Health inspection·May 30, 2025

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on review of facility policy and resident council minutes, observations, and staff and resident interviews, it was determined that the facility failed to provide sufficient nursing staff and services to promote the physical and mental well-being and meet the needs for four of 19 residents interviewed (Residents R3, R24, R25, and R43). Findings include: Review of facility policy entitled Cell Phone/Camera Usage, with a policy review date of 5/01/25, revealed that Personal cell phones should not be used during work time. Review of grievances in January of 2025 revealed that there were concerns with staff members on their cell phones and education was provided by the Director of Nursing (DON). Review of resident council minutes over three months from February, March, and April of 2025, revealed the following: April 2025 resident council minutes revealed there were complaints of staff observed constantly on their phones; Most of the occurrences were on day and afternoon shift; Call bell wait times were 30 minutes or longer. Interviews during the resident council meeting on 5/28/25, between 11:00 a.m. and 11:45 a.m. revealed four of four alert and oriented residents in attendance had concerns related to staff not responding to their call bells timely. All residents in attendance revealed that staff are constantly on their telephones texting or having private conversations with other people. All residents in the resident coucil meeting stated that it delays their care response times and it makes residents upset. Resident R24 indicated that it could take 30-45 minutes for his/her call bell to be answered and staff are typically seen in the hallways, at the nurse's station, or in resident's rooms talking or on their phones having private conversations. Resident R3 indicated that he/she will wait for 30 minutes to 60 minutes to receive assistance to use the restroom after placing his/her call bell on and requires full assistance by staff. Residents R3, R24, R25, and R43 indicated they wait 30 minutes or longer when their call bell is placed on to be responded to by staff. All residents agreed that they observe staff on their phones and standing talking to one another during their shifts. During observations of two of two resident care areas during the week of the survey, from 5/27/25, to 5/30/25, there were observations of staff sitting at the nurses stations and in the hallway on their personal cell phones. During an interview with the DON and Assistant Director of Nursing on 5/30/25, at approximately Page 1 of 4 395524 395524 05/30/2025 Kadima Rehabilitation & Nursing at New Castle 715 Harbor Street New Castle, PA 16101

F 0725 1:15 p.m. it was confirmed that residents do complain to administration about employees on their cell phones. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(1) Management Residents Affected - Some 28 Pa. Code 211.12(d)(4)(5) Nursing services 395524 Page 2 of 4 395524 05/30/2025 Kadima Rehabilitation & Nursing at New Castle 715 Harbor Street New Castle, PA 16101

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 review of facility policies, dietary and clinical records, observations, and resident and staff interviews, it was determined that the facility failed to provide daily menus, update menu changes, and notify residents of a change to the menu; and failed to provide a nutritionally adequate menu for one of one residents noted with a gluten free allergy (Resident R1). Findings include: A facility policy entitled Dietary Services Administration dated 5/01/25, revealed sufficient food will meet the nutritional needs of residents and shall be prepared as planned for each meal. Menus are followed. Menus are posted in all dining rooms and on all resident units. Special diets shall be prepared and served as ordered. A facility policy entitled Menu Item Substitution dated 5/01/25, revealed a resident shall receive a substitute food item of equal nutritive value when a scheduled menu item is not available. The substitute will be approved by the facility Dietitian. After the scheduled menu item has been determined to be unavailable, the Dining Services Manager in consultation with the Dietitian will select an appropriate substitute. A list of substitutable items for each menu category that has been approved and signed by the Dietitian will be available for changes needed in absence of the Dietitian. The day's menu sheet and diet extension will be revised to reflect the substitution. A facility provided foodservice invoice dated 5/02/25, revealed purchases of one case of gluten free pasta penne and one case of gluten free hamburger buns. The facility menu dated for week three, revealed Chicken Patty on Bun, French Fries, Mexicali Corn, Pudding, and a Choice of Beverage. Resident R10's clinical record revealed an admission date of 7/26/23, with diagnoses that included chronic respiratory failure with hypoxia (a condition where the lungs cannot deliver enough oxygen to the blood resulting in low oxygen in the blood), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and affects the way a person breathes), diabetes mellitus (a disease that result in too much sugar in the blood), and cardiac heart failure (CHF, a chronic condition in which the heart doesn't pump blood as well as it should). During an interview on 5/27/25, at 1:00 p.m. Resident R10 indicated that alternatives are not always available for each meal and what is on the menu is not always available due to the kitchen runs out of food. Resident R10 further indicated that they are never told of food substitutions and no menu is provided. There was no menu observed in Resident R10's room. On 5/28/25, at 12:45 p.m. Resident R10 further indicated that the kitchen did not have hamburgers for the lunch meal. Resident R10 explained that a hamburger was what they chose instead of the chicken patty sandwich. When the Activity Assistant inquired about his lunch and dinner food choice that morning. Resident R10 stated, Sometimes you just get what you get, it's a surprise. During an interview and observation on 5/27/25, at 2:20 p.m. the Dietary Manager confirmed the facility failed to post the daily menus, including an alternate menu, on the dining room menu board for all residents and family members to view. The Dietary Manager further revealed the Activity Assistant reviews daily with each resident what is on the menu for lunch and dinner, including an 395524 Page 3 of 4 395524 05/30/2025 Kadima Rehabilitation & Nursing at New Castle 715 Harbor Street New Castle, PA 16101

F 0803 alternative and if there is a food substitution, the Activity Assistant notifies the resident population. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/28/25, at 9:30 a.m. the Activity Assistant Employee E1 indicated he/she will meet with each resident every morning regarding their lunch and dinner food selection, then provides an accumulated list of the residents' food choices to the kitchen each morning prior to lunch. If a resident's food choice in unavailable due to insufficient food or other reasons, Activity Assistant Employee E1 indicated that they do not then notify each resident that their food choice is unavailable; the resident will learn his/her desired food choice is something different when the lunch meal and/or dinner meal arrive to them. Residents Affected - Some Resident R1's clinical record revealed an admission date of 4/29/25, and discharge date of 5/24/25, with diagnoses that included COPD, muscle weakness, abnormalities of gait and mobility, and CHF. Review of Resident R1's physician progress note dated 5/01/25, revealed food allergies to gluten and wheat. An interview with the Dietary Manager on 5/29/25, at 11:30 a.m. revealed a facility provided invoice that included two gluten free food items for Resident R1. The Dietary Manager indicated that pasta, hamburgers, and hamburger buns were purchased for Resident R1's consumption related to their gluten free allergy. No bread, cereal, crackers, or other food items were purchased. The Dietary Manager confirmed that at times Resident R1 had limited food items and/or choices for each meal due to their gluten free allergy, and the menu could not be followed to its entirety due to insufficient gluten free food the facility had to offer. During an interview on 5/30/25, at 12:35 p.m. the Nursing Home Administrator (NHA) confirmed that the menu should be posted and followed daily for all residents and family members to readily view, and if the menu cannot be followed, the residents should be notified in a timely manner what the food substitution will be. The NHA further confirmed that Resident R1 had a gluten free allergy and there was an insufficient variety of food items to provide nutritionally adequate meals while Resident R1 resided at the facility from 4/29/25, through 5/24/25. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.6(a) Dietary Services 28 Pa. Code 211.10(c) Resident Care Policies 395524 Page 4 of 4