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Inspection visit

Health inspection

KADIMA REHABILITATION & NURSING AT LUZERNECMS #3954848 citations on this visit
8 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select facility policy, and staff interview it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medication for one of 15 sampled residents. (Resident 29). Residents Affected - Some Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. Review of the facility policy titled Medication Administration last reviewed by the facility on September 16, 2024, revealed that medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Medications are administered in accordance with written orders of the attending physician. A review of the clinical record revealed Resident 29 was admitted to the facility on [DATE], with diagnoses to include atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls which causes obstruction of blood flow), hypertension (high blood pressure) and dementia with mild psychotic disturbance (chronic disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning experiencing hallucinations and delusions). A review of the physician's order dated November 5, 2024, revealed an order for Amlodipine Besylate (medication used to treat high blood pressure) Oral Tablet 2.5 mg, give 1 tablet by mouth one time a day for HTN (hypertension). HOLD for SBP<110 (systolic blood pressure less than 110), DBP<60 (diastolic blood pressure less than 60), or HR<60 (heart rate less than 60). Review of the Medication Administration Record (MAR) for November 2024, December 2024, and January (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 20 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 01/16/2025 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 0684 2025, revealed Resident 29's Amlodipine Besylate was administered on the following dates nineteen (19 times) outside of the physician ordered parameters: Level of Harm - Minimal harm or potential for actual harm November 6, 2024 Residents Affected - Some no blood pressure or heart rate documented November 7, 2024 no blood pressure or heart rate documented November 9, 2024 BP 100/60 HR 84 November 10, 2024 BP 100/60 HR 84 November 12, 2024 BP 112/62 HR 58 November 13, 2024 BP 112/62 HR 58 November 14, 2024 BP 112/62 HR 58 November 15, 2024 BP 112/62 HR 58 November 16, 2024 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 2 of 20 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 01/16/2025 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 0684 BP 92/64 Level of Harm - Minimal harm or potential for actual harm HR 54 November 18, 2024 Residents Affected - Some BP 130/74 HR 54 November 21, 2024 BP 110/62 HR 50 November 24, 2024 BP 118/60 HR 58 November 28, 2024 BP 140/70 HR 56 November 29, 2024 BP 140/70 HR 56 December 2, 2024 BP 124/70 HR 52 December 16, 2024 BP 116/62 HR 56 January 4, 2025 BP 98/52 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 3 of 20 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 01/16/2025 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 0684 HR 70 Level of Harm - Minimal harm or potential for actual harm January 5, 2025 BP 102/60 Residents Affected - Some HR 70 January 11, 2025 BP 100/50 HR 50 During an interview on January 15, 2025, at 12:10 PM the Director of Nursing (DON) confirmed that nursing staff failed to follow acceptable standards of nursing practice during medication administration resulting in multiple medication errors. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 4 of 20 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 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, resident and staff interview it was determined the facility failed to develop and implement effective safety measures to prevent the ingestion of an illegal substance for one resident out of 15 residents sampled. (Resident 25). Findings include: A clinical record review revealed Resident 25 was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, bipolar type (a mental health condition that combines symptoms of schizophrenia and bipolar disorder- people with this condition experience periods of extreme energy, irritability, and restlessness and/or periods of depressive episodes, low energy, and hopelessness), chronic pain, and polysubstance use disorder (includes use of drugs such as cocaine, misuse of alcohol, tobacco, or a prescription medicine such as opioids). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 28, 2024, revealed that Resident 9 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). Review of the resident's clinical record revealed a progress note dated December 9, 2024, at 7:59 PM, indicated Resident 25 exhibited slurred speech, and tremors (involuntary, rhythmic shaking or trembling of a body part)and an inability to hold a can of soda ,which he dropped. Documentation indicated no change in cognition, heart rate was 104 (normal value is between 60 and 100), and blood pressure was 106/84 (normal is less than 120/80). According to the documentation, Resident 25 declined to go to the hospital and stated, I will be ok in a little while. A subsequent progress note dated December 10, 2024, at 2:11 AM, indicated worsening symptoms, including tremors, slurred speech, diaphoresis (sweating), a heart rate of 139, and oxygen saturation of 89% (normal is between 95% and 100%) on room air. The physician ordered transfer to the emergency room. A change in condition note dated December 10, 2024, at 2:11 AM, indicated Resident 25 experienced tremoring, was diaphoretic (sweating), heart rate was 139, oxygen saturation was 89% on room air (normal is between 95% and 100%), and had slurred speech. The physician ordered the resident to be