Inspection·February 29, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Further review of Resident 2's clinical record revealed an admission Agreement packet dated February 8, 2024, indicated that Advance Directives information was provided but did not indicate if the facility asked the resident if he would like to formulate an advance directive. There was no documented evidence that the facility determined if the resident had or did not have an Advance Directive or Healthcare Power of Attorney. A review of the clinical record revealed that Resident 13 was admitted to the facility on [DATE], with diagnoses which included seizures and dysphagia (difficulty swallowing). Review of Resident 13's quarterly Minimum Data Set (MDS- a federally mandated standardized assessment process completed periodically to plan resident care) dated February 6, 2024, revealed that the resident was moderately cognitively impaired with a BIMS (brief interview mental screening tool used to screen and identify cognitive impairment) score of 12 (8 to 12 indicates moderate cognitive impairment). Resident 13's clinical record revealed a Pennsylvania Physician Orders for Life-Sustaining Treatment but no documented evidence of an Advance Directive or if the facility asked the resident if he would like information to formulate an advance directive. Further review of Resident 13's clinical record revealed an admission Agreement packet dated June 1, 2023, indicated that Advance Directives information was provided but did not indicate if the facility asked the resident if he would like to formulate an advance directive. There was no documented evidence that the facility determined if the resident had or did not have an Advance Directive or Healthcare Power of Attorney. A review of the clinical record revealed Resident 21 was admitted to the facility on [DATE], with diagnoses to include major depressive disorder (a mood disorder that causes pervasive feelings of hopelessness, sadness, and loss of interest in activities that were once pleasurable) and congestive heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 26, 2024 revealed that Resident 21 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). Further review of Resident 21's clinical record revealed an admission notice packet dated December 23, 2021, indicating that advance directive information was provided but did not indicate if the facility asked the resident if he would like to formulate an advance directive. A clinical record review failed to reveal evidence of an advance directive or if the facility asked the resident if he would like information to formulate an advance directive. There was no documented evidence that the facility determined if the resident had or did not have an advance directive or durable healthcare power of attorney. An interview with the social services director (SSD) on February 28, 2024, at 1:00 PM confirmed there was no documented evidence to indicate that the facility had determined if Residents 2, 13, and 21 had or did not have an advance directive upon admission to the facility. The SSD confirmed there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 2 of 30 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 02/29/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm was no documented evidence that Residents 2, 13, and 21 were made aware of the right to formulate an advance directive and that information to formulate an advance directive could be requested and provided by the facility. 28 Pa. Code 201.29 (a)(b) Resident rights Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 3 of 30 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 02/29/2024 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and facility documentation, and an interview with staff, it was determined that the facility failed to provide the required advance notice, through a Notice of Medicare Non-Coverage (CMS 10123-NOMNC), regarding the termination of Medicare services for one of the three residents sampled (Resident 26). Residents Affected - Some Findings include: A review of the Centers for Medicare and Medicaid Services Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 revealed that the NOMNC must be delivered at least two calendar days before Medicare-covered services end or on the second to last day of service if care is not being provided daily. A clinical record review revealed Resident 26 was admitted to the facility on [DATE]. A clinical record review revealed that the facility provided Resident 26's representative with a Notice of Medicare Non-Coverage (CMS 10123-NOMNC) letter dated November 9, 2023. The notice indicated that Medicare would likely not pay for the resident's skilled services after November 9, 2023. Further clinical record review failed to find evidence that Resident 26 or Resident 26's representative were provided at least a two-day notice before Medicare-covered services ended. A clinical record review revealed a social services progress note dated November 9, 2023, at 12:54 PM indicating NOMNC verbal consent with {resident representative}. A certified letter was sent for signature. During an interview on February 28, 2024, at approximately 1:00 PM, the Director of Social Services confirmed that the facility failed to provide the required advance notice to Resident 26 or Resident 26's representitive through a Notice of Medicare Non-Coverage (CMS 10123-NOMNC), regarding non-coverage of Medicare 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 4 of 30 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 02/29/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, a review of facility policy, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a clean and homelike resident environment on two of two nursing units (North and South nursing units) and failed to ensure comfortable water temperatures including three residents out of the 13 sampled (Residents 13, 21, and 25), and three out of the six residents interviewed during a resident group interview (Residents 5, 23, and 28). Findings Include: An observation of resident room [ROOM NUMBER] on February 27, 2024, at 8:45 AM revealed the white window blinds were bent and missing fins. A dirt buildup was visible on the window sill between the window and the screen. During an interview on February 27, 2024, at 8:52 AM, Resident 21 stated that he gets a draft in his room through drill holes that are utilized to hold the air-conditioning unit in place during the summer months. Resident 21 explained that he was provided a piece of duct tape to put over the holes to stop the draft. An observation of resident room [ROOM NUMBER], Resident 21's room, at the time of the interview, revealed multiple 0.5 cm holes in the window frame and a strip of black duct tape to the left of the resident's window. Resident 21 also stated that the shower water temperature is cold a lot of the time. He explained that he doesn't shower in the morning because the water temperature in the morning is often cold. An observation of resident room [ROOM NUMBER] on February 27, 2024, at 10:46 AM revealed the white window blinds were cracked and missing fins. A dirt buildup was visible on the window sill between the window and the screen. During an interview on February 27, 2024, at 12:30 PM, Resident 25 stated that when he takes a shower, the water is hot for about a minute, but then it turns very cold. He explained that he never gets to take a warm shower. During a resident group interview on February 28, 2024, at 10:00 AM, three residents in attendance (Residents 5, 23, and 28) voiced concerns about cold water temperatures during showers. Resident 5 explained that the shower water temperatures are often cold. Resident 23 stated that he arranged his shower schedule to avoid the times of day when the shower water temperatures are very cold. Resident 23 explained that there is not enough hot water in the mid-morning through early afternoon for an enjoyable shower, so he showers early in the morning or in the evening if possible. Resident 28 stated that she takes her shower early in the morning so she has enough hot water for her shower. An observation of the shower on the North Nursing Unit on February 29, 2024, at 9:40 AM revealed a buildup of hair and debris in the shower drain. A review of the facility Shower/Bathing Policy, last reviewed by the facility on October 20, 2023, revealed that staff were to adjust the temperature of the water before placing residents under the shower . Check temperature. Water should be per the resident's preference and not exceed state or federal guidelines specific to water temperature. