Inspection·September 7, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 staff interview it was determined that the facility failed to provide person-centered quality care by failing to follow physician orders for medication administration and accurately monitor bowel activity and administration of the bowel protocol as prescribed for one resident out of seven 7 sampled (Resident 11). Residents Affected - Few Findings include: A review of the clinical record revealed that Resident 11 was admitted to the facility on [DATE], with diagnoses to include, stiff-man syndrome (a rare autoimmune neurological disorder that most commonly causes muscle stiffness and painful spasms that come and go and can worsen over time.) and chronic pain. The resident had physician orders dated August 28, 2023, for MS Contin (an opioid medication for pain) 15 milligrams (mg) by mouth two times a day (8:00 a.m. and 8:00 p.m.) for chronic pain, and Pregabalin (Lyrica- used to treat pain caused by nerve damage) 75 mg by mouth two times a day (9:00 a.m. and 9:00 p.m.) for chronic pain. Review of Resident 11's Medication Administration Record (MAR) for August 2023, revealed that both medications were given on August 28, 2023, at 8:00 p.m. and 9:00 p.m. respectively. The August 2023 MAR indicated that MS Contin and Pregabalin were not given on August 29, 2023, at 8:00 a.m. and 9:00 a.m. as scheduled, and documentation on the MAR noted to see nurses notes. Review of nurses notes dated August 29, 2023 at 9:00 a.m. indicated that the MS Contin was not available for administration to the resident, but failed to indicate why the Pregabalin was not given. Interview with the Director of Nursing on September 7, 2023 at 11:15 a.m. revealed that the resident arrived at the with two doses of each of the above medications. The resident was one dose of each on the day of admission, August 28, 2023, but the DON was unable to state why the second dose of each drug was not administered to the resident on August 29, 2023 at 8:00 a.m. and 9:00 a.m. as scheduled. Resident 11 had current physician orders in effect during August 2023 and thru the time of the survey ending September 7, 2023, for the following bowel regimen: Milk of Magnesia (MOM) Suspension 400 MG/5ML (Magnesium Hydroxide), give 30 ml by mouth as needed for constipation at bedtime on day 3. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395484 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 09/07/2023 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)