sent to the emergency room for an evaluation. Review of physician Progress Note dated December 10, 2024, indicated that Resident 25 was sent to the emergency room for an overdose event. According to the progress note, a visitor from outside the facility brought him in CBD Gummies or so we are told and so the resident maintains. The Nursing Home to Hospital Transfer form dated December 10, 2024, revealed that a visitor had given Resident #25 a marijuana edible gummy on the evening of December 9, 2024. Review of hospital After Visit Summary dated December 10, 2024, revealed that Resident 25 was evaluated in the emergency room for shortness of breath and diagnosed with behavior change due to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 5 of 20 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 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 substance use. Level of Harm - Minimal harm or potential for actual harm According to the summary, the resident received two naloxone injections (medication used to reverse the life-threatening effects of a known or suspected opiate/narcotic overdose) 2mg at 2:46 AM, and again at 3:14 AM. Residents Affected - Few A review of the resident's care plan failed to identify interventions or a plan to prevent the recurrence of consumption of nonprescribed medications. There was no documentation indicating the resident received education regarding the risks of ingesting nonprescribed substances. During an interview on January 16, 2025, at 1:30 PM, the Director of Nursing confirmed that the facility had not implemented interventions to prevent the resident from being provided with or consuming nonprescribed medications. The Director also confirmed that no education regarding the risks of consuming nonprescribed substances had been provided to Resident #25. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12 (d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 6 of 20 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 01/16/2025 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** determined the facility failed to assess, evaluate, monitor nutritional parameters, and develop and implement individualized nutritional interventions to maintain nutritional parameters and deter weight loss for three residents (Residents 18, 12, and 29) out of 15 residents sampled. Residents Affected - Some Findings include: The Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards: Responsibilities of the Licensed Dietitian/ Nutritionist Section 21.711 Professional Conduct indicated that the Licensed Dietitian/ Nutritionist shall provide information which will enable patients to make their own informed decisions regarding nutrition and dietetic therapy, including the reasonable expectations of the professional relationship. Review of the Facility assessment dated [DATE], failed to indicate the necessity of a qualified dietitian or clinically qualified nutrition professional to meet the nutritional needs of the residents. During interview with the foodservice director (FSD) on January 14, 2025, at approximately 9:30 AM confirmed she was the full-time Certified Dietary Manager but does not meet the minimum qualifications to be the qualified dietitian or clinically qualified nutrition professional. The FSD stated the facility does employ a part-time registered dietitian who works remotely. The FSD stated that she interacts with the registered dietitian via e-mail and telephone to provide/receive updates on residents. The FSD stated she does visit residents to obtain food preferences which are added to each resident's meal ticket and documented in the clinical record. The FSD also noted that she attends plan of care meetings for residents. A review of the facility's Nutrition Assessment Policy last reviewed September 16, 2024, indicated a nutrition assessment shall be completed for each resident admitted to the facility. The dietitian or the dining services manager under the guidance of the dietitian is responsible for developing a nutrition assessment for each resident admitted to the facility. A nutrition assessment will be conducted, and such information will include at least the following information: Weight Height Hematological data (information related to blood) Nutritional intake Eating habits Food preferences and dislikes Dietary restrictions Diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 7 of 20 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 01/16/2025 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 Other information deemed necessary and appropriate. Level of Harm - Minimal harm or potential for actual harm Nutrition assessments shall be initiated within 72 hours of admission to the facility and completed prior to developing the resident's MDS 3.0 assessment and care plan. Residents Affected - Some Nutrition assessments will be reviewed quarterly and revised as necessary. A review of the facility Resident Weights policy last reviewed September 16, 2024, indicated 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 the first 2 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 4 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 monthly weights will be completed by the seventh of the month. Re-weights will be obtained within 72 hours of a monthly weight if a weight change is greater than 3%. If the weight change is validated, the licensed nurse will notify the physician and dietitian. The licensed nurse will notify the interdisciplinary team for further assessment if the weight change is significant (a weight loss or gain of 5% in a month, 7.5% in 90 days, or 10% in 6 months), the family will be notified. All weights will be transcribed (including weekly weights and any reweigh) in the