Health inspection·April 17, 2025

F 0623 28 Pa. Code 201.29(a) Resident rights 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 2 of 6 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 04/17/2025 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and the facility's bed hold policy and staff interview it was determined the facility failed to provide written notice of the specifics of the facility's bed hold policy to the resident, responsible party or legal representative at the time of the transfer, to include the duration and reserve bed payment for one resident out of five sampled (Resident 1). Findings include: A review of a facility policy for bed hold (no policy review date available at the time of the survey) revealed, for Medicaid residents, the bed will be held while a resident is in the hospital or on therapeutic leave. Medicaid pays for hospitalization of 15 days and therapeutic leave of 30 days. The resident is allowed to return to the facility in this time frame. If there is no bed available at the facility, on the date of hospital discharge, the facility will make every effort to place the resident in a local facility. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE]. A review of an admission Minimum Data Set assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) indicated that the resident was severely cognitively impaired with a BIMS score of 3 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 0 to 7 indicating severe, cognitive impairment) and a diagnosis of dementia and a history of alcohol abuse. Further review of the record revealed that Resident 1 had been adjudicated incapacitated by the court on April 4, 2023, with a guardian appointed to oversee both medical and financial decisions. At the time of the survey, only the first page of the four-page guardianship order was present in the clinical record. During an interview with the Director of Social Services on April 17, 2025, at 11:00 AM, she acknowledged the complete guardianship order was not on file and confirmed she had to contact the guardian during the survey to obtain the remaining pages, which were subsequently placed in the record. Review of the admission agreement including decisions for care and treatment provided by the facility, dated April 22, 2024, revealed it included information regarding resident transfers and the facility's bed-hold policy. The agreement was signed by Resident 1; however, there was no documented evidence that the court-appointed guardian had reviewed or signed the agreement, nor that a copy of the agreement and the facility's bed-hold policy had been provided to the guardian upon admission. Resident 1 was transferred to the hospital on three occasions: February 3, 2025; February 10, 2025; and February 24, 2025. There was no documented evidence that the resident's guardian was provided written notice at the time of transfer or within 24 hours of transfer, detailing the facility's bed-hold policy, including the duration of the bed-hold, if any; any associated reserve bed payment agreement; or the resident's right to return to the next available bed. The facility failed to provide written bed-hold information to the representative of a resident who had a documented diagnosis of dementia, was severely cognitively impaired, and had been legally declared incapacitated. This information is critical to ensuring the resident's representative can make (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 3 of 6 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 04/17/2025 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 0625 informed decisions regarding the resident's care and potential return to the facility. Level of Harm - Minimal harm or potential for actual harm During an interview with the Nursing Home Administrator (NHA) on April 17, 2025, at approximately 11:15 AM, the NHA stated that the business office manager (BOM) was responsible for issuing bed-hold information. She further reported the facility had not had a BOM for a long time and was unable to provide the previous BOM's dates of employment. The NHA confirmed the facility did not issue any written notice of its bed-hold policy to the resident's representative at the time of Resident 1's hospital transfers on the dates noted above. Residents Affected - Few 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 201.29 (b)Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 4 of 6 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 04/17/2025 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Based on review of clinical records, facility policy provided to residents upon transfer from the facility, and interview with facility staff revealed the facility failed to demonstrate the implementation of specifically delineated procedures for Medicaid payor source bed holds and the provision of notices of the facility's bed hold policy in an understandable language that allow a resident to return to the facility after a transfer to the emergency room for one resident out of five reviewed. (Resident 1). Findings include: A review of the facility's policy titled Bed Reservations for Medicaid Covered Residents (no policy revision date noted) indicated that Medicaid residents are permitted a maximum of 15 consecutive bed-hold days per hospitalization. The policy further states that residents shall be allowed to return to the nursing facility immediately upon the first availability of a bed in a semi-private room, provided the resident continues to require the facility's services. A review of Resident 1's clinical record revealed the resident was covered under a Medicaid managed care plan and was transferred to the hospital on February 24, 2025, for behavioral concerns, including physical aggression toward staff. Nursing documentation on that date described the resident as increasingly agitated, unresponsive to redirection, and having physically assaulted a nurse. The physician and emergency services were contacted, and the resident was sent to the emergency department at 7:51 AM. Despite the facility's policy and the resident's Medicaid status, there was no documented evidence that a written notice of the facility's bed-hold or readmission policy, specifically regarding the 15-day Medicaid bed-hold entitlement, was provided to the resident or the resident's representative at the time of transfer. There was no evidence the resident or responsible party was informed in writing about their rights to return, nor any indication that they accepted or declined a bed hold. Social service notes dated February 26 and 27, 2025, documented that attempts were made to place Resident 1 in other facilities due to his behaviors. All contacted facilities declined to accept the resident. The clinical record from February 28 through March 10, 2025, indicated the resident remained hospitalized , with no documented discharge plan from the facility. Documentation submitted during the survey included multiple emails from hospital staff between February 25 and March 11, 2025, requesting that Resident 1 be readmitted . On February 25, 2025, the facility's corporate admissions representative stated the resident would not be accepted back until specific conditions were met: no need for one-to-one supervision or video monitoring, no use of PRN (as needed) medications or restraints, and a minimum of 72 hours free from behavioral interventions. Despite continued requests from the hospital through March 11, 2025, the facility did not permit the resident's return. There was no evidence of clinical reassessment or documented evaluation by the facility regarding its ability to meet Resident 1's care needs. The facility did not demonstrate efforts to coordinate with the hospital to plan for the resident's return. Furthermore, there were no transfer or discharge planning documents completed by the facility, and the resident's record did not include documentation of the decision to decline or accept a bed-hold. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 5 of 6 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 04/17/2025 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on April 17, 2025, the Nursing Home Administrator and Director of Nursing confirmed that the resident was initially admitted per corporate directive. Both acknowledged the resident had a history of aggressive behaviors and stated that due to concerns for the safety of staff and other residents, the facility determined it could not meet his needs. However, there was no documented evidence that the facility conducted a formal review of its ability to accommodate the resident's behavioral health needs upon potential readmission. 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 201.29 (b)Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 6 of 6