Inspection·June 11, 2025

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. The part-time registered dietitian's role does not include on-site oversight or consultation to the food and nutrition services department. During an interview conducted on June 10, 2025, at 11:00 AM, the Nursing Home Administrator (NHA) confirmed the facility's full-time RD was hired on February 3, 2025, and resigned on May 30, 2025. The NHA stated that since the resignation, Employee 5, a registered dietitian, agreed to provide services remotely for approximately 10 hours per week. The NHA confirmed the RD had a full-time job elsewhere and was not available to the facility during regular day shift hours (8:00 AM to 4:00 PM). All dietary documentation and nutritional assessments from May 30, 2025, to the time of the survey were completed remotely. The NHA also confirmed that the corporate RD did not conduct on-site supervisory oversight of the food and nutrition services department, including staff training, direct observation of residents for nutritional assessments, or monitoring of meal services. The facility failed to ensure compliance with federal requirements by not providing the necessary on-site oversight and consultation by a qualified dietitian or clinically qualified nutrition professional. This failure created the potential for inadequate monitoring and coordination of food and nutrition services necessary to meet residents' clinical and nutritional needs. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18 (b)(1)(3)(e)(1)(6) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 2 of 15 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 06/11/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on a review of the facility's planned cycle menus, staff interviews, and observations, it was determined the facility failed to ensure meals were prepared and served in accordance with planned menus to meet the nutritional needs and specialized dietary requirements for 14 residents. Specifically, the facility failed to follow planned menus for 4 of 4 residents requiring a pureed diet (Residents 11, 12, 4, and 5), 9 of 9 residents requiring a mechanical ground diet (Residents 13, 14, 15, 16, 17, 18, 19, 20, and 21), and 1 of 1 resident requiring a gluten-free diet (Resident 2). Findings included: A review of the planned lunch menu for June 10, 2025, revealed the listed items included beef steak and peppers (2 oz), a vegetable blend (1/2 cup), Texas toast (1/2 slice), and gelatin with fruit. Further review of the facility's diet extension menu for that day indicated the pureed diet (a method for turning solid foods into a smooth, creamy, or paste-like consistency for residents with a chewing or swallowing problem) should have included pureed beef pepper steak, pureed vegetables, pureed Texas toast, and fruited gelatin. The mechanical ground diet was to include ground pepper steak, soft vegetables, half a slice of Texas toast, and fruited gelatin. An observation of the lunch meal preparation on June 10, 2025, at approximately 12:00 PM revealed that Employee 2, cook, used a large amount of ground beef mixed with spices, cooked the mixture in a frying pan, and then placed an unmeasured amount of the cooked beef into a blender. He added an unmeasured amount of tap water and later a thickening agent without measuring. The resulting mixture was blended and placed into the steam table for service as the pureed entrée. In addition to this, mashed potatoes were also present on the steam table. An observation of the lunch meal service June 10, 2025, from approximately 12:15 PM to 1:00 PM, Residents 11, 12, 4, and 5 were observed receiving a pureed meal consisting of pureed ground beef (not puree pepper steak), pureed carrots, mashed potatoes, and gelatin without fruit. These food items were not consistent with the pureed menu for that day. During an interview conducted on June 10, 2025, at 2:00 PM, Employee 2 stated that he added mashed potatoes to the pureed meals because he believed the residents needed something else on the plate. He acknowledged that he omitted the pureed Texas toast because he did not know how to prepare it and could not explain why the gelatin did not include fruit. An observation conducted on June 10, 2025, between 12:15 PM and 1:00 PM revealed that Residents 13, 14, 15, 16, 17, 18, 19, 20, and 21 received meals inconsistent with the facility's posted menu and their prescribed diet texture. A review of the residents' tray tickets indicated that all were to receive a mechanical soft texture diet. A mechanical soft diet is a texture-modified diet intended for individuals who have difficulty chewing or swallowing; foods on this diet are typically finely chopped or ground to make them easier to consume. The planned lunch menu extensions for June 10, 2025, specified that residents on a mechanical soft diet were to receive chopped pepper steak, chopped carrots, and gelatin with fruit. However, direct observation revealed that the residents were instead served chopped fried ground (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 3 of 15 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 06/11/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some beef, whole carrots, a slice of Texas toast, and plain gelatin without fruit. The omission of the correct entrée, substitution of ingredients, and failure to provide fruit in the gelatin were not consistent with the planned menu or prescribed dietary modifications. In a separate interview on June 10, 2025, at 12:15 PM, Employee 1, the Certified Dietary Manager (CDM), confirmed a discrepancy between the planned portion size of beef steak and peppers, listed as 2 oz on the menu and 6 oz on resident tray tickets. She confirmed that when she orders the food weekly, in advance of the meals she relies on the serving size to determine the amount needed to be ordered. She stated that in this case she ordered a 4 oz portion size for the meal, which she believed was an acceptable compromise. She stated that She acknowledged that she did not consult the facility's Registered Dietitian (RD) regarding the discrepancy because he works remotely and has limited availability. She further confirmed there was insufficient beef steak and peppers available, which led to substitution with ground beef. She acknowledged that the cook did not follow facility recipes, and that he had only been cooking for three weeks. She also confirmed that fruit was not included in the gelatin dessert, contrary to the menu. She confirmed that the facility failed to follow the planned menus. The diet on the facility menu exchange for June 10, 2025, entitled Gluten free (gluten-free diet involves excluding foods that contain gluten, a protein found in wheat, barley, rye, and spelt, foods to avoid includes bread, pasta, cereals, and many processed foods) revealed that no alternative food items were listed for the lunch meal. An observation of lunch service on June 10, 2025, revealed that Resident 2, who requires a gluten-free diet, received the standard menu items, including steak and peppers, mixed vegetables, Texas toast, and gelatin without fruit. During an interview on June 10, 2025, at 2:00 PM, Resident 2 stated that the facility refused to accommodate her gluten allergy and informed her she would have to purchase her own gluten-free food. She stated that she had limited funds and was unable to afford to consistently supply her own food items. During an interview on June 10, 2025, at approximately 2:00 PM, Employee 1, CDM, confirmed that Resident 2 had purchased her own gluten-free bread. She stated that the facility occasionally had gluten-free pasta available but acknowledged that there was no formal gluten-free menu to meet the resident's dietary needs. The facility failed to follow planned menus and ensure residents received meals in accordance with their prescribed dietary needs. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.6 (a) Dietary Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 4 of 15 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 06/11/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, test tray evaluation, review of resident concern forms, and resident and staff interviews, it was determined the facility failed to ensure foods were served at safe and palatable temperatures for residents consuming regular diets identified for 1 test tray and 7 of 7 residents (Residents 1, 3, 6, 7,8, 9, and 10) who voiced concerns related to food temperature, palatability, or meal service timeliness. Residents Affected - Some Findings include: According to the federal regulation 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. A review of facility resident concern forms revealed recurring complaints related to food temperature, palatability, and timeliness of meal service: On April 22, May 11, and May 29, 2025, Resident 6 complained of cold food and poor taste. On April 25, 2025, Resident 3 reported unpalatable food and small portion sizes. On April 25, 2025, Resident 7 complained of receiving cold food. On April 29, 2025, Resident 9 voiced concerns about cold food and poor food quality. On April 16, 2025, Resident 10 expressed dissatisfaction with late meals, cold temperatures, and poor taste. On May 5 and May 21, 2025, Resident 1 complained of late meal delivery, poor food temperature, and lack of flavor. A review of the facility's posted meal service schedule revealed that lunch for the first hall and dining room cart was scheduled for 12:15 PM, and the second hall and dining room cart was scheduled for 12:30 PM. Observation of the kitchen tray line on June 10, 2025, at 12:30 PM, revealed that the first hallway and dining room cart (Cart One) did not leave the kitchen until 12:45 PM, and Cart Two did not leave the kitchen until 1:05 PM. Further observation on the nursing unit at approximately 1:15 PM showed staff pushing a cart of meal trays from the hallway into the dining room. The last tray was served to residents at approximately 1:35 PM. Residents had been seated in the dining room since approximately 11:30 AM. A test tray