resident's electronic medical record. A review of the facility Enteral Tube (flexible tube placed in stomach in which medications and liquid nutritional supplements are given to provide calories, nourishment, and fluids) Medication Administration Policy last reviewed September 16, 2024, indicated the facility assures the safe and effective administration of enteral formulas and medications via enteral tubes. Selection of enteral formulas, routes and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident's condition, in consultation with the physician, dietitian, and consultant pharmacist. Enteral formulas, equipment, route of administration, and flow rate are based on an assessment of the resident's condition and need. Clinical record review revealed that Resident 18 was admitted to the facility on [DATE], with diagnoses to include Huntington's disease (inherited condition that affects cells in your brain and causes physical and emotional changes that get worse over time) and oropharyngeal dysphagia (difficulty swallowing). A review of Resident 18's quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 20, 2024, revealed the resident had a BIMS score of 3 (Brief Interview for Mental Status- a tool that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severely cognitively impaired), weighed 122 pounds, 62 inches tall, had no significant weight loss or weight gain, and was on a mechanically altered diet (change in texture of solids or liquids to assist swallowing). A review of the resident's Weight Record revealed the following: July 11, 2024- 129.7 pounds. August 5, 2024- 126.9 pounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 8 of 20 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 01/16/2025 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 September 1, 2024- 124.4 pounds. Level of Harm - Minimal harm or potential for actual harm October 4, 2024- 122.2 pounds. November 2024- no weight obtained. Residents Affected - Some December 2024- no weight obtained. Further review of the clinical record revealed no documented evidence of a reason for not obtaining a monthly weight for the months of November 2024 and December 2024. A quarterly nutrition note written by the registered dietitian dated December 18, 2024, noted the resident's current weight is 122.2 pounds, height 62 inches, BMI (body mass index, measure that relates body weight to height to determine healthy weight) 22.3 below ideal body weight, receives regular puree (foods are blenderized to pudding consistency) with nectar-thick liquids, average intakes 75-100%. Divided plate at meals and Kennedy cup (spill-proof drinking cup) for hot beverages. Resident eats meals in the dining room. Offered health shakes (nutritional beverage) twice daily, fortified cereal three times per day, 30 ml liquid protein (liquid nutritional supplement) twice daily, skin intact, no edema noted. Continue diet and supplements as ordered, monitor weights, and intakes for significant changes. Offer assistance as needed and honor preferences. Follow with interdisciplinary care plan team. A nurses note dated December 30, 2024, indicated the resident was positive for COVID-19, had a poor appetite skin turgor (elasticity or firmness of the skin) was fair. A nurses note dated December 30, 2024, at 6:51 PM noted a physician order to start Normal Saline IV (intravenous- fluids given through a tube inserted into a vein)1000 ml at 80 cc/hour over 12 hours to prevent dehydration. A nurses note dated December 31, 2024, at 9:52 AM noted the resident was having difficulty catching her breath, SPO2 (measure of amount of oxygen in the blood) 84% and the resident was coughing with poor effort to cough. Suctioned for large amount of thick white mucous, after suctioning SPO2 92% on oxygen 2 liters/min via nasal cannula. 911 called. Ambulance arrived and resident was transferred with IV in left hand to emergency room. CRNP (certified registered nurse practitioner) and resident representative was made aware. A nurses note dated December 31, 2024, at 9:05 PM indicated the resident returned from the hospital after IV fluids were given at the hospital. The Resident's representative was made aware of return. A nurse's note dated January 2, 2025, at 3:54 PM indicated the resident remained lethargic. Resident representative called with update with resident representative asking for IV fluids. Attempted to start IV per orders (physician) and resident representative request. IV insertion attempt unsuccessful. Resident representative was agreeable to sending resident to the emergency department for IV fluids and hospice placement. A nurses note dated January 10, 2025, noted the resident was readmitted to the facility with diagnosis of COVID-19 related pneumonia. New feeding tube in place. Resident was strict NPO (nothing by mouth). Jevity 1.5 at 25 ml/hr continuous as per hospital nutritionist, resident is too high risk for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 9 of 20 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 01/16/2025 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 bolus feedings. Free water flushes every 6 hours at 60 ml. Level of Harm - Minimal harm or potential for actual harm A physician order dated January 11, 2025, noted an order for Jevity 1.5 10 ml/hr for 22 hours. Assess for tolerance by monitoring residual, nausea/vomiting. Advance by 10 ml/hr every 24 hours until goal of 45 ml/hr is reached. Residents Affected - Some A nursing change in condition note dated January 12, 2025, at 7:43 AM indicated the resident with no urine output for 2 shifts (sixteen hours). Dry mucous membranes, skin turgor dry. CRNP and resident representative aware. New order to send to emergency room for evaluation