Health inspection·October 26, 2023

F 0689 A nursing note dated May 14, 2023, at 4:26 PM indicated the facility planned to initiate 15 minute checks of Resident 1. Level of Harm - Actual harm Residents Affected - Few Facility documentation revealed that staff conducted every 15 minute checks of the resident until 11:15 PM on May 14, 2023 (approximately 7 hours after the resident had fallen that afternoon). There was no documented evidence that the facility had continued to provide increased supervision of the resident's activities to promote resident safety and prevent additional falls. A progress note dated June 7, 2023, at 8:31 PM revealed that staff heard the resident calling out from another resident's room. Staff found the resident on the floor complaining of left foot pain. The resident stated at that time she had tripped on a floor mat next to the bed in that room. An incident report dated June 7, 2023, revealed that the resident was found on the floor in another resident's room. The facility identified the root cause of the fall to be the resident self-ambulating into another resident's room. According to this report the resident would be provided increased supervision and a therapy screen would be conducted. A review of the resident's clinical record conducted during the survey ending October 26, 2023, revealed no documented evidence that a therapy screen was conducted after the resident's fall on June 7, 2023. There was also no evidence that the facility staff had increased supervision of the resident. A review of the resident's care plan for potential for falls revealed no new planned interventions after the resident's fall on June 7, 2023, to prevent further falls. A nursing note dated October 14, 2023, at 9:48 PM revealed that Resident 1 was standing at the nursing station. The resident then stumbled over her feet falling to the ground landing on her bottom and her back. An incident report dated October 14, 2023, indicated the resident had fallen while standing at the nurse's station. The resident tripped over her feet and landed on the ground. The facility identified the resident wasn't wearing shoes but was wearing non-skid socks. A PT (physical therapy) screen was recommended at that time. A review of the resident's clinical record revealed no evidence that the physical therapy screen was completed after the resident's fall on October 14, 2023. A review of the resident's care plan for potential for falls revealed no new planned interventions after the resident's fall on October 14, 2023, to prevent further falls. A review of an occupational therapy (OT) encounter note dated October 17, 2023, revealed that the resident had ambulated with OT to the dining room with hand held assistance and fair balance. An OT encounter note dated October 18, 2023, indicated that the therapist conducted functional mobility with the resident with new shoes on. At that time, the resident displayed increased tripping and shuffling with the left foot. The resident was using the therapist and furniture for stabilization. The resident's shoes were removed and they were not recommended for the resident's use at that time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395730 If continuation sheet Page 2 of 4 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 395730 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612 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 - Actual harm A review of an OT encounter note dated October 19, 2023, revealed that functional mobility was completed with the resident. The resident ambulated around with facility with the occupational therapist. It was noted that the resident continued to shuffle when she walks and showed varied understanding with provided education. Residents Affected - Few A nursing note dated October 20, 2023, at 7:56 AM revealed that at 7:29 AM on that date staff witnessed the resident fall. An incident report dated October 20, 2023, indicated that staff heard calls for help and found the resident in the hall on the floor. Employee 1, housekeeping staff, reported at that time that the resident was walking down the hall and then fell to the floor. The resident reported pain in her left leg after the fall. The facility indicated that the resident was to be screened by PT (physical therapy) and wear proper footwear. Occupational therapy noted on October 18, 2023, that the resident's shoes were not recommended for the resident's use. There was no evidence of the appropriateness of the resident's footwear at the time of the resident's fall on October 20, 2023. A review of an x-ray report dated October 20, 2023, revealed the resident had sustained a left intertrochanteric fracture with varus angulation (hip fracture) as a result of this fall. The resident was transferred to the hospital on October 20, 2023, and returned to the facility on October 24, 2023. A review of the resident's clinical record conducted during the survey ending October 26, 2023, revealed a PT screen was not completed after the resident's fall on October 20, 2023. A review of the resident's care plan for potential for falls indicated that on October 20, 2023, the facility implemented a new intervention for the bed to be in the lowest position despite the resident not falling from her bed but while ambulating on the unit. An interview with the Employee 2, Director of Rehab, on October 26, 2023, at approximately 9:30 AM confirmed that there was no documented evidence that PT (physical therapy) had ever screened the resident after the above noted falls in the facility. She further confirmed that there are no notes from physical therapy to indicate that the resident was ever seen or treated by PT since her admission to the facility on December 23, 2019. She stated PT would be the discipline responsible for assessing the resident's ambulation and determine the resident's needs for appropriate assistance with ambulation for her for safety. The facility repeatedly identified the planned approach of physical therapy screening of the resident after falls, which were not conducted. There was no evidence of a thorough and accurate assessment of the resident's functional ambulation abilities and level of assistance needed or any assistance devices that may be required. The facility failed to implement planned interventions, including physical therapy screens and assuring appropriate footwear, to prevent falls while ambulating, and failed to provide necessary staff supervision and assistance with ambulation to prevent falls and serious injury to the resident. Observation on the facility's one resident unit on October 26, 2023, at 9:47 AM revealed the hallways of the resident unit were lined with linen carts, housekeeping carts, wheelchairs, broad chairs, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395730 If continuation sheet Page 3 of 4 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 395730 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612 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 and mechanical lifts, obstructing access to the handrails. Level of Harm - Actual harm Observation on the nursing unit on October 26, 2023, at 1:15 PM revealed the handrails remained obstructed with linen carts, housekeeping carts, wheelchairs, broad chairs, and mechanical lifts. Residents Affected - Few Interview with the director of nursing and nursing home administrator on October 26, 2023, at approximately 1:45 PM confirmed the facility failed to provide individualized effective safety interventions and necessary staff assistance and supervision to Resident 1 to prevent falls. The NHA and DON also confirmed that the halls of the resident unit were lined with equipment, preventing unimpeded access to the handrails and creating an impediment to resident mobility. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. 28 Pa. Code 201.18 (e)(2.1) Management 28 Pa. Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395730 If continuation sheet Page 4 of 4