evaluated in the presence of the Certified Dietary Manager (CDM) at 1:37 PM on June 10, 2025, revealed the following food temperatures: Beef and pepper entrée: 124°F (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 5 of 15 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 06/11/2025 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 0804 Mixed vegetables: 114.7°F Level of Harm - Minimal harm or potential for actual harm Beef gravy: 90°F Texas toast: 65°F Residents Affected - Some Coffee: 149°F The beef and pepper entrée was bland and tough to chew. The vegetables were bland and mushy in consistency, and the Texas toast was hard and difficult to chew. During an interview on June 10, 2025, at 2:00 PM, Resident 1 stated that she eats her meals in her room and frequently receives food that is cold, unappetizing, or does not match the posted menu or her meal ticket. She indicated that dietary staff had previously spoken to her in response to her concern forms and assured her the issues would be addressed; however, the problems persisted as of the survey date. An interview conducted with Employee 1 (CDM) on June 10, 2025, at approximately 1:45 PM, confirmed the facility failed to ensure that meals were served at temperatures that are palatable and in accordance with regulatory guidelines. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(3) Management. 28 Pa. Code 211.6(a)Dietary services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 6 of 15 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 06/11/2025 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 0809 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on a review of facility policies, observations, and staff and resident interviews, it was determined that the facility failed to provide meals in accordance with resident needs and preferences to ensure adequate nutrition and hydration and failed to consistently provide bedtime snacks as required for 3 of 36 residents. This deficient practice resulted in a lack of nutritionally adequate meals for 36 of 36 residents in the facility, created the potential for nutritional deficiencies, and placed all residents in Immediate Jeopardy to their health and safety. Findings include: A review of the facility's undated policy titled Frequency of Meals revealed that each resident shall receive three meals daily as well as snacks in between meals. The policy indicated that bedtime snacks are routinely offered to residents based on preference and are documented in the electronic medical record. It also stated that no more than 14 hours should pass between the evening meal and breakfast unless a nourishing bedtime snack is provided. During the survey conducted on June 10 and 11, 2025, facility administration was repeatedly asked to provide documentation of an emergency meal plan and food inventory. However, no documentation was provided during the survey. On June 10, 2025, the facility's kitchen dishwasher was taken out of service due to unresolved sanitation issues. The three-compartment sink was noted to be non-operational due to a lack of sanitation chemicals. As of the June 11, 2025, breakfast meal, meals were served using disposable containers and utensils. A review of an email from the facility's part-time, remote Registered Dietitian (RD), dated June 10, 2025, at 9:44 PM, indicated approval of a menu substitution due to sanitation issues in the kitchen. However, the communication did not identify what items would be served or address the consistency or therapeutic needs of residents, such as pureed or gluten free diets. There was no documentation confirming the meals provided met the nutritional needs or physician-ordered dietary restrictions for the residents. On June 11, 2025, the scheduled Certified Dietary Manager (CDM) and cook failed to report for duty for the 6:00 AM to 6:00 PM shift. There was no qualified dietary staff present to prepare resident meals. At 8:30 AM on June 11, 2025, observations revealed that administrative staff were delivering meals to residents from a metal tiered cart. The breakfast consisted of mini muffins, applesauce, yogurt, cold cereal, juice, and milk. Four residents requiring puréed diets received a pouch of commercial baby food. a yogurt and fruit mix consisting of pureed bananas, pineapple, avocado and granola, containing approximately 100 calories. There was no evidence that the substitute breakfast provided adequate calories or nutrients or complied with the planned menu, which included: Cream of wheat Cheesy egg bake (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 7 of 15 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 06/11/2025 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 0809 Banana bread Level of Harm - Immediate jeopardy to resident health or safety Margarine Residents Affected - Many Coffee Milk/one cup Observation of the lunch meal on June 11, 2025, at 12:30 PM revealed that residents received assorted lunch meat sandwiches, canned beets, fruit cups, potato chips or cheese curls, and a juice cup. The