely. 28 Pa. Code 211.2 (a)(d)(2) Physician services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 17 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and interviews with staff, it was determined the facility failed to provide therapeutic and medically related social services to promote the psychosocial well-being of one of two residents reviewed for discharge planning (Resident 6), coordination of required mental health services for two of three residents (Resident 12 and 4) and assisting and arranging to meet a resident's communication needs for one resident out of 14 sampled (Resident 32). Residents Affected - Some Findings include: According to long term care regulatory guidelines, examples of medically-related social services include: o §483.15, Transitions of Care, §483.20, Resident Assessments (PASARR), and §483.21, Comprehensive Person-Centered Care Planning; o Assisting or arranging for a resident's communication of needs through the resident's primary method of communication or in a language that the resident understands; o Making referrals and obtaining needed services from outside entities o Transitions of care services (e.g., assisting the resident with identifying community placement options and completion of the application process, arranging intake for home care services for residents returning home, assisting with transfer arrangements to other facilities); o Providing or arranging for needed mental and psychosocial counseling services; o Identifying and seeking ways to support residents' individual needs through the assessment and care planning process; Review of clinical record of Resident 12 revealed diagnoses to include schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a mental condition with episodes of mood swings ranging from depressive lows to manic highs). Further review of Resident 12's clinical record revealed a PASARR Level I (federally required assessment to help ensure that all individuals with serious mental disorders and/or intellectual disabilities are not inappropriately placed in nursing homes for long term care) dated March 17, 2023, with the following outcome: Individual has a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition; requires further evaluation (Level II). A PASARR Level II determination letter dated March 21, 2023, indicated that, You do have evidence of a Mental Health condition that meets the criteria for review by the Office of Mental Health and Substance Abuse Services (OMHSAS). You may benefit from specialized mental health services. The County Mental Health office shall assist the nursing facility in accessing mental health services for you in accordance with OMHSAS Bulletin-16-11. The treatment must be provided by qualified mental health professionals, and treatment can include partial psychiatric hospitalization, peer support services, psychiatric outpatient clinic services, mobile mental health treatment, crisis intervention (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 18 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some services, targeted mental health care management, and outpatient drug and alcohol services. Residents who reside in the Nursing Facility may receive specialized mental health services either in the facility or in the community. Review of Resident 12's current care plan conducted during the survey ending April 20, 2023, revealed no care plan developed in relationship to the PASARR II determination. The care plan failed to identify the individual and specific referrals made, or services recommended and/or provided to the resident as the result of the resident's mental health condition and PASARR II. Review of clinical record of Resident 4 revealed diagnoses to include schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a mental condition with episodes of mood swings ranging from depressive lows to manic highs). Further review of Resident 4's clinical record revealed a PASARR Level I (federally required assessment to help ensure that all individuals with serious mental disorders and/or intellectual disabilities are not inappropriately placed in nursing homes for long term care) dated November 15, 2022, with the following outcome: Individual has a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition; requires further evaluation (Level II). A PASARR Level II determination letter dated February 8, 2023, indicated that, You do have evidence of a Mental Health condition that meets the criteria for review by the Office of Mental Health and Substance Abuse Services (OMHSAS). You may benefit from specialized mental health services. The County Mental Health office shall assist the nursing facility in accessing mental health services for you in accordance with OMHSAS Bulletin-16-11. The treatment must be provided by qualified mental health professionals, and treatment can include partial psychiatric hospitalization, peer support services, psychiatric outpatient clinic services, mobile mental health treatment, crisis intervention services, targeted mental health care management, and outpatient drug and alcohol services. Residents who reside in the Nursing Facility may receive specialized mental health services either in the facility or in the community. Review of Resident 4's current care plan conducted during the survey ending April 20, 2023, revealed no care plan developed in relationship to the PASARR II determination. The care plan failed to identify the individual and specific referrals made, or services recommended and/or provided to the resident as the result of the resident's mental health condition and PASARR