395590
06/03/2025
Kadima Rehabilitation & Nursing at Lititz
125 South Broad Street Lititz, PA 17543
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm or potential for actual harm
Based on review of the Pennsylvania Nursing Practice Act, residents' clinical records, and the facility's investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that a registered nurse completed a timely assessment when changes in condition occurred for one of 5 residents reviewed (Resident 1).
Residents Affected - Few
Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 16, 2025, revealed that the resident was cognitively impaired and required extensive assistance from staff for daily care. A nursing note for Resident 1, dated May 8, 2025, at 4:30 a.m. revealed that the resident was found lying on the floor. The resident was assessed by the registered nurse (RN) and there was an open area on the left leg below the knee with slight bleeding noted. The resident had no complaint of pain and vital signs were within normal limits. A nursing note for Resident 1, dated May 8, 2025, at 2:00 p.m. revealed that the resident began to complain of a new onset severe pain, and her blood pressure was 70/44 (normal 120/80) and respirations were 22 (normal 12-20 at rest) the Registered Nurse supervisor and Director of Nursing were made aware of the change in the resident's condition. There was no documented evidence that a registered nurse assessed Resident 1's change in condition when she began to complain of new onset pain or a low blood pressure of 70/44. Interview with the Director of Nursing on June 2, 2025, at 10:02 a.m. confirmed that Resident 1 should have been assessed by a registered nurse and the assessment should have been documented in the resident's medical record. 28 Pa. Code 211.12(d)(1)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.
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395590
395590
06/03/2025
Kadima Rehabilitation & Nursing at Lititz
125 South Broad Street Lititz, PA 17543
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm or potential for actual harm
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that dependent residents were provided with the necessary services to maintain personal hygiene, by failing to provide showers as scheduled for one of 5 residents reviewed (Resident 3).
Residents Affected - Few
Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 2, 2025, revealed that the resident was cognitively intact and required maximum staff assistance with daily care needs. The facility's shower schedule, undated, indicated that Resident 3 was to receive a shower twice weekly on Mondays and Thursdays in the morning. A review of the clinical records for Resident 3 revealed that she did not receive showers in the month of May 2025 on May 1,5, 19,26, and 29th. Interview with the Director of Nursing on June 2, 2025, at 2:02 p.m. confirmed that Resident 3 had not received a shower on the above dates in May 2025 and should have. 28 Pa. Code 211.12(d)(5) Nursing services.
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395590
06/03/2025
Kadima Rehabilitation & Nursing at Lititz
125 South Broad Street Lititz, PA 17543
F 0842
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Based on review clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for three of 5 residents reviewed (Resident 3,4,5).
Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 2, 2025, revealed that the resident was cognitively intact and required maximum staff assistance with daily care needs. An activities of daily living care plan for Resident 3 dated, January 24, 2025, revealed that the resident was to be turned and repositioned every two hours. Review of the clinical records for Resident 3 for May 2025 revealed that there was no documented evidence the resident was repositioned every two hours during day shift on May 1, 3,4,5,6, 11, 14, 17, 18, 19,20, 21, 26, 30, and 31, 2025; during the evening shift on May 5, 7,9,10,11, 19, 24, 25, 26, and 29, 2025 and the night shift on May 6, 15, 24, 30, and 31, 2025. Interview with Resident 3 on June 2, 2025, at 8:51 a.m. revealed that she is able to self-re-position in bed she just needs some extra help sometimes. An admission MDS assessment for Resident 4, dated April 21, 2025, revealed that the resident was cognitively intact and required maximum staff assistance with daily care needs. A skin integrity care plan for Resident 4 dated, April 16, 2025, revealed that the resident was to be turned and repositioned every two hours. Review of the clinical records for Resident 4 for May 2025 revealed that there was no documented evidence the resident was repositioned every two hours for the month of May 2025. An admission diagnosis for Resident 5 for May 30, 2025, revealed that the resident had a diagnosis of femur fracture and stroke. An activities of daily living care plan for Resident 5 dated May 27, 2025, revealed that the resident was to be turned and repositioned every 2 hours as tolerated. Review of the clinical records for Resident 5 revealed no documented evidence the resident was turned and repositioned in May of 2025, June 1 or June 2, 2025. Interview with the Director of Nursing on June 2, 2025, at 12:33 p.m. revealed there is no documented evidence that the above residents were repositioned every 2 hours, and it should have been. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(5) Nursing services.
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