and treatment. A nurses note date January 12, 2025, at 2:03 PM indicated the resident returned from the hospital with a physician order to flush feeding tube with water, 120 ml, every 4 hours. A physician order dated January 16, 2025, noted an order for Jevity 1.5 at 45 ml/hr for 22 hours daily via g-tube (a tube surgically inserted through the abdomen into the stomach). The resident was readmitted on [DATE], with a feeding tube in place due to high aspiration risk, yet no weight was obtained until January 15, 2025, revealing further weight loss to 114 lbs. (7% over 3 months) since the last recorded weight on October 4, 2024. Despite the significant weight loss, there was no evidence that the registered dietitian evaluated the resident's nutritional requirements or updated the care plan following the implementation of enteral feeding. The nursing home administrator confirmed on January 16, 2025, at 10:00 AM that the facility lacked an on-site dietitian and relied on a part-time remote dietitian, without face-to-face interaction with the residents, resulting in limited oversight of residents' nutritional needs. The NHA confirmed that weights were to be timely obtained and nutritional assessments were to be timely completed to ensure nutritional parameters are maintained to the extent possible for each resident. Clinical record review revealed that Resident 12 was admitted to the facility on [DATE], with diagnosis which included cerebral infarction (stroke- occurs when blood flow to the brain is blocked). Further review of the clinical record revealed a registered dietitian note dated September 14, 2024, which noted the resident receives a puree diet with pudding-thickened liquids. Monitor weights and food and fluid intakes for significant changes. Honor preferences and offer assistance as needed. Follow with care team. A review of the resident's weights noted the following: October 4, 2024- 114.6 pounds. November 3, 2024- 112.8 pounds December 3, 2024- 113.6 pounds January 1, 2025- 106.8- pounds Resident 12 experienced a 6.8 lb. weight loss (5.9%) between December 3, 2024, and January 1, 2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 10 of 20 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 01/16/2025 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 A reweight was not obtained within the required 72-hour timeframe per facility policy. Level of Harm - Minimal harm or potential for actual harm Following surveyor inquiry, a reweight obtained on January 15, 2025, (14 days late) showed 112.6 lbs. The Director of Nursing confirmed on January 15, 2025, that the reweight was not timely obtained. Residents Affected - Some A review of the clinical record revealed Resident 29 was admitted to the facility on [DATE], with diagnoses to include atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls which causes obstruction of blood flow), hypertension (high blood pressure) and dementia with mild psychotic disturbance (chronic disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning experiencing hallucinations and delusions). A quarterly Minimum Data Set Assessment (MDS- standardized assessment process conducted at periodic intervals to plan resident care) dated November 3, 2024, revealed the resident was moderately cognitively impaired with a BIMS score of 8 (Brief Interview for Mental Status-a tool to assess the resident's attention, orientation, and the ability to register and recall new information, a score of 8-12 equates to moderate cognitive impairment). Review of Resident 29's plan of care initiated on October 19, 2023, revealed a focus area that the resident may be nutritionally at risk related to therapeutic diet, dementia, diabetes, hypertension and GERD with interventions to consult with the dietician, honor food preferences, monitor for changes in the amount of food consumed, monitor for signs and symptoms of diet intolerance and dehydration, provide diet as ordered: consistent carbohydrate/heart healthy diet, regular texture, think liquids, record and monitor intakes, and record and monitor weights as ordered. Resident 29's weight record revealed: June 3, 2024, 140.2 lbs. July 8, 2024, 132.2 lbs. (5.71% weight loss in one month) August 5, 2024, 129.2 lbs. September 10, 2024, 127.4 lbs. Resident 29 experienced significant weight loss from 140.2 lbs. (June 2024) to 132.2 lbs. (July 2024, a 5.71% loss). No reweight was conducted within the 72-hour timeframe as required, and there was no evidence that the physician, dietitian, or interdisciplinary team was notified of the significant weight change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 11 of 20 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 01/16/2025 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 Level of Harm - Minimal harm or potential for actual harm Further review of the clinical record revealed no evidence that the physician or the dietitian was notified of the resident's significant weight loss of 8 lbs., or 5.71% on July 8, 2024. There was no evidence that the licensed nurse notified the Interdisciplinary Team for further assessment for the significant weight loss on July 8, 2024, as per facility policy. Residents Affected - Some There was no documented evidence that the facility identified Resident 29's continued weight loss during the month of August 2024. Review of a dietary note dated September 11, 2024, indicated the resident's current weight was 127.4 lbs., -1.8 lbs. x 30 days, -13lbs. /-10.2 lbs. x 180 days. Height is 63, BMI 21.9 which is below her ideal body weight of 140-169 lbs. Weight monitoring continued to show ongoing weight loss, but no updated nutritional assessments or individualized interventions were documented between the resident's