meal was served in Styrofoam containers. The planned lunch menu was beef fajitas, Spanish rice, Mexicali corn, a peanut cookie, and a roll. Residents were not offered menu choices or therapeutic diet accommodations. There was no documentation to verify that the meals served were nutritionally equivalent to the planned menu. During an interview conducted on June 11, 2025, at 11:00 AM, the Corporate Regional Director of Operations stated the facility's dietary staff walked out in April 2025. In response, the activity director and Employee 4 (nurse aide) agreed to temporarily assist in the kitchen until replacement staff could be hired. The Certified Dietary Manager (Employee 1) was hired on April 30, 2025, and a cook (Employee 2) was hired approximately one month prior to the survey. The Registered Dietitian (RD) had been hired on February 3, 2025, but resigned on May 30, 2025. The director stated the RD agreed to remain available on an as-needed basis, working remotely for up to 10 hours per week; however, she confirmed the RD did not physically come to the facility to oversee the dietary and nutrition program. At the time of the survey, only one cook was employed at the facility, and this individual, hired several weeks earlier, did not have any prior culinary experience. The director further stated the activity director and Employee 4 (nurse aide )would be scheduled to cook once their primary roles could be adjusted to accommodate all departmental staffing needs. She acknowledged these individuals had limited experience cooking in a skilled nursing facility and confirmed there was minimal oversight in the dietary department due to ongoing staffing challenges. Interviews conducted on June 11, 2025, revealed further concerns regarding snack service: At 1:00 PM, Resident 1 stated she had not been offered a bedtime snack in months and would like one. At 1:05 PM, Residents 2 and 3 also reported not receiving bedtime snacks for several months. At 2:00 PM, the activity director reported that snacks were stored in two locked cabinets and a locked refrigerator in the dining/activity room. She was unaware of any process to offer bedtime snacks consistently. At 2:15 PM, the Director of Nursing and Nursing Home Administrator stated they personally distributed bedtime snacks on June 10, 2025. However, there was no documentation to support this claim, and multiple residents reported that bedtime snacks had not been consistently provided. The DON stated that it was the responsibility of nursing staff to ensure that all residents were offered a bedtime snack. However, residents continued to state that staff do not offer snacks at bedtime. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 8 of 15 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 06/11/2025 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 0809 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many On June 11, 2025, the surveyor was informed upon arrival that both the facility's cook and Certified Dietary Manager (CDM) were absent and had not reported to work. As a result, the facility was unable to prepare or serve the planned breakfast meal to residents. In response, facility administration attempted to serve a limited breakfast consisting of cold cereal, milk, and other basic food items. For residents requiring texture-modified diets, including puréed diets, the facility substituted commercial baby food products, which provided only 100 calories per serving. There was no documentation or evidence that these substitutes were nutritionally equivalent or met therapeutic dietary needs. The facility did not have a contingency plan in place to ensure the timely and appropriate provision of meals when dietary staff were unavailable. No qualified cook was scheduled for the remainder of the day, placing the lunch and dinner meals for June 11, 2025, in further jeopardy. This failure to provide adequate meals placed all residents at risk for nutritional compromise. As a result of the facility's failure to ensure the provision of required meals, the survey team determined that a serious adverse outcome was likely, and the facility was unable to demonstrate that residents' dietary needs were being met. This condition was determined to constitute Immediate Jeopardy to resident health and safety. Immediate Jeopardy was identified on June 11, 2025, at 10:30 AM and the Immediate Jeopardy template was provided to the Nursing Home Administrator regarding the facility's failure to comply with regulatory guidelines which requires the facility to provide at least three meals daily at regular times, comparable to normal mealtimes in the community, in accordance with resident needs, preferences, requests, and care plans. The failure to ensure the availability of nutritionally adequate meals for all residents, especially those requiring therapeutic diets, resulted in serious risk of harm to residents with conditions such as diabetes, unintentional weight loss, dysphagia, and cognitive impairment. The facility was notified of the Immediate