II. An interview with the Director of Nursing on April 20, 2023 at 10:00 AM confirmed that the PA-PASARR-ID II form completed had identified Residents 12 and 4 as target residents and were unable to provide evidence of coordination of services including care planning. There was no evidence at the time of the survey that the facility had timely identified and coordinated the provision of specialized mental health services for Residents 12 and 4. A review of Resident 6's clinical record revealed admission to the facility on August 19, 2022, with diagnoses including congestive heart failure (chronic condition in which the heart does not pump as well as it should) and depression. During interview with Resident 6 on April 18, 2023, at 10:00 AM the resident stated that he was satisfied at the facility, but if possible, would like to transfer to a facility, which allowed smoking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 19 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some There was no evidence of the resident's discharge plans or assessment of the resident's potential for discharge to lesser level of care, identification of the resident's discharge goals or if the resident's placement was long term. Review of Resident 6's current plan of care, in effect at the time of the survey ending April 20, 2023, revealed no documented evidence of the resident's discharge goals or the development of a discharge plan to meet this resident's goals for discharge. The resident's care plan did not identify that the resident was to remain in the facility for continuing long term care. Interview with the administrator on April 20, 2023, at approximately 10:00 AM failed to provide documented evidence that a functioning discharge planning process, that begins on admission, and involves identifying each resident's discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure a successful discharge had been developed for Resident 6. An admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan a resident's care) dated March 10, 2023, revealed Resident 32 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact) and that the resident's preferred language was Spanish. A review of clinical record revealed that Resident 32 was admitted to the facility on [DATE], with diagnoses to include diabetes, anxiety, acute respiratory failure with hypoxia, tracheostomy, and gastro-esophageal reflux disease (GERD). A nurses' note dated March 3, 2023, at 2:17 PM, indicated the resident was admitted to facility at this time. The resident's daughter was present at bedside at this time. The entry noted that the resident speaks Spanish and a translator was at the resident's bedside. Interview with Resident 32, on April 19, 2023, at approximately 8:05 AM, revealed that the resident was lying in bed. After knocking, and obtaining visual acknowledgment of entrance, the surveyor entered the resident's room. There was no communication binder-book or communication board visibly present in the resident's room to allow the survey or to communicate with the resident. An attempt was made to communicate with the alert and oriented resident in English, but the resident did not appear to understand. A second observation of Resident 32, on April 19, 2023, at approximately 9:55 AM, in the presence of the Director of Nursing (DON), revealed the resident was sitting up in bed. During this the DON confirmed that there was no communication binder-book , communication or other communication tool present in the resident's room to communicate with the resident A review of Resident 32's comprehensive plan of care in effect during the survey ending April 20, 2023, revealed that the resident's care plan did not address that the resident's primary spoken language was Spanish and failed to address the resident's communication needs and the measures planned to maintain the resident's communication abilities and methods for staff to effectively communicate with the resident in the absence of an interpreter. Interview with the Nursing Home Administrator (NHA) on April 19, 2023, at approximately 1:45 PM, confirmed that the facility failed to develop and implement a functional system to maintain this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 20 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 resident's communication abilities Level of Harm - Minimal harm or potential for actual harm Interview with the NHA on April 26, 2023, at approximately 10:00 AM revealed that at the time of the survey ending April 20, 2023, and presently the facility lacked the services of social worker or social service designee since April 16, 2023. Additionally, the facility was without a social worker or social service designee from December 27, 2023, until February 27, 2023, and the NHA also stated that social services staff are shared with a sister facility. Residents Affected - Some Refer F660, F644 and F676 28 Pa. Code 211.16 (a)(b) Social Services 28 Pa. Code 201.25 Discharge policy 28 Pa. Code 211.11 (d)(e) Resident care plan FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 21 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, observations and staff and resident interviews it was determined that the facility failed to provide, or secure, dental services for one resident out of 14 sampled (Resident 4). Residents Affected - Few Findings include: A review of the clinical record revealed that Resident 4 was admitted to the facility on [DATE] with diagnoses to include schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a mental condition with episodes of mood swings ranging from depressive