Health inspection·June 18, 2024

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 and resident and staff interviews, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment and ready availability of clean bath linens, to at least three of the five residents sampled (Residents 1, 2, and 22) and on two of the two nursing halls. Findings include: During an interview on June 18, 2024, at 8:50 AM, Resident 1 stated the facility has a good part-time housekeeper. He stated that the bathrooms and hallways are dirty when this housekeeper is not working. He said he is upset because he uses a shared bathroom, and often finds feces on the toilet and floor in this bathroom that he shares with another resident. During a facility tour on June 18, 2024, at 9:00 AM, an observation of the resident shower room [ROOM NUMBER] revealed a soiled brief, used wash towels, and clothing on the floor. A used wet wash towel was observed hanging from the metal grab bar in the shower. A stained clothing protector was observed in the wash tub. Pieces of black debris were observed on the shower tiles. A gray fabric was observed partially covering the drain. Debris was observed in the shower drain holes. The caulking around the shower floor and shower wall was discolored black, yellow, and tan. An observation on June 18, 2024, at 9:15 AM of the hallways in front of the nursing station and both resident room hallways revealed dirt, debris, and stains, including small white pieces of paper, brown food particles, gray and white discolorations, pieces of clear tape, white food crumbs, and an empty blue pill casing. An observation on June 28, 2024, at 9:20 AM in resident room [ROOM NUMBER] revealed yellow and brown food debris on the bedroom floor. A gray discoloration stain was observed on the floor near the bed and garbage can. The privacy curtains were observed to have tan and gray stains. The radiator cover near the resident window side bed was observed with tan liquid stains and gray scuff marks. A white piece of used tissue paper and small pieces of white paper were observed on the floor near the window-side garbage can. Dead insects and debris were observed under the cover of the overhead light fixture. During an interview on June 28, 2024, at 9:25 AM, Resident 22 stated that the facility's housekeeper does a good job, but when she is off, the facility is a mess. She stated that the facility does not have enough housekeeping staff to keep everything clean. She stated that the wash cloths are stained and dirty, and often not enough are available when needed for personal care. Resident 22 stated (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 7 Event ID: 395484 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2024 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)