Jeopardy on June 11, 2025, at 10:30 AM. An acceptable immediate corrective action plan was received later that day at 2:00 PM. The plan included the following measures: Immediate Actions to Remove the Immediate Jeopardy: All residents received lunch on June 11, 2025. The meal was prepared by facility staff with prior food service experience. Puréed and special diet meals were prepared with guidance from the CDM and reviewed by nursing staff to ensure dietary accuracy. All residents were assessed by the RN Supervisor for signs of harm related to the altered breakfast meal. Assessments included vital signs, hydration status, and glucose monitoring for diabetic residents. No residents were found to have suffered harm. Repairs to the kitchen's three-compartment sink and dishwasher sanitation systems were completed by the facility's vendor. The kitchen was returned to full operational status. The regular facility menu was resumed for the dinner meal on June 11, 2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 9 of 15 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 06/11/2025 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 0809 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Residents and/or their responsible parties were notified of the temporary menu changes and the use of disposable products. This communication was documented in the clinical record. Facility staff with documented training in food safety and meal preparation continued to prepare and serve meals according to the approved menu. Although the department was typically staffed with two full-time cooks, only one full-time cook remained on staff. Four cross-trained and competent employees were placed on a two-week rotating schedule to provide consistent support to the cook. Facility department heads were cross-trained and deemed competent to assist in kitchen operations during staffing emergencies. Documentation of each meal served, including who prepared it and what was provided, was initiated to ensure accountability. The Immediate Jeopardy was removed on June 11, 2025, at 4:00 PM following verification that the corrective actions had been implemented. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1)(2.1)(3) Management. 28 Pa. Code 211.6(a) Dietary Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 10 of 15 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 06/11/2025 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 0812 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on a review of facility policies, manufacturer instructions for use, staff interviews, and observations, it was determined that the facility failed to follow safe and sanitary food handling practices during the washing, sanitizing, and preparation of cooking equipment, dishware, tableware, and utensils in the facility's kitchen. This failure resulted in the improper sanitization of food-contact surfaces, created an increased potential for foodborne illness, and placed 36 out of 36 residents in a condition of Immediate Jeopardy to their health and safety. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). The Food and Drug Administration (FDA) requires commercial food service establishments to clean and sanitize all equipment and utensils that come into contact with food using an effective two-step process: cleaning (removal of debris) and sanitizing (elimination of microorganisms). During a tour of the dietary department on June 10, 2025, at 11:30 AM, observations revealed the facility's low-temperature dish machine and three-compartment sink were both in use. The dish machine requires chlorine-based sanitizer at a concentration between 50-100 parts per million (ppm) per manufacturer instructions. The three-compartment sink system (comprised of a wash, rinse, and sanitize basin) is intended for manual dishwashing, with the sanitizing compartment requiring 200-400 ppm of quaternary ammonium solution, with a required soak time of at least 60 seconds and subsequent air-drying. A review of the facility's undated policy titled Low Temperature Dish Machine Temperatures and Sanitizer Testing revealed procedures intended to ensure effective cleaning and sanitization of dishware through the facility's commercial dish machine. According to the policy, the required temperature range for the wash and rinse cycle is 120-140 degrees Fahrenheit. The sanitizer used in the final rinse is expected to reach a concentration of 50 parts per million (PPM) of chlorine. The policy outlines the following procedures: 1. The dish machine is to be refilled with water at the start of each cycle. 2. A test run must be completed before placing any dishes into the machine. If the machine achieves the minimum required temperature, the result must be recorded on the dish machine temperature and sanitizer monitoring log. 3. If the required temperature is not achieved, an additional test cycle is to be conducted. If the machine still fails to meet the required temperature, the Dining Services Manager and/or Administrator must be notified, and no dishware is to be processed until the issue is corrected. 