admission in October 2023 and September 2024 Interview with the Director of Nursing (DON) on January 16, 2025, at approximately 12:15 PM confirmed the facility failed to obtain and record Resident 29's reweights and failed to timely notify the physician and dietician of the residents significant weight loss that occurred on June 8, 2024, to provide the necessary information to accurately assess the resident's nutritional status and needs and evaluate the adequacy of the resident's nutritional intake and plan nutritional support as necessary. Refer F801, F838 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 12 of 20 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 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select facility policy, observation, and staff interview, it was determined the facility failed to maintain oxygen equipment in a functional and sanitary manner for two residents out of 15 sampled (Residents 13 and 24). Residents Affected - Few Findings include: Review of the facility policy titled Oxygen Concentrator last reviewed by the facility on September 16, 2024, revealed that precautions will be taken to maintain the integrity of the oxygen concentrator (bedside machine that concentrates ambient air to supply an oxygen-rich gas stream) unit and to promote safety during oxygen administration. Be sure the cabinet air filter is in place. The air filter is to be removed from the door in the back of the unit by nursing. Wash the filter in warm water and towel dry. Do not operate the unit without the air filter or while the air filter is still damp. Review of Resident 13's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disease (COPD- lung disease that blocks airflow and makes it difficult to breathe), and hypertension (high blood pressure). The resident had a current physician's order dated October 29, 2024, for oxygen therapy administration via nasal cannula (flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen) at 4.0 liters per minute for shortness of breath due to COPD. An observation conducted on January 14, 2024 at 10:55 AM revealed that Resident 13 was awake and lying in bed with supplemental oxygen in place via an oxygen concentrator with the liter flow set at 4.0 liters per minute. The resident's oxygen concentrator filter was missing from the unit. Review of Resident 24's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include moderate persistent asthma (airwys become inflamed, narrow and swell, and produce extra mucus, making if difficult to breathe) and dependence on supplemental oxygen. The resident had a current physician's order dated November 4, 2024, for oxygen therapy administration via nasal cannula (flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen) at 2.0 liters per minute PRN (as needed) for shortness of breath. May increase up to 5 liters per minute for SPO2 below 90%, every 8 hours as need for shortness of breath. An observation conducted on January 14, 2025 at 11:33 AM revealed that Resident 24 was lying in his bed with supplemental oxygen in place via an oxygen concentrator with the liter flow set at 2.0 liters per minute. The resident's oxygen concentrator filter was visibly covered in dust. Interview with Employee 1 (licensed practical nurse) on January 14, 2025, at 11:40 AM confirmed that Resident 24's the oxygen concentrator filter was covered in dust. Employee 1 confirmed that the oxygen concentrator filter was missing for Resident 13. Interview with Nursing Home Administrator on January 16, 2025, at 12:20 PM confirmed the condition of the oxygen concentrators were not consistent with facility policy for maintenance of oxygen delivery equipment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 13 of 20 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 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.10 (a)(c) Resident Care Policies Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 14 of 20 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 01/16/2025 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 staff interview, a review of personnel files and employee credentials, it was determined 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 failed to ensure the full-time director of food and nutrition services, who was not a qualified dietitian or other clinically qualified nutrition professional, received frequently scheduled consultations from a qualified dietitian or other clinically qualified nutritional professional. Findings include: Federal regulations require the facility to employ sufficient staff with the appropriate competencies and skill sets to meet the nutritional needs of residents, considering resident assessments, individual plans of care, and the facility assessment. In the absence of a full-time qualified dietitian, the Director of Food and Nutrition Services must meet minimum qualifications and receive frequent consultations from a qualified dietitian or other clinically qualified nutrition professional The Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards: Responsibilities of the Licensed Dietitian/ Nutritionist Section 21.711 Professional Conduct indicated that the Licensed Dietitian/ Nutritionist shall provide information which will enable patients to make their own informed decisions regarding nutrition and dietetic therapy, including the reasonable expectations of the professional relationship. Review of the Facility assessment dated [DATE], failed to indicate the necessity of a qualified dietitian or clinically qualified nutrition professional to meet the nutritional needs of the residents. During interview on January 14, 2025, at approximately 9:30 AM the full-time foodservice director (FSD) confirmed she was a Certified Dietary Manager but does not meet the minimum qualifications to be the qualified dietitian or clinically qualified nutrition professional. The FSD stated that the facility does employ a part-time registered dietitian (RD) who works remotely. The FSD stated that she interacts with the RD via e-mail and telephone to provide/receive updates on residents. The FSD stated that she does visit residents to obtain food preferences which are added to each resident's meal ticket and documented in the clinical record. The FSD also noted that she attends plan of care meetings for residents. 