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 5 of 30 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 02/29/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some According to PA State Regulations: 205.63 (c) The facility shall ensure that water for baths and showers is at a safe and comfortable temperature before the resident is bathed. 205.63 (c) Hot water outlets accessible to residents shall be controlled so that the water temperature of the outlets does not exceed 110°F. During an interview with Resident 13 on February 27, 2024, at approximately 10:15 AM, revealed that the resident stated that at times when he receives a shower, the water feels cold. Resident 13 also stated that for a bed bath or hygiene in his room, the water is also cold at times. During observation of the resident's private bathroom at this time, the hot water was turned on at the sink by the surveyor and allowed to run but did not feel warm to touch. An interview with employee 3 (nurse aide) on February 28, 2024, at approximately 1:00 PM confirmed that at times, before giving a resident a shower, the water must run for a few minutes for the water to warm up. An interview with employee 4 (nurse aide) on February 29, 2024, at approximately 9:50 AM confirmed that the water does not always warm up enough to give a shower, and the resident's shower will have to be rescheduled. During an interview with the maintenance director on February 29, 2024, at 10:00 AM, it was revealed that water temperatures in the facility are monitored three times weekly and failed to identify any concerns with water temperatures not being at a comfortable temperature (98.6 to 110 degrees Fahrenheit). During an interview on February 29, 2024, at 10:45 AM, the director of nursing and administrator confirmed that comfortable water temperatures should be maintained during the resident's shower or bed bath and residents' environment was to be maintained in a clean and comfortable manner. 28 Pa Code 201.18 (e)(2.1) Management. 28 Pa Code 205.37 (e) Equipment for bathrooms. 28 Pa Code 205.63 (b) Plumbing and piping systems required for existing construction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 6 of 30 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 02/29/2024 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. 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 the facility's abuse policy, select facility investigation reports, and clinical records, and staff interview, it was determined that the facility failed to ensure one resident out of 13 sampled was free from misappropriation of resident property, medication (Resident 13). Residents Affected - Few Findings included: A review of the facility Abuse Protection Policy last reviewed October 20, 2023, revealed that the residents have the right to be free from verbal, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. abuse, neglect, misappropriation of resident property, and exploitation. Further it is indicated misappropriation is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's permission. A review of the clinical record review revealed that Resident 13 was admitted to the facility on [DATE], with diagnoses which include congestive heart failure and depression. The resident had a physician order initially dated April 12, 2023, for Oxycodone HCL (opioid pain medication) 5 mg one tablet daily for chronic pain. A review of a facility investigation report dated February 22, 2024, at approximately 9:00 AM revealed that employee 1 (LPN) reported to the director of nursing that she was popping an Oxycodone 5 mg (pill number 14 on blister card) for Resident 13 when she noticed that pill number 13 looked like it was tampered with. Employee 1 (LPN) then looked at the medication more closely and noted that pill number 14 and pill number 13 was Claritin (as per Google search and facility inventory). The house stock (of Claritin) is the same pill that was in the blister pack for pill number 14 and pill number 13. Resident 13 was administered the correct medication. Employee 1 (LPN) administered Oxycodone 5 mg pill number 12 from the blister pack under the director of nursing's direction. The state agency, local area agency on aging, and the police were notified of the incident. Interview with employee 1 (LPN) on February 28, 2024, at 10:00 AM revealed that on the day of the incident (February 22, 2024) she popped Resident 13's Oxycodone 5 mg from the blister pack and noticed that the next pill looked tampered with. Employee 1 (LPN) did a Google search of the pill that she popped and the one that looked tampered with by the number on the pill and found that it was Claritin. The incident was then reported to the director of nursing. Employee 1 stated that Resident 13 did receive his medication with the director of nursing approval to ensure an accurate count of the resident's remaining Oxycodone 5 mg medication. An interview with the director of nursing (DON) on February 27, 2024, at approximately 1:00 PM confirmed the facility failed to ensure Resident 21 was free from misappropriation of resident property, the resident's medication. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 7 of 30 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 02/29/2024 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 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on a review of clinical records and written transfer notices, and staff interview, it was determined that the facility failed to ensure that a written notice of a facility initiated hospital transfer of the resident was provided to the resident and the resident's representative for one resident out of five residents sampled (Resident 12). The findings include: Regulatory requirements indicate that before a facility transfers or discharges a resident, the facility must notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. A review of Resident 12's clinical record revealed that the resident was transferred to the hospital on November 15, 2023, and returned to the facility on November 20, 2023. Clinical record review revealed no evidence that a written notice was provided to Resident 12 and the resident representative regarding the resident's transfer to the hospital on November 15, 2023, which included the required the reason for the transfer, contact and address information for the Office of the State Long-Term Care Ombudsman, and if applicable, information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. Interview with the Nursing Home Administrator (NHA) on February 29, 2024, at approximately 10:30 AM, confirmed that there was no documented evidence that a written notification of transfer was provided to the resident and the resident's representative. 28 Pa. Code 201.29 (c) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 8 of 30 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 02/29/2024 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 that 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 residents out of 13 sampled (Residents 3, 22, and 12). Residents Affected - Some Findings include: According to the RAI User's Manual dated October 2023, Section A 1500 Preadmission Screening and Resident Review (PASRR) is to be completed if the type of assessment is an admission assessment, significant change or annual assessment. The annual MDS Assessment of Resident 3 dated December 8, 2023, revealed 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. A review of Resident 3's clinical record revealed a Level I PASRR was completed on July 27, 2021, by the transferring facility, which indicated that the resident met the criteria for a Level II PASRR. A further review of the resident's clinical record, revealed a letter of determination dated June 24, 2021, indicating the resident met the criteria for specialized services. A review of the clinical record revealed that Resident 22 was admitted to the facility on [DATE]. According to the RAI User's Manual, Section N, Medications, items in this section assesses, a resident received medications during the seven-day look back period. A review of Resident 22's Quarterly MDS assessment dated [DATE], revealed Section N0415 indicated