4. Sanitizer levels are to be tested at each meal service using chlorine test strips. Testing is to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 11 of 15 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 06/11/2025 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 0812 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many occur during the rinse/sanitizing phase of the machine's first test cycle. The chlorine concentration result must be documented on the log. If the reading falls outside the target range of 50 PPM, the Dining Services Manager and/or Administrator is to be notified immediately for corrective action. In addition to the dish machine, the facility utilizes a three-compartment sink for the manual cleaning and sanitization of cooking and eating utensils. The three-sink method is the manual procedure for cleaning and sanitizing dishes in commercial settings. Rather than providing additional workspace to perform the same function, the three compartments allow kitchen staff to wash, rinse, and sanitize dishes. Each step has its own set of rules and requirements. The FDA requires commercial foodservice establishments to both clean and sanitize their dishes in their manual washing process. Three compartment sinks have a logical order to help properly clean and sanitize dishes. While those who misunderstand the terms use them interchangeably, cleaning and sanitizing refer to two separate functions. Cleaning is the act of removing surface debris, and sanitizing is the act of using a chemical agent or hot water to eliminate invisible bacteria. Label each sink to help staff remember the FDA required three compartment sink order. The three-compartment sink process follows a standardized sequence: Sink 1 (Wash): Dishes are scrubbed in warm, soapy water at a minimum temperature of 110°F to remove debris. Sink 2 (Rinse): Items are rinsed in clean water, also at a minimum temperature of 110°F, to remove detergent. Sink 3 (Sanitize): Dishes are soaked in a chemical sanitizing solution. The facility uses a quaternary ammonium solution requiring a concentration between 200-400 PPM with a soak time of at least 60 seconds. Air-Dry: All items are to be air-dried following sanitization. Towel drying is not permitted, as it may result in recontamination. The process for washing utensils by hand consists of five essential steps: scraping excess food, washing in warm detergent, rinsing in clean water, soaking in sanitizer, and air-drying. Labeling each sink helps ensure adherence to this critical workflow and minimizes the risk of cross-contamination. A review of an undated facility policy titled Manual Dishwashing confirmed these expectations. The policy states that all eating and drinking utensils, as well as food-contact surfaces of equipment, must be thoroughly washed, rinsed, and sanitized as outlined below: 1. Equipment and utensils are to be washed in warm detergent solution and rinsed free of residue. 2. Items must be sanitized by immersion in a sanitizing solution for at least one minute. 3. All sanitized items must be air-dried. 4. Sanitizer concentration must be verified using appropriate test strips, with a target of 200 PPM for quaternary ammonium solution. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 12 of 15 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 06/11/2025 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 0812 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many 5. A log will be maintained any time manual dish washing is completed. The log will record the validation of sanitizer strength using chlorine test strips. An interview conducted with Employee 1, the Certified Dietary Manager, revealed that the facility's dishwashing machine had been in continuous use since her start date on April 30, 2025. She confirmed the machine is a low-temperature commercial dishwasher, which relies on chemical sanitization rather than high heat to clean and disinfect dishware. Employee 1 stated that sanitizer test strips, which are used to verify the concentration of the sanitizing agent during the rinse cycle, could not be located. She further explained that sanitizer concentration checks are expected to be performed several times daily, yet acknowledged there was no documentation available to confirm that such testing had occurred. At the time of the survey, no temperature or sanitizer level logs were provided. She also reported being unaware of any staff performing or documenting testing of the dishwasher during her employment. Employee 1 indicated that she works in the kitchen Monday through Friday from 7:00 a.m. to 3:00 p.m. Simultaneous observation of the three-compartment sink on June 10, 2025, revealed that the rubber hoses connecting both the dish detergent and sanitizer dispensers were missing, and no sanitizer agent was present in the kitchen. As a result, the sanitizer compartment of the sink could not function as designed. At approximately 11:45 AM, Employee 2 (cook) was observed preparing