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 15 of 20 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 01/16/2025 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 supplementation. Level of Harm - Minimal harm or potential for actual harm The facility's FSD had limited scope of practice and lacked necessary credentials/qualifications to provide the operational and nutritional oversight of a RD or clinically qualified nutrition professional. Residents Affected - Many A review of a facility provided job description for the RD indicated that the primary purpose of the job description is to implement, coordinate, and evaluate the medical nutrition therapy for the residents, provide resident, and family education, provide nutritional assessment and consultation to assist planning, organizing, and directing the food and nutritional services of the facility. Functions of the RD included to perform administrative duties such as completing necessary forms, reports, evaluations, studies, etc., to assure control of the Food Service Department, inspect food storage rooms, utility/janitorial closets, etc., for upkeep and supply control, participate in facility surveys (inspections) made by authorized government agencies, assist in developing methods for determining quality and quantity of food served, and participate in Quality Assurance programs, and any facility committee or program, which seeks to improve the performance or accuracy of resident care. However, the RD's part time remote status limited her ability to fulfill these responsibilities effectively. Interview with the nursing home administrator (NHA) on January 16, 2025, at 9:00 AM failed to provide documentation confirming the RD's role included on site consultation or oversight, or that the FSD received frequently scheduled consultations from the RD. Interview with the part-time RD on January 16, 2025, at 1:30 PM revealed that she works remotely and has worked with the facility on-and-off since December 18, 2020. The RD confirmed that she completes all job tasks including nutritional assessments remotely with input from the interdisciplinary team including nursing and the FSD. The RD confirmed that she accesses residents' clinical records remotely. The RD stated that she does not contact residents on the phone before completing nutritional assessments and had not been in the facility to observe the residents' ability to eat, interview residents and provide nutritional consultation or observe the residents for signs and symptoms of nutritional and hydration inadequacies/deficiencies and provide oversight of the operations of the food and nutritional services department. Refer F692, F838 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 16 of 20 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 01/16/2025 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on a review of professional literature, the facility's assessment, facility documentation, a review of the medical and nutritional needs of the resident census, and staff interview it was determined the facility failed to conduct and document a facility-wide assessment, using evidence-based methods, which identified and accurately reflected the specific resources necessary and available to care for its specific resident population. Findings include: Review of the Centers for Medicare and Medicaid Services Memorandum, Revised Guidance for Long-Term Care Facility Assessment Requirements (QSO-24-13-NH) dated June 18, 2024, revealed the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions), and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. Further review revealed the assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess to deliver the necessary care required by the residents being served. Review of the Facility Assessment, last reviewed by the facility on November 29, 2024, indicated the number of resident beds in the facility is 37 and the average daily census of the facility is 36 residents. There was no further information specific to the facility, the facility's population, and facility resources necessary to care for its residents competently during both day-to-day operations and emergencies. The Facility Assessment failed to accurately reflect the current staff employed in the facility to ensure a sufficient and competent number of qualified staff are available to meet each resident's needs. Review of the facility's Resident Matrix (list of all residents in the facility), dated January 14, 2025, revealed a total census of 35 residents. Of the 35 residents, the Matrix identified one resident (Resident 18) receiving enteral feeding (method of feeding that delivers food and fluid via a tube inserted into the stomach or small intestine) who would require services of a qualified dietitian. During an interview on January 14, 2025, at approximately 9:30 AM the full-time foodservice director (FSD) confirmed she was a Certified Dietary Manager but does not meet the minimum qualifications to be the qualified dietitian or clinically qualified nutrition professional. The FSD stated that the facility does employ a part-time registered dietitian who