the resident received anticoagulant medications during the look back period. A review of Resident 22's clinical record from December 2023 revealed that the resident did not receive anticoagulant medication during the look back period. Telephone interview with the registered nurse assessment coordinator (RNAC) on February 27, 2024, at approximately 1:35 PM, confirmed that Resident 3's annual MDS assessment dated [DATE], was inaccurate, with respect to completion of Section A 1500 related to the PASRR, and Resident 22's quarterly MDS dated [DATE], with respect to completion of Section N 0415 related to anticoagulant usage, was inaccurate. A review of the clinical record revealed that Resident 12 was admitted to the facility on [DATE]. A review of Resident 12's Quarterly MDS assessment dated [DATE], revealed Section N0415 indicated the resident received anticoagulant medications during the look back period. A review of Resident 12's clinical record from February 2024 revealed that the resident did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 9 of 30 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 02/29/2024 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 receive anticoagulant medication during the look back period. Level of Harm - Minimal harm or potential for actual harm Interview with the director of nursing on February 28, 2024, confirmed that Resident 12's quarterly MDS dated [DATE], with respect to completion of Section N 0415 related to anticoagulant usage, was inaccurate. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 10 of 30 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 02/29/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select facility investigations, and staff interviews, it was determined that the facility failed to timely develop a person-centered care plan to address a resident's high risk for falls and meet the safety needs of one resident out of 13 sampled (Resident 10). Findings include: A clinical record review revealed that Resident 10 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and schizophrenia (a chronic mental health disorder that involves problems with cognition, behavior, and emotions). A review of an annual comprehensive Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 7, 2023, revealed a care area assessment (CAA- process provides guidance on how to focus on key issues identified during a comprehensive MDS assessment and directs facility staff and health professionals to evaluate triggered care areas) for Resent 10's potential problem with falls related to his difficulty maintaining sitting balance and impaired balance during transitions. The care area assessment worksheet dated April 7, 2023, indicated a care plan will be developed and implemented to address the resident's functional status. A clinical record review revealed a care plan dated April 13, 2023, which did not include Resident 10's potential problems with falls related to his difficulty maintaining sitting balance and impaired balance during transitions. A review of the clinical record of Resident 10 revealed fall risk evaluation forms dated July 2, 2023, and October 2, 2023, which indicated that Resident 10 was at high risk for falls. A review of the resident care plan in effect from July 2, 2023, through the January 24, 2024, revealed that the facility failed to address the resident's risk for falls and safety needs on the plan of care. A review of a quarterly MDS assessment, dated December 23, 2023, revealed that Resident 10 has moderate cognitive impairment with a BIMS score of 10 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 - 12 indicates moderate cognitive impairment). A review of Resident 10's MDS, Section GG0170 Mobility, dated December 23, 2023, revealed that he required partial or moderate assistance from staff to move from a seated position to a standing position, transferring from chair to chair, or ambulating 10 feet. A physical therapy Discharge summary dated [DATE], revealed that Resident 10 was not assessed for his ability to pick up objects due to safety concerns. The summary indicated that Resident 10 received physical therapy services from December 9, 2023, through January 6, 2024. He was discharged because he reached his maximum potential with skilled therapy services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 11 of 30 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 02/29/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A progress note dated January 24, 2024, at 11:15 AM revealed that Resident 10 was found on the floor in front of his wheelchair with the tray table pushed away. The wheelchair brakes were locked. The resident was wearing non-skid footwear. A clinical record review revealed that following Resident 10's fall on January 24, 2024, a plan of care focus was developed relating to the resident's potential for falls related to cognitive impairment, dated January 24, 2024. Interventions developed included a call bell reminder sign on the wall, 15-minute safety checks, keeping the bed in the lowest position, keeping the call bell within reach, offering the resident to get out of bed during confusion periods, and reminding the resident to use the call ball. During an interview on February 29, 2024, at approximately 12:00 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the facility failed to timely develop and implement a plan of care to address Resident 10's risk of falling until after he fell on January 24, 2024. The DON and NHA confirmed that Resident 10 was evaluated as a high risk for falls in July 2023 and October 2023, which was not addressed on the resident's care plan. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 12 of 30 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 02/29/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility policy, and investigation reports, and observation, and staff and resident interviews, it was determined that the facility failed to provide timely and consistent care, according to professional standards of practice, to prevent multiple facility acquired, unstageable pressure sores for one out of the 13 residents sampled (Resident 10). Residents Affected - Few Findings include: A clinical record review revealed that Resident 10 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and schizophrenia (a chronic mental health disorder that involves problems with cognition, behavior, and emotions). The resident's care plan, dated [DATE], indicated that Resident 10 has potential for impairment to skin integrity with deceased mobility and bowel incontinence with interventions for encouraging good nutrition and hydration, keeping skin dry and clean, monitoring skin every shift and reporting findings to the nurse, and providing pressure mattress as ordered. A physician's order for a pressure-reducing mattress was initiated on [DATE]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated [DATE], revealed that the resident required maximum staff assistance for dressing and undressing his lower body and required partial or moderate assistance from staff to maintain perineal hygiene. The resident required partial or moderate assistance from staff to roll from lying on the back to the left and right sides in bed and partial or moderate assistance from staff to move from a lying position to a sitting position when in bed. A Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE], indicated that Resident 10 was at mild risk of developing pressure injuries. A review of Resident 10's Treatment Administration Record (TAR) for [DATE] revealed that skin inspection occurred on [DATE], and 17, 2024. A weekly skin review dated [DATE], indicated that Resident 10's skin was intact. A review of a documentation survey report revealed that Resident 10 received a shower on [DATE], at 7:51 PM. A review of a documentation survey report revealed no evidence that Resident 10 was provided preventative skin care or turning and repositioning on [DATE], during the night shift (11:00 PM through 7:00 AM). A review of a documentation survey report revealed that Resident 10 was utilizing a low-air-loss mattress (an alternating pressure with low air loss system mattress designed to prevent and treat pressure injuries) during the months of [DATE] and [DATE] prior to pressure sore development. However, the Nursing Home Administrator stated during interview on February 29, 2024, at 11 AM that