the lunch meal. While wearing gloves, he placed dirty pots and kitchen utensils into the first compartment of the sink, rinsed them, and then transferred the items into the dishwashing machine. After running the machine, he moved to the clean side and removed the washed items with the same gloved hands. He then returned to the stove and proceeded to drain a large pot of cooked vegetables directly into the first compartment of the sink-the same compartment used moments earlier for rinsing soiled cookware. The sink was not cleaned or disinfected before or after draining the vegetables. Employee 2 then resumed cooking without removing or changing gloves or washing his hands. Following this, Employee 2 retrieved a large container of raw ground beef, removed the plastic wrap, and placed the meat into a mixing bowl using the same gloved hands. He then accessed the spice shelf above the preparation area, removed three individual spice containers, opened each one, added the spices to the meat, and returned the containers to the shelf. Still wearing the same gloves, he manually mixed the raw meat, opened the oven, stirred a pan of food already cooking, and transferred portions of the seasoned ground beef into a frying pan. After cooking the beef, he placed half of it into a serving pan on the steam table and transferred the other half into a blender. He carried the blender to the sink, turned the faucet on and off, added a thickening agent from a bag, and blended the mixture. The pureed product was then poured into a second serving pan on the steam table. At approximately 12:30 PM, Employee 2 served the prepared food to residents from the steam table. Throughout the entire process, from handling dirty utensils, cooked vegetables, and raw meat to preparing and serving the meal, Employee 2 did not change his gloves or wash his hands at any time. At approximately 12:30 PM, the Maintenance Director and the Facility Administrator were notified of the concerns related to the dishwashing and sanitization system. The Maintenance Director immediately inspected the three-compartment sink, the dishwashing machine, and the chemical storage area located in the basement directly beneath the kitchen. During the inspection, he confirmed that the sanitizer was not connected to the three-compartment sink. He was unable to explain why the rubber hoses that supply chemicals to the sink had been removed. He further explained that the dishwashing machine receives its sanitizing chemicals through tubing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 13 of 15 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 06/11/2025 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 0812 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many that runs from the basement chemical storage area into the machine. However, he acknowledged that the tubing in the basement was unlabeled and disorganized, and stated that the wrong chemical had likely been dispensed into the dish machine as a result. The Maintenance Director reported that the dietary department was responsible for monitoring and testing the chemical levels but was unable to provide the manufacturer's user guide or technical specifications for the dishwashing machine at the time of the survey. He stated that the facility used a split system, meaning that multiple chemicals were distributed to both the dish machine and the three-compartment sink. To evaluate the system, he reported conducting a dye test to trace the chemical tubing and identify where each line was connected. Following his inspection, he reconnected the chemical supply hoses to the three-compartment sink and confirmed that chemical dispensing to the dish machine was properly restored. In an interview conducted at 12:45 PM on June 10, 2025, Employee 3 (Dietary Aide), who had been employed at the facility for approximately one month, stated that the soap and sanitizer had not been connected to the three-compartment sink since the beginning of her employment. She confirmed that the sink was regularly used to wash and rinse pots, pans, and to drain food items, but no sanitizing step was performed. She further stated that she did not know who was responsible for maintaining or testing the chemical sanitizers for either the sink or the dishwashing machine. At approximately 1:30 PM that same day, Employee 2 (Cook) reported that he had also been employed at the facility for one month. He stated he was originally hired as a dietary aide and received no education on the sanitation process, including how to properly use the dishwasher or three-compartment sink. He was unable to explain why he failed to wash his hands or change gloves during meal preparation and stated, I didn't know. He further disclosed that he was made the cook after the prior kitchen staff walked out shortly after he was hired. During an interview June 10, 2025, at 2:00 PM, the Nursing Home Administrator stated the dishwasher is leased. He was unable to provide the lease agreement or a maintenance schedule. It could not be determined