works remotely. The FSD stated that she interacts with the registered dietitian via e-mail and telephone to provide/receive updates on residents. The FSD stated that she does visit residents to obtain food preferences which are added to each resident's meal ticket and documented in the clinical record. The FSD also noted that she attends plan of care meetings for residents. An interview with the NHA on November 20, 2024, at 9:30 AM confirmed the current part-time registered dietitian who also works for sister facilities works remotely and completes nutritional assessments and nutritional progress notes offsite, without face-to-face interaction with the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 17 of 20 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 01/16/2025 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The facility failed to conduct and document a comprehensive facility-wide assessment, which is required to identify the specific resources necessary to meet the unique needs of its resident population. This deficient practice has the potential to negatively affect the quality of care and quality of life for all residents. During an interview on January 16, 2025, at 9:00 AM the Nursing Home Administrator confirmed that the Facility Assessment did not contain all the required information. Refer F692, F801 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 18 of 20 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 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policy and clinical records, and staff interview, it was determined the facility failed to offer and/or provide the pneumococcal immunization, unless the immunization was medically contraindicated or the resident has already been immunized, to one resident out of five residents reviewed (Residents 29). Residents Affected - Few Findings include: A review of facility policy titled Influenza and Pneumococcal Pneumonia Vaccination and Immunization Program last reviewed September 16, 2024, revealed that each resident is offered a pneumococcal immunization unless the immunization is medically contraindicated. Nursing staff will provide education information to the resident/authorized representative prior to the administration of each vaccine. Once education has been completed, a signed consent form is to be obtained prior to administration of the vaccine. A review of the clinical record revealed that Resident 29 was admitted to the facility on [DATE], with diagnoses to include atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls which causes obstruction of blood flow), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and diabetes (body has trouble controlling blood sugar and using it for energy). Review of Resident 29's Informed Consent for Pneumococcal Vaccine signed by Resident 29's resident representative on July 18, 2024, indicated permission for the facility to administer the pneumococcal vaccine. Further review of the clinical record revealed no documented evidence the facility administered the pneumococcal vaccine as requested per the signed consent. Interview with the Director of Nursing on January 16, 2025, at 12:08 PM confirmed the facility failed to provide pneumococcal immunizations to Residents 29. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa Code 211.5 (f)(i) Medical records 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 19 of 20 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 01/16/2025 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 the facility failed to provide the regulatory required minimum square footage in nine of 21 resident rooms. Findings include: Observations made on Janaury 14, 2025, at 9:30 AM, revealed square footage was not adequate in the following resident rooms: room [ROOM NUMBER] is a single-bedded resident room, which requires a minimum of 100 square feet. The square footage of this room measured 85 square feet. Resident rooms 15, 16, 17, 18, 19, 20, 21, and 23 are two- bedded resident rooms with square footage measurements of only 143 square feet. These multi-bed rooms failed to provide the minimum square footage requirement of 80 square feet per bed, or a total of 160 square feet in a semi-private room. CFR 483.90(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 20 of 20

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Citations

8 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0684GeneralS&S Epotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0689GeneralS&S Dpotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0692GeneralS&S Epotential for harm

    F692 - Assisted nutrition and hydration

    Provide enough food/fluids to maintain a resident's health.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0801GeneralS&S Fpotential for harm

    F801 - Staffing

    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.

  • 0838GeneralS&S Fpotential for harm

    F838 - Facility assessment

    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

  • 0883GeneralS&S Dpotential for harm

    F883 - Influenza and pneumococcal immunizations

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 0912GeneralS&S Bno actual harm

    F912 - Measure at least 80 square feet per resident in multiple resident

    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

FAQ · About this visit

Common questions about this visit

What happened during the January 16, 2025 survey of KADIMA REHABILITATION & NURSING AT LUZERNE?

This was a inspection survey of KADIMA REHABILITATION & NURSING AT LUZERNE on January 16, 2025. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at KADIMA REHABILITATION & NURSING AT LUZERNE on January 16, 2025?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.