Health inspection·July 23, 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 and maintenance services to maintain a clean and safe resident environment. Findings include: An observation on July 23, 2024, at 9:09 AM revealed dirt and debris was on the floors throughout the hallway of the south side nursing unit. Observation in the common resident bathroom on this hall revealed hair and a dried yellow-urine like substance on the toilet. Observation in resident room [ROOM NUMBER] revealed dried feces on the toilet and toilet seat. Dirt and debris was observed on the bathroom floor. Dirt, debris and a dried red substance was observed on the floor of resident room [ROOM NUMBER]. [NAME] streaks were observed on the wall next to the door. Observation in resident room [ROOM NUMBER] revealed dried stain streaks on the wall next to the resident's dresser. There was an accummulation of dust and dirt stuck to these streaks on the wall. Observation in the resident shower room on the north hall revealed a black and brown mold like substance coating the caulking extending the perimeter of the floor of the shower. Observation in resident room [ROOM NUMBER] revealed a dried brown substance on the floor along with food crumbs scattered about the floor. Observation in the resident's bathroom, revealed black streaks extending down the base of the toiled and dried fecal-like brown spots on the toilet seat. Observation of the resident shower room in the middle hall revealed cracked floor tiles. Observation in resident room [ROOM NUMBER] revealed dried liquid spots on the floor and dried brown drips on the wall. An accummulation of dust and dirt was observed behind the ice machine in the resident dining room. Interview with the Director of Nursing on July 23, 2024, at approximately 2:15 PM confirmed that the facility is to be maintained daily to provide a clean and sanitary environment for the residents. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395484 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 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)