lows to manic highs). Observation and interview with Resident 4 on April 18, 2023 at approximately 9:30 AM revealed that the resident expressed concerns about his teeth and stated that he has multiple cavities. When the resident smiled, darkened areas, that appeared to be cavities, were observed on the resident's front bottom teeth. An admission MDS dated [DATE] indicated that Resident 4 had obvious or likely cavity or broken natural teeth. Review of the CAA (care assessment summary) area of the admission MDS indicated a dental care was to be addressed in the resident's comprehensive plan of care. A review of Resident 4's comprehensive plan of care initially dated November 14, 2022 revealed no documented evidence that the resident's care plan addressed the resident's dental care or needs and any interventions to address Resident 4's dental needs. Interview with the director of nursing on April 20, 2023 at 11:00 AM confirmed that Resident 4 currently had unmet dental needs and the resident is in need of dental services. 28 Pa. Code 211.15 (a) Dental Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 22 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview, it was determined that the facility failed timely ascertain a resident's eligibility to receive the influenza and pneumococcal immunizations and provide immunization if eligible as desired by one of five residents reviewed (Resident 15). Residents Affected - Few Findings include: A review of the clinical record revealed that Resident 15 was admitted to the facility on [DATE]. The resident's consent form for the influenza and pneumococcal immunizations was signed by the resident on December 5, 2022, noting that the resident wanted to receive both the influenza and pneumococcal vaccines unless medically contraindicated. However, until surveyor inquiry at the time of the survey on April 19, 2023, the facility had not consulted with the resident's resident's physician to determine any possible medical contraindications for the resident's immunizations. Interview with the Director of Nursing on April 20, 2023, at approximately 9:30 a.m. confirmed that Resident 15 consented to receive both the influenza and pneumococcal vaccine on December 5, 2022, which were not administered to the resident. The facility failed to contact the resident's physician to determine any medical contraindications or prior vaccination until April 19, 2023, during the survey. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services 28 Pa Code 201.29 (a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 23 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview it was determined that the facility failed to demonstrate an effective maintenance program of regular inspection of all bed frames, mattresses, and bed rails to assure that the mattress fit the bed frames properly limiting entrapment zones and promoting resident comfort and safety for 21 resident beds with side rails and further failed to ensure the availability of a functioning bed for all current licensed and certified resident beds (Resident rooms [ROOM NUMBER]). Findings include: Observations on April 20, 2023, at approximately 9:30 AM confirmed that side rails were in use on the residents' beds in Resident Rooms which included: Q3-1, Q7-1, Q7-2, 8-1, 8-2, 9-2, Q10-1, Q10-2, 11-2, 12-1, 14-1, 14-3, 15-2, 17-1, 17-2, 18-2, 19-2, 20-1, 21-2, 23-1, and 23-1. Side rails were in use on each resident bed noted. Interview with the administrator on April 20, 2023 at approximately 11:00 AM failed to provide documented evidence to demonstrate regular inspections of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment related to the use of these side rails Observations throughout the survey which included April 18, 2023, at 8:30 AM and April 20, 2023, at 9:00 AM revealed that Resident room [ROOM NUMBER], Resident room [ROOM NUMBER], and Resident room [ROOM NUMBER]v were all licensed and certified as semi-private rooms. However, each room contained only one bed and there was one resident residing in each room. Interview with the administrator on April 20, 2023 at approximately 9:30 AM confirmed that the facility removed the second beds from the double bedded rooms because they were broken. The administrator stated that at present replacement beds were not readily available in the facility and would only be purchased by the facility when needed. The facility failed to provide a bed for every licensed and certified resident room in the facility. 28 Pa. Code 205.71 Beds and furnishings 28 Pa. Code 207.2 (a) Administrator's responsibility FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 24 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and space measurements provided by the facility, it was determined that the facility failed to provide the regulatory required minimum square footage in nine of 21 resident rooms. Findings include: Observations made on April 18, 2023 at 8:30 AM, revealed square footage was not adequate in the following resident rooms: room [ROOM NUMBER] is a single-bedded resident room, which requires a minimum of 100 square feet. The square footage of this room measured 85 square feet. Resident rooms 15, 16, 17, 18, 19, 20, 21, and 23 are two- bedded resident rooms with square footage measurements of only 143 square feet. These multi-bed rooms failed to provide the minimum square footage requirement of 80 square feet per bed, or a total of 160 square feet in a semi-private room. CFR 483.70(d)(1)(ii) Bedrooms 28 Pa. Code: 205.20 (d)(f) Resident bedrooms FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 25 of 25