the resident was not utilizing a low-air-loss mattress, but a regular standard mattress during those months, until [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 13 of 30 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 02/29/2024 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 0686 A facility investigation report dated [DATE], indicated that Employees B3, Nurse Aide, and Employee B4, Nurse Aide, identified that the resident had skin impairments on [DATE] at 11:05 AM Level of Harm - Actual harm Residents Affected - Few Nursing notes dated [DATE], at 7:29 PM indicated that Resident 10 presented with deep purple discoloration to his right buttock, right hip, and sacral area; the skin was intact. No drainage and no tenderness were noted. The resident denied pain or discomfort. The on-call physician was notified and the resident was immediately placed on an air mattress and referred to a wound consultant for evaluation and treatment. There was no documented evidence of a treatment ordered at the time of discovery of the pressure sores, but referred to the outside wound consultant for evaluation and treatment during their next visit. A witness statement dated [DATE], provided by Employee B4, Nurse Aide, indicated that while doing care on {Resident 10}, she spotted {discoloration to the resident's bilateral buttocks} and went to the RN right away. Employee B4 indicated that she did not notice the {discoloration} the day before. A review of a facility investigation report dated [DATE] revealed that Employee B4, NA, later admitted to not providing care to Resident 10 during her shift {[DATE]} from 7:00 AM until 11:00 AM. The report indicated that Employee B4 was terminated. A witness statement dated [DATE], provided by Employee B2, registered nurse, revealed that she assessed the resident and observed redness with darkened areas to the residents right and left buttocks and sacral area. A new mattress was immediately placed on the resident's bed. A witness statement dated [DATE], provided by Employee B5, Nurse Aide, indicated that on [DATE], {11:00 PM-7:00 AM}, Employee B5 provided care for {Resident 10}. Employee B5 indicated that she did not notice any discoloration on the resident's buttocks, but the resident did not want to be repositioned, and the charge nurse was notified (Employee B6). A witness statement dated [DATE], provided by Employee B6, a Licensed Practical Nurse, indicated that on [DATE], she was not notified of any areas or any refusals in care or repositioning. Employee B6 indicated that she did not see any {discolorations on Resident 10} on [DATE], at 7:00 PM through [DATE], at 7:00 AM. An external provider wound evaluation and management summary dated [DATE] revealed Resident 10 presented with (Site 1) an unstageable deep tissue injury (DTI) wound on the resident's sacrum measuring 3.0 cm x 3.0 cm described as having intact skin with purple/maroon discoloration and no exudate. (Site 2) An unstageable DTI wound on the resident's right hip measuring 4.0 cm x 10.0 cm described as having intact skin with purple/maroon discoloration and no exudate. (Site 3) An unstageable DTI wound on the resident's right ischium measuring 6.0 cm x 7.0 cm described as having intact skin with purple/maroon discoloration and no exudate. The evaluation indicated that distribution and appearance of wounds to appear to be pressure. The external provider recommended a full panel of labs to work out possible causes of skin decline. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as A pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. These lesions may herald the subsequent development of a Stage III-IV pressure ulcers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 14 of 30 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 02/29/2024 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 0686 Three days after the pressure areas were identified, a physician's order was initiated on [DATE], for skin prep wipes to apply to right hip area topically every shift for wound house barrier to periwound. Level of Harm - Actual harm Residents Affected - Few A physician's order was also initiated on [DATE], to reposition the resident every hour and document any refusals every shift. A progress note dated [DATE], at 7:08 AM indicated that Resident 10's right heel was pink, skin intact, and blanchable. The inner aspect of the left heel presented with a quarter-sized red area, skin intact and blanchable. Skin prep is applied to both heels and heels elevated off the surface with a pillow. A progress note dated [DATE], at 1:56 PM indicated that the physician was in to see the resident. Areas to the right hip, right ischium, and right buttock noted improvement. Ischial area debrided. Bilateral heel lifts were ordered at this time. A physician's order was initiated on [DATE], to apply skin prep to bilateral heels every shift for redness. A hematology consultation report dated February 2, 2024, indicated findings of mild lymphopenia-likely medication-related and sequela (a pathological condition resulting from a prior disease, injury, or attack) of prior COVID infection, not neutropenic (a condition where you have too few neutrophils, a type of white blood cell that fights infections by destroying germs). The consult noted the diagnosis of pressure-related injury. An external provider wound evaluation and management summary dated February 5, 2024, revealed that the stage II sacrum pressure injury (site 1) had been resolved. An unstageable DTI wound (site 2) on the resident's right hip measuring 5.0 cm x 1.0 cm described as having intact skin with purple/maroon discoloration and no exudate. An unstageable (due to necrosis) pressure injury (site 3) on the resident's right ischium measured 5.0 cm x 5.0 cm x 0.2 cm described as having light serous exudate and 100% slough. The note indicated that the wound was stable with an insignificant amount of necrotic tissue and no signs of infection. An unstageable DTI wound (site 4) on the resident's left heel was indicated as resolved. An external provider wound evaluation and management summary dated February 12, 2024, revealed that the unstageable DTI wound (site 2) of the resident's right hip had resolved. A full thickness stage III pressure injury (site 3) on the resident's right ischium measuring 3.5 cm x 4.0 cm x 0.2 cm was described as improving and as having a light serous exudate with 100% slough. An external wound provider communication document indicated that the February 19, 2024, wound management appointment was rescheduled. A clinical record review revealed that Resident 10 developed the following in-house acquired pressure sores from [DATE], through February 26, 2024: (site 1) unstageable deep tissue injury (DTI) sacrum measuring 3.0 cm x 3.0 cm. (site 2) unstageable deep tissue injury (DTI) right hip measuring 4.0 cm x 10.0 cm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 15 of 30 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 02/29/2024 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 0686 (site 3) unstageable deep tissue injury (DTI) right ischium measuring 6.0 cm x 7.0 cm. Level of Harm - Actual harm (site 4) unstageable deep tissue injury (DTI) resident's left heel Residents Affected - Few (site 6) partial thickness stage II pressure injury resident's left buttocks 0.5 cm x 1.0 cm x 0.1 cm An external provider wound evaluation and management summary dated February 26, 2024, revealed a full thickness stage III pressure injury (site 3) on the resident's right ischium measuring 3.5 cm x 3.0 cm x 0.2 cm. The wound was described as improving with light serous exudate, 60% slough, and 40% granulation tissue. A new partial thickness stage II pressure injury (site 6) on the resident's left buttock measuring 0.5 cm x 1.0 cm x 0.1 cm was described as having no exudate and having open areas with exposed dermis. An observation on February 29, 2024, at 8:50 AM revealed a superficial wound on Resident 10's left buttocks. The wound was measured by Employee 1, Licensed Practical Nurse, as 1.0 cm x 1.0 cm. The resident's buttocks wound was red in color with no drainage. Another wound on the resident's right ischium was measured by Employee 1 as 4.0 cm x 3.2 cm. The wound was pink in color with a thin, whitish film. After Employee 1 wiped the resident's ischium wound, a faint yellow liquid was visible on the white wipe. Resident 10 stated that he was not in pain during the wound treatment. The facility failed to demonstrate the timely implementation of measures necessary to prevent skin breakdown, including pressure relief, turning and repositioning, and preventative care prior to the identification of the multiple facility acquired deep tissue injuries. During an interview on February 29, 2024, at approximately 11:15 PM, the Director of Nursing and Nursing Home Administrator (NHA) confirmed that Resident 10 was using a regular standard mattress, not an alternating air mattress, prior to [DATE]. The DON stated during interview on February 29, 2024, at 11:30 AM indicated that the facility determined that Employee B4 failed to provide care for Resident 10 on [DATE], from 7:00 AM through 11:00 AM as a contributing factor to the resident's skin breakdown. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 16 of 30 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 02/29/2024 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 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 clinical record and select facility policy review, and staff interview it was revealed that the facility failed to monitor weight and evaluate nutritional and hydration requirements to ensure acceptable parameters of nutritional status are maintained to the extent possible for one resident out of 13 sampled (Resident 2). Residents Affected - Few Findings include: Review of the facility Resident Weights policy last reviewed October 20, 2023, indicated that weights must be obtained routinely to monitor the parameters of nutrition over time, and identify residents at risk for significant weight change. Upon admission/readmission, the resident will be weighed each day for two days. The first weight will be within 24 hours of admission or readmission. After admission weights are obtained, the individual will be weighed weekly for four weeks. After the first 4 weeks, the interdisciplinary team will determine the need for continuation of weekly weights or a change to monthly weights. All weights will be transcribed (including weekly and any reweigh) in the resident's electronic medical record. Review of the facility Nutrition Management policy last reviewed October 20, 2023, indicated that based on a resident's comprehensive assessment, the facility will ensure that a resident: maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; receives a therapeutic diet when there is a nutritional problem. In evaluating weight loss, the dietitian will consider the resident's usual weight through adult life, and the potential for weight loss related to any medical conditions. It should be noted if the resident was on a calorie-restricted diet prior to admission. Location and degree of any present edema should be noted. A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses, which included diabetes, esophagitis, dysphagia (difficulty swallowing), and depression. Further review of the clinical record revealed no documented evidence that a weight was obtained upon admission on [DATE], or weekly (weeks of February 15 or February 22, 2024) as per facility policy. As of the survey on February 28, 2024, the facility had not yet obtained the resident's weight. Further review of the clinical record at the time of the survey ending February 29, 2024, revealed no documented evidence that a complete nutritional assessment was completed by the registered dietitian to evaluate the nutritional and hydration needs and nutritional risk for Resident 2 who was admitted to the facility on [DATE]. Interview with the director of nursing (DON) on February 28, 2024, at 10:00 AM confirmed that Resident 2's weight was not obtained as per facility policy. The DON confirmed that a nutritional assessment was not completed by the dietitian to evaluate the resident's nutritional and hydration needs and establish nutritional interventions to meet the resident's nutritional and hydration requirements to the extent possible. The DON confirmed that the facility did not currently employ a dietitian. Refer F801 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 17 of 30 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 02/29/2024 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 0692 28 Pa. Code 211.5 (f) Medical Records. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 18 of 30 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 02/29/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policy and controlled drug records and observation and staff interview, it was determined that the facility failed to implement pharmacy procedures to promote accurate administration, and records accounting for controlled drugs for five of eight residents sampled (Resident 13, 7, 24, 19, and 8), and reconciliation of controlled drugs on one of two medication carts (North). Finding include: A review of the facility policy Medication ordering, receiving, and storage (Controlled Substance), and Medication Storage in the facility (ID3: Controlled medication storage) last reviewed by the facility October 20, 2023, stated nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty will make the count together. They must document and report any discrepancies to the director of nursing services. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. If a major discrepancy, or a pattern of discrepancies occur, or if there is apparent criminal activity, the director of nursing notifies the administrator, medical director, and pharmacy immediately. During the observation of the medication administration pass, on February 27, 2024, at approximately 8:26 AM, revealed Employee 1, Licensed Practical Nurse (LPN), on the North medication cart. A review of the shift-to-shift accountability form, as identified by Employee 1 (LPN), untitled, for February 2024, for the North Hall, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify that nursing staff counted the controlled drugs in the respective medication cart: February 20, and 21, 2024. A review of Resident 13's clinical record revealed he was admitted to the facility on [DATE], with diagnoses to include pain. A physician order dated May 17, 2023, was noted for Tramadol (an opioid pain medication) 50 milligram (mg), give 0.5 tablet (25 mg) by mouth every 12 hours for chronic pain. The controlled substance record, accounting for Resident 13's supply of Tramadol 50 mg, 0.5 tablet, (25 mg) revealed that on February 23, 2024, at 2100 (9:00 PM), dose given 1, amount remaining 26. However, a closer look revealed the nurse failed to sign the sheet. Interview with Employee 1, LPN, on February 27, 2024, at approximately 8:30 AM, confirmed the above observations of the shift to shift, and the controlled substance record was not signed and that the expectation is that it should have been signed. A continued observation of medication administration pass on February 27, 2024, at approximately 8:53 AM, revealed Employee 2, (LPN) on the South Medication cart. A review of Resident 7's clinical record revealed she was most recently admitted to the facility on [DATE], with diagnoses to include anxiety, and pain. A physician order dated January 25, 2024, was noted for Hydrocodone-Acetaminophen (an opioid pain medication) 10-325 mg, give 1 tablet by mouth every 4 hours for chronic pain. The controlled substance record, accounting for Resident 7's supply of Hydrocodone-Acetaminophen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 19 of 30 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 02/29/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 10-325 mg revealed that on February 22, 2024, at 0400 (4:00 AM), dose given 1, amount remaining 59, February 23, 2024, at 0800 (8:00 AM), dose given 1, amount remaining 58, February 23, 2024, at 1200 (12:00 PM), dose given 1, amount remaining 57, February 23, 2024, at 1600 (4:00 PM), dose given 1, amount remaining 56, February 23, 2024, at 2000 (8:00 PM), dose given 1, amount remaining 55, and February 24, 2024, at 0000 (12:00 AM), dose given 1, amount remaining 54. (The dose given on February 22, 2024, at 0400 [4:00 AM] was incorrectly dated the 22nd, the correct date should have been February 23, 2024). A physician order dated January 1, 2024, was noted for Lorazepam (antianxiety medication) 1 mg, give 1 tablet by mouth two times a day related to anxiety. The controlled substance record, accounting for Resident 7's supply of Lorazepam 1 