when the dishwasher was last inspected as part of routine maintenance. On June 11, 2025, at approximately 11:00 AM, a service technician from the dishwasher leasing company inspected the unit. He confirmed that the chemicals were correctly connected at the time of his inspection and verified that the machine was functioning properly, including dispensing chemicals at appropriate sanitization levels. However, he clarified that the sanitization systems for the dishwasher and three-compartment sink were not part of a shared split system, as previously stated by the Maintenance Director, noting that each system required a different parts-per-million (PPM) concentration. The technician was unable to verify the history of prior maintenance visits to the facility. Additionally, an environmental observation of the kitchen conducted between 11:00 AM and 3:00 PM on June 10, 2025, revealed unsanitary conditions. The floors were coated with a thick, black, sticky film, and debris including used gloves, paper, and plastic waste was present underneath the three-compartment sink. Uncovered garbage cans were positioned next to the food preparation and coffee/condiment stations. Food residue and staining were noted on the stainless-steel tables, sinks, and the exterior of the dishwasher. Numerous plates, bowls, and coffee cups were visibly soiled with dried food particles, and the silverware was similarly soiled. An ice machine in the dining room had heavy lint covering the two exterior filters. Immediate Jeopardy was identified and called on June 10, 2025, at 5:40 PM and the Immediate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 14 of 15 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 06/11/2025 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 0812 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Jeopardy template was provided to the Nusing Home Administrator regarding the facility's failure to follow proper sanitation practices while cleaning and sanitizing food preparation equipment, cooking utensils, dishware, and tableware. These failures resulted in the improper sanitization of items used in the preparation and service of food to residents, thereby placing all residents at risk for foodborne illness. In response, the facility submitted an immediate corrective action plan at 8:00 PM on June 10, 2025. The plan included the immediate removal of both the low-temperature dishwasher and the three-compartment sink from service. Disposable dishware, utensils, and cups were implemented for all resident meals. All food preparation and cooking surfaces were thoroughly cleaned and sanitized using an EPA-registered food-contact surface sanitizer. The chemical vendor was contacted for an on-site visit on June 11, 2025, to assess and correct the chemical delivery system. Sanitizer supply lines were connected, labeled, and tested to ensure accurate chemical dispensing. Manufacturer-recommended test strips were used to verify that the low-temperature dishwasher dispensed sanitizer at the required concentration of 50-100 parts per million (ppm) chlorine, and that the three-compartment sink's sanitizer compartment achieved the required 200 ppm quaternary ammonium solution. Multiple cycles were run through the dish machine using indicator strips to confirm consistent sanitizer concentration. A qualified food safety consultant or chemical vendor technician verified proper function of the system and issued written confirmation of compliance. Equipment was returned to service only after full verification. On June 11, 2025, dietary staff were re-educated on proper procedures, including the use and testing of sanitizer concentrations in both dish machines and manual sinks, cross-contamination prevention (specifically prohibiting food preparation in the sink), and correct test strip usage with required ppm ranges. Competency was verified through return demonstrations, and all staff training was documented and retained in the dietary department's records. The facility also implemented a monitoring and oversight plan. Beginning June 11, 2025, a designated supervisor, either the Dietary Manager or the Infection Preventionist, was assigned to observe and document sanitizer concentration testing three times daily for seven days, and then daily for an additional 30 days. The assigned supervisor was also responsible for reviewing and initialing test strip logs each shift and conducting random inspections of sanitized dishware to assess for cleanliness and residue. An inventory check was performed, and all necessary test strips and chemical supplies were reordered to ensure ongoing availability. Policies and procedures related to sanitization and kitchen practices were reviewed and revised as needed. The Immediate Jeopardy was lifted on June 11, 2025, at 4:10 PM, after verification that the corrective action plan had been fully implemented. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1)(2.1)(3) Management. 28 Pa. Code 211.6 (a)(f) Dietary Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 15 of 15