mg, revealed that on February 17, 2024, at 1620 (4:20 PM), dose given 1, amount remaining 28, February 18, 2024, at 0500 (5:00 AM), dose given 1, amount remaining 27, February 18, 2024, at 1615 (4:15 PM), dose given 1, amount remaining 26, February 18, 2024, at 0500 (5:00 AM). (The previous dose given on February 18, 2024, at 0500 [5:00 AM] was incorrectly dated February 18, the correct date should have been February 19, 2024). February 21, 2024, at 1610 (4:10 PM), dose given 1, amount remaining 20, February 22, 2024, at 0500 (5:00 AM), dose given 1, amount remaining 19, February 22, 2024, at 1550 (3:50 PM), dose given 1, amount remaining 18, and February 22, 2024, at 0500 (5:00 AM), dose given 1, amount remaining 17. (The previous dose given on February 22, 2024, at 0500 [5:00 AM] was incorrectly dated February 22, the correct date should have been February 23, 2024). A review of Resident 24's clinical record revealed he was most recently admitted to the facility on [DATE], with diagnoses to include cerebral infarction (stroke), dementia (group of symptoms affecting memory, thinking and social abilities), and right sided hemiplegia and hemiparesis (weakness on one side of the body). A physician order dated September 22, 2023, was noted for Lorazepam (antianxiety medication) 0.5 mg, give 1 tablet via G-tube (feeding tube) every 8 hours with agitation, related to dementia. The controlled substance record, accounting for Resident 24's supply of Lorazepam 0.5 mg, revealed that on February 19, 2024, at 0000 (12:00 AM), dose given 1, amount remaining 36, February 19, 2024, at 0900 (9:00 AM), dose given 1, amount remaining 35, February 19, 2024, at 1642 (4:42 PM), dose given 1, amount remaining 34, and February 19, 2024, at 12 AM, dose given 1, amount remaining 33. (The previous dose given on February 19, 2024, at 12 AM was incorrectly dated February 19, the correct date should have been February 20, 2024). And on February 22, 2024, at 0000 (12:00 AM), dose given 1, amount remaining 28, February 22, 2024, at 0900 (9:00 AM), dose given 1, amount remaining 27, February 22, 2024, at 1707 (5:07 PM), dose given 1, amount remaining 26, and on February 22, 2024, at 0000 (12:00 AM), dose given 1, amount remaining 25. (The previous dose given on February 22, 2024, at 0000 (12:00 AM), was incorrectly dated February 22, the correct date should have been February 23, 2024). A review of Resident 19's clinical record revealed she was most recently admitted to the facility on [DATE], with diagnoses to include anxiety. A physician order dated March 22, 2023, was noted for clonazepam (antianxiety medication) 1 mg, give 1 tablet by mouth every 12 hours for anxiety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 20 of 30 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 02/29/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm The controlled substance record, accounting for Resident 19's supply of clonazepam 1 mg, revealed that on February 10, 2024, at 0915 (9:15 AM), dose given 1, amount remaining 53, February 10, 2024, at 2132 (9:32 PM), dose given 1, amount remaining 52, and on February 10, 2024, at 0930 (9:30 AM), dose given 1, amount remaining 51. (The previous dose given on February 10, 2024, at 0930 (9:30 AM), was incorrectly dated February 10, the correct date should have been February 11, 2024). Residents Affected - Some A review of Resident 8's clinical record revealed she was admitted to the facility on [DATE], with diagnoses to include chronic pain, anxiety, conversion disorder with seizures or convulsions. A review of current physician orders dated November 28, 2023, was noted for Pregabalin (a controlled anticonvulsant) capsule 75 mg, give 2 capsules by mouth 1 time a day for restless leg syndrome. A continued review of current physician orders dated December 13, 2023, revealed Pregabalin capsule 75 mg, give 1 capsule by mouth 1 time a day for chronic pain. A review of February 2024, Medication Administration Record (MAR), revealed Lyrica (Pregabalin), oral capsule 75 mg, give 1 capsule by mouth one time a day for chronic pain, 0900 (9:00 AM), and Pregabalin oral capsule 75 mg, give 2 capsule by mouth one time a day for restless leg syndrome, 2100 (9:00 PM). The controlled substance record, accounting for Resident 8's Pregabalin, stated, Pregabalin (Lyrica) capsule 75 mg, take 1 capsule by mouth once daily and take 2 capsules (150 mg) by mouth at bedtime. Handwritten, in three (3) different locations on the controlled substance record was the words PM dose, PM, and P.M. A closer look revealed that on February 21, 2024, at 2020 (8:20 PM), dose given 1, amount remaining 16, February 21, 2024, at 2008 (8:08 PM), dose given 1, amount remaining 15, (The previous dose given on February 21, 2024, at 2008 (8:08 PM), was incorrectly dated February 21, the correct date should have been February 22, 2024). The facility failed to identify the discrepancies between the resident's controlled substance records, and the shift-to-shift accountability forms, failing to implement procedures to promote accuracy in administration, and accounting of controlled drugs and decrease the potential for drug diversion. During an interview with the Director of Nursing (DON) on February 28, 2024, at approximately 12:00 PM, confirmed the above findings, and stated that her expectation is that the controlled substance record accurately reflect the medication accounting/use and administration to the resident, and that at change of shift to demonstrate that they completed the count of the controlled drugs to identify potential discrepancies and that the facility failed to implement procedures reconciliation and accurate controlled drug medication records. Refer F761 28 Pa. Code 211.19(a)(1)(k) Pharmacy services 28 Pa. Code 211.5 (f) Medical records 28 Pa. Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 21 of 30 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 02/29/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policy and clinical records, observation and staff interview, it was determined that the facility failed to ensure that medications were labeled according to accepted labeling requirements for one of five residents sampled (Resident 8). Findings include: A review of the facility's policy Disposition of Medications last reviewed by the facility October 20, 2023, indicated it is the policy to establish guidance for the disposition of medications to implement safe and responsible disposition practices of discontinues medications in order to protect residents and staff from improper diversion or accidental exposure. Medications discontinues by prescriber order, are destroyed onsite with disposition being reported on a paper form which is then scanned into the electronic medical record. Medications are removed from the medication cart immediately upon receipt of an order to discontinue in an effort to avoid inadvertent administration. A review of Resident 8's clinical record revealed she was admitted to the facility on [DATE], with diagnoses to include chronic pain, anxiety, conversion disorder with seizures or convulsions. A current physician order dated November 28, 2023, was noted for Pregabalin (a controlled anticonvulsant) capsule 75 milligram (mg), give 2 capsules by mouth 1 time a day for restless leg syndrome, and an order dated December 13, 2023, for Pregabalin capsule 75 mg, give 1 capsule by mouth 1 time a day for chronic pain. A review of February 2024, Medication Administration Record (MAR), revealed Lyrica (Pregabalin), oral capsule 75 mg, give 1 capsule by mouth once daily for chronic pain, 0900 (9:00 AM), and Pregabalin oral capsule 75 mg, give 2 capsule by mouth once daily for restless leg syndrome, 2100 (9:00 PM). An observation of medication administration pass on February 27, 2024, at approximately 8:53 AM, revealed Employee 2, (LPN) on the South Medication cart. The controlled substance record, accounting for Resident 8's Pregabalin, revealed Pregabalin (Lyrica) capsule 75 mg, take 1 capsule by mouth once daily and take 2 capsules (150 mg) by mouth at bedtime. Handwritten, in three (3) different locations on the controlled substance record was the words AM dose, AM, and A.M. A second controlled substance record, accounting for Resident 8's Pregabalin, revealed Pregabalin (Lyrica) capsule 75 mg, take 1 capsule by mouth once daily and take 2 capsules (150 mg) by mouth at bedtime. Handwritten, in three (3) different locations on the controlled substance record was the words PM dose, PM, and P.M. However a closer observation of the second controlled substance record for Resident 8's Pregabalin, PM dose, revealed on February 21, 2024, at 2020 (8:20 PM), dose given 1, amount remaining 16, and February 21, 2024, at 2008 (8:08 PM), dose given 1, amount remaining 15, (The previous dose given on February 21, 2024, at 2008 (8:08 PM), was incorrectly dated February 21, the correct date should have been February 22, 2024), which was confirmed during interview with Employee 2, LPN, on February 27, 2024, at approximately 9:15 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 22 of 30 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 02/29/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm In the presence of Employee 2, (LPN), the surveyor requested to view the medication card (blister pack) of the Pregabalin (Lyrica). Located within the medication cart, was a locked drawer containing two (2) blister cards for the Pregabalin (Lyrica). The first, 1 of 2, was labeled Pregabalin (Lyrica) capsule 75 mg, take 1 capsule by mouth once daily and take 2 capsules (150 mg) by mouth at bedtime, date filled February 10, 2024. Handwritten on the blister card, in two (2) different locations were the words AM dose, AM. Residents Affected - Few The second, 2 of 2, blister back was labeled Pregabalin (Lyrica) capsule 75 mg, take 1 capsule by mouth once daily and take 2 capsules (150 mg) by mouth at bedtime, date filled February 10, 2024. Handwritten on the blister card, in two (2) different locations were the words PM dose, PM. Employee 2, LPN, on February 27, 2024, at approximately 9:15 AM, confirmed there was no additional medication blister packs of medication Pregabalin (Lyrica) for Resident 8 and that the two blister packs were labeled the same with the notation added for the AM dose and PM dose. A review of physician orders dated June 28, 2023, was noted for Tramadol (an opioid pain medication) 50 mg, give 1 tablet by mouth every 12 hours for chronic pain. Discontinued November 24, 2023, an order dated November 24, 2023, for Tramadol 50 mg, give 1 tablet by mouth every 12 hours as needed for severe pain 8-10, discontinued December 1, 2023, an order dated December 1, 2023, for Tramadol 50 mg, give 1 tablet by mouth every 12 hours as needed for moderate to severe pain 4-10, discontinued December 12, 2023, an order dated December 12, 2023, was noted for Tramadol 50 mg, give 1 tablet by mouth every 8 hours as needed for moderate to severe pain 4-10, discontinued January 1, 2024, and an order dated January 1, 2024, for Tramadol 50 mg, give 1 tablet by mouth every 8 hours as needed for severe pain 8-10 A review of the resident's February 2024, Medication Administration Record (MAR), revealed Tramadol oral tablet, 50 mg, give 1 tablet by mouth every 8 hours as needed for severe pain 8-10. The controlled substance record, accounting for Resident 8's Tramadol oral tablet, 50 mg, give 1 tablet by mouth every 8 hours as needed for severe pain, was labeled take 1 tablet by mouth every 12 hours, date filled November 28, 2023. In the presence of Employee 2, (LPN), the surveyor requested to view the medication cards of Tramadol oral tablet, 50 mg. Located within the medication cart, was a locked drawer containing one blister card of Tramadol 50 mg tablets. The medication blister card was labeled take 1 tablet by mouth every 12 hours, date filled November 28, 2023. Employee 2, LPN, on February 27, 2024, at approximately 9:15 AM,confirmed that the labels on the Tramadol 50 mg, controlled substance record, and medication blister pack, was not correct, and did not match the current physician orders. Interview with the Director of Nursing (DON), on February 28, 2024, at approximately 12:00 PM, confirmed that pregabalin (Lyrica) should have been labeled with individual labels for the administration times of (AM, PM) and the label on the medication blister pack containing the Tramadol 50 mg, and controlled substance record, did not presently match the current physician order. Refer F 755 28 Pa Code 211.12 (d)(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 23 of 30 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 02/29/2024 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 0761 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 24 of 30 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 02/29/2024 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 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. **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 to provide sufficient staff with the necessary skill set and competencies to ensure appropriate nutritional oversight for residents in the facility and nutritional assessment for one (Resident 2) out of 13 residents reviewed. Findings include: During an interview conducted on February 27, 2024, at 9:15 AM the foodservice director confirmed that she worked full-time and was a certified dietary manager (CDM). The CDM stated that the facility no longer employed a qualified dietitian on a full-time, part-time, or consultant basis. Interview with the nursing home administrator on February 27, 2024, at 10:00 AM confirmed that the facility's qualified dietitian resigned on January 3, 2024. A review of the Certifying Board for Dietary managers (the credentialing agency for the Association of Nutrition and Food Service professionals) scope of practice for certified dietary managers, these individuals were able to conduct routine nutritional screening including food/fluid intake information, calculate nutrient intake, implement diet plans and orders, utilize standard nutrition nutrition care procedures, document nutritional care screening data in the medical record and complete forms, review meal intakes, complete meal rounds, document food intake, participate in care conferences and review the effectiveness of nutritional care. Basic diet information could be provided using evidence based education materials. Their scope of practice did not include the clinical assessment and evaluation of residents for medically related nutritional therapy or to make recommendations regarding medications or supplementation. The facility's food service director had limited scope of practice and lacked necessary credentials/qualifications to provide the operational and nutritional oversight of a Registered Dietitian or clinically qualified nutrition professional. According to review of Resident 2's clinical record the resident was admitted to the facility on [DATE], with diagnoses which included diabetes, esophagitis, dysphagia (difficulty swallowing), and depression. Review of the clinical record revealed no documented evidence that a nutritional assessment was completed by a qualified dietitian to evaluate the nutritional needs and nutritional risk for Resident 2 who was admitted to the facility on [DATE]. Interview with the administrator on February 28, 2024, at approximately 11:00 AM confirmed that the facility had not yet hired a qualified dietitian or clinically qualified nutrition professional. Refer F692 28 Pa. Code: 201.18(e)(1)(6) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 25 of 30 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 02/29/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, it was determined that the facility failed to properly maintain garbage and refuse containers in garbage storage area in a sanitary manner. Residents Affected - Many Findings include: Observation on February 27, 2024, at 8:15 AM revealed the dumpster lid was not closed and two bags of garbage were placed on the ground next to the dumpster. There was scattered debris including paper wrappers, a slice of bread, and empty plastic beverage bottles on the ground surrounding the dumpster. Observation on February 28, 2024, at 2:30 PM revealed two bags of garbage on the ground next to the dumpster. Interview with the foodservice director (FSD) on February 29, 2024, at 11:45 AM confirmed that both dietary and housekeeping used the dumpsters. The FSD garbage was to be placed in the facility's dumpster and dumpster lids were to be kept closed. The FSD confirmed that the area surrounding the dumpster was to be maintained in a sanitary manner. 28 Pa. Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 26 of 30 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 02/29/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of the facility's infection control tracking logs and policy, and staff interviews it was determined that the facility failed to maintain a comprehensive program to monitor the development and spread of infections within the facility and plan preventative measures accordingly and failed to ensure the consistent implementation of infection control procedures designed to prevent the potential for the spread of infection during the medication administration for two out of two medication carts (North and South). Residents Affected - Many Findings include: A review of the facility's infection control policy, last reviewed October 20, 2023, provided by the facility during the survey of February 29, 2024, revealed that the facility will maintain an infection control program designed to provide a safe, sanitary, comfortable environment and to help prevent the development and transmission of disease and infection. The facility assures that there is an infection control program that is effective for investigation, controlling and preventing infections. This facility will assign an infection control coordinator to collect data, monitor and analyze and make recommendations. This data will be submitted to the Quality Assurance Performance Improvement (QAPI) committee. Ongoing monitoring for occurrence of infections for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment. Implementation of Control Measures and Precautions include basics such as cleaning and hand hygiene, as well as Standard and Transmission Based Precautions. At the time of review of the facility's infection control program on February 29, 2024, at 11:00 AM the facility was unable to provide the facility's infection control tracking for prior months and the current month. There was no documented evidence of facility infection control data and infection control tracking which reflected a current functioning tracking system to monitor and investigate causes of infection and manner of spread. There was no documented evidence of a system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner. There was no documented evidence of detailed data collection that could be used by the facility to track infections and to identify any potential trends contained in the tracking data. There was no documented evidence at the time of the survey that based on the available tracking data that the facility had identified any possible trends to implement specific interventions to prevent the spread of any of the infections. It could not be determined if the facility determined which infections required the implementation of isolation protocols, required treatment, the specific room location, location acquired, infectious organism or antibiotic therapy. There was no indication that the facility was compiling data and evaluating the data to determine what could be done to prevent the spread or recurrence of infection. The facility failed to include the necessary details to conduct routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections [i.e., healthcare associated infection (HAI) and community-acquired), infection risks, communicable disease outbreaks, and to maintain or improve resident health status and to track staff for adherence to infection control policies and procedures and the potential need for corrective action. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 27 of 30 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 02/29/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Interview with the director of nursing (DON) and administrator (NHA) on February 29, 2024, at 11:00 AM revealed that they were both newly hired at the facility and the facility did not currently employ an infection preventionist. The administrator confirmed that the facility did not have an infection preventionist (IP) since January 22, 2024, and were unable to locate the infection surveillance and tracking records maintained by the previous IP. Residents Affected - Many Observation of medication administration pass, on February 27, 2024, at approximately 8:26 AM, revealed Employee 1, Licensed Practical Nurse (LPN), on the North medication cart. A cell phone was observed laying on the top of the medication cart, towards the back, beneath the computer screen. Interview with Employee 1, LPN, on February 27, 2024, at approximately 8:27 AM, confirmed the observation, and stated it was her own personal cell phone, and verified that she had not adhered to infection control procedures during this medication pass. A continued observation of medication administration pass on February 27, 2024, at approximately 8:53 AM, revealed Employee 2, (LPN) on the South Medication cart. Employee 2, LPN, used hand sanitizer, which was located on the top of the medication cart. After sanitizing her hands, Employee 2 then used the computer mouse, rearranged various items on the top of the medication cart, opened the medication cart drawer, in preparation to administer medications to Resident 25. Employee 2 (LPN) did not wash or sanitize her hands after these tasks and prior to preparing medications. Employee 2 (LPN) removed a plastic sleeve of pills which included Potassium, and Levetiracetam. After tearing the sleeve open, and reading the packet, the 2 pills, (Potassium, and Levetiracetam) fell out onto the top of the medication cart. Employee 2 (LPN) proceeded to pick each pill up using her bare hands, one at a time, and placing them into the medication cup. Employee 2 (LPN) then removed plastic pill bottles which included guaifenesin, thiamine, and aspirin. She removed the medications out of the bottles and placed each medication (guaifenesin, thiamine, and aspirin) one at a time, in her bare hands. Employee 2 then placed each medication, one at a time, touching each medication, in a medication cup for administration to Resident 25. Employee 2 (LPN) then administered the medications to Resident 25. Interview with Employee 2, LPN, on February 27, 2024, at approximately 9:13 AM, confirmed that she touched the resident's medications with bare hands, and she had not adhered to infection control procedures during this medication pass. Interview with the Director of Nursing (DON), on February 28, 2024, at approximately 12:00 PM, confirmed the facility had not adhered to infection control procedures during this medication pass. Refer F882 28 Pa. Code 211.10 (a)(d) Resident care policies 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 28 of 30 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 02/29/2024 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on a review of select facility policy and staff interview, it was determined that the facility did not have one or more individuals serving as the Infection Preventionist (IP) responsible for the facility's infection prevention plan. Findings included: A review of the facility's infection control policy, last reviewed October 20, 2023, provided by the facility during the survey of February 29, 2024, revealed that the facility will maintain an infection control program designed to provide a safe, sanitary, comfortable environment and to help prevent the development and transmission of disease and infection. The facility assures that there is an infection control program that is effective for investigation, controlling and preventing infections. This facility will assign an infection control coordinator to collect data, monitor and analyze and make recommendations. This data will be submitted to the Quality Assurance Performance Improvement (QAPI) committee. Interview with the nursing home administrator (NHA) on February 27, 2024, at approximately 8:45 AM, revealed that the facility had been without an Infection Preventionist (IP) since the previous IP left on January 22, 2024. The NHA confirmed that the facility does not currently have an infection Preventionist performing the regulatory required duties, and that current ongoing infection prevention and control program (IPCP) was not being completed as expected. Refer F880 28 Pa. Code 201.18 (e)(6) Management 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12 (d)(4) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 29 of 30 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 02/29/2024 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 February 27, 2024, 9:00 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 30 of 30