Inspection visit
Health inspection
11 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a
review of select facility policy and clinical records and staff interview, it was determined that the facility
failed to afford residents the right to formulate an Advance Directive (a written instruction such as a living
will or durable power of attorney for health care for when the individual is incapacitated) and accurately
identify the resident's future health care wishes as evidenced by four out of 12 Residents sampled
(Residents 2, 10, 11, and 12).
The findings include:
Review of facility's Advance Directives policy last reviewed by the facility [DATE], indicated that an Advance
Directive is a written instruction such as a living will or durable power of attorney for health care recognized
under state law, relating to the provision of health care when the individual is incapacitated. The document
expresses wishes about treatment preferences and the designation of a surrogate if the individual is
incapacitated. The social worker will meet with the resident/family upon admission, quarterly, annually, and
as needed to review.
A review of the clinical record revealed that Resident 10 was admitted to the facility on [DATE], with
diagnoses which include end stage renal disease.
Review of Resident 10's admission Minimum Data Set (MDS- a federally mandated standardized
assessment process completed periodically to plan resident care) dated [DATE], 2023, revealed that the
resident was cognitively intact with a BIMS (brief interview mental screening tool used to screen and
identify cognitive impairment) score of 15 (13 to 15 indicates cognitively intact).
Resident 10's clinical record revealed a Pennsylvania Physician Orders for Life-Sustaining Treatment (The
POLST is not intended to replace an advance health care directive document or other medical orders. The
POLST process and health care decision-making works best when the person has appointed a healthcare
agent to speak for them when they become unable to speak for themselves. A health care agent can only
be appointed through an advance health care directive or a health care power of attorney), but no
documented evidence of Advance Directives or if the facility asked the resident if she would like information
to formulate an Advance Directive.
Interview with the Social Services Director (SSD) on [DATE], at approximately 10:00 AM confirmed there
was no documented evidence to indicate that the facility had determined if Resident 10 had or did not have
an Advance Directive upon admission to the facility. The SSD confirmed there was also no documented
evidence that Resident 10 was made aware of the right to formulate an Advance Directive and that
information to formulate an advance directive could be requested and provided by the
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
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Event ID:
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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
12/07/2023
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 0578
facility.
Level of Harm - Minimal harm
or potential for actual harm
A review of the clinical record revealed that Resident 2 was re-admitted to the facility on [DATE], and was
cognitively impaired with a BIMS score of 11. A physician's order dated [DATE], from previous admission
was noted declaring the resident as a CPR (Cardio-pulmonary resuscitation).
Residents Affected - Some
Review of Resident 2's clinical record revealed there was no Advance Directive on the Resident's medical
record or documented evidence that the Resident had been given an opportunity to formulate Advance
Directives if they chose to do so.
A review of the clinical record revealed that Resident 11 was admitted to the facility on [DATE], Resident's
cognition was impaired with a BIMS score of 11. A physician's order dated [DATE], indicated the Resident
as a CPR (Cardio-pulmonary resuscitation).
Review of Resident 11's clinical record revealed there was no Advance Directive on the resident's medical
record or documented evidence that the resident had been given an opportunity to formulate Advance
Directives if they chose to do so.
A review of the clinical record revealed that Resident 12 was admitted to the facility on [DATE], Resident
was cognitively intact, with a BIMS score of 15. A physician's order dated [DATE], (approximately nine
months after admission) indicated the resident was a DNR (Do Not Resuscitate [Cardio-pulmonary
resuscitation (CPR) was not to be performed in the event of the cessation of heart and lung functions]), no
tube feed/hydration, comfort measures only.
Review of Resident 12's clinical record revealed there was no Advance Directive on the Resident's medical
record or documented evidence that the resident had been given an opportunity to formulate Advance
Directives if they chose to do so.
In an interview with the Nursing Home Administrator (NHA) on [DATE], at approximately 2:30 p.m., the NHA
confirmed that the above residents did not have an Advanced Directive in their clinical record and there was
no documented evidence for an opportunity to formulate an Advanced Directive was in the clinical record.
28 Pa. Code 201.29 (a) Resident rights
28 Pa. Code 211.5 (f) Medical records
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Event ID:
Facility ID:
395730
If continuation sheet
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Printed: 05/15/2026
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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
12/07/2023
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 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
Based on a review of the facility's abuse prevention policy and employee personnel files and staff interview,
it was determined that the facility failed to implement their established abuse prohibition policy and
procedures for training new employees as evidenced by two newly hired employees (Employees 1 and 5)
and screening potential employees for one (Employee 5) out of five newly hired employees reviewed.
Residents Affected - Some
Findings include:
A review of facility policy titled Abuse Protection last reviewed by the facility January 4, 2023, revealed that
the facility conducts employee background checks and will not knowingly employ any individual who has
been convicted of abusing, neglecting, or mistreating individuals. Additionally, mandated staff
training/orientation programs that include such topics as abuse prevention, identification, and reporting of
abuse, stress management, dealing with violent behavior or catastrophic reactions, etc. Training is provided
at time of hire, annually, and as needed.
Review of employee personnel files revealed that Employee 1 (Registered Nurse) started to work in the
facility on August 1, 2023. There was no evidence that Employee 1 was provided training on the facility's
abuse policy during the orientation process.
Interview with Employee 1 on December 5, 2023, at approximately 10:30 AM confirmed that she did not
receive training on the facility's abuse policy during her facility orientation or prior to beginning work with
residents.
Review of Employee 5's personnel file revealed a hire date of August 30, 2023. There was no evidence the
Employee 5 was provided training on the facility's abuse policy during the orientation process. Further
review of Employee 5's personnel file revealed that there was no evidence the facility performed an
employee background check prior to/ during the hiring process.
Interview with the Nursing Home Administrator on December 7, 2023, at 1 PM verified that the facility was
unable to provide evidence that that the facility abuse policy was consistently implemented with each newly
hired employee for training and screening.
28 Pa Code 201.18 (e)(1) Management
28 Pa. Code 201.29 (a)(c) Resident rights
28 Pa. Code 201.20 (b) Staff Development
28 Pa. Code 201.19 (6) Personnel policies and procedures
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395730
If continuation sheet
Page 3 of 17
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
12/07/2023
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 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Many
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of clinical records and facility-initiated transfer notices and a staff interview, it was determined that
the facility failed to ensure that a written notice of facility-initiated transfer to the hospital were provided to
the resident and the resident's representative and failed to provide copies of written notices of
facility-initiated hospital transfers of residents to a representative of the Office of the State Ombudsman for
two out of 12 residents reviewed (Residents 9 and 2).
Findings include:
Regulatory requirements indicate that before a facility transfers or discharges a resident, the facility must
notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the
move in writing and in a language and manner they understand. The facility must send a copy of the notice
to to the resident and/or resident's representative and to a representative of the Office of the State
Long-Term Care Ombudsman.
A review of the clinical record revealed that Resident 9 was transferred to the hospital on August 24, 2023,
and returned to the facility on the same day after declining treatment.
A review of the clinical record revealed that Resident 2 was transferred to the hospital on November 28,
2023, and was readmitted to the facility on [DATE].
There was no evidence that written notices of these facility initiated transfers were provided to the residents
and their representatives.
An interview with the Nursing Home Administrator (NHA) on December 6, 2023, at approximately 10:20
AM, confirmed that there was no evidence that written notifications of facility-initiated transfers were
provided to the residents and the residents' representatives. The NHA further confirmed that there was no
evidence that copies were sent to a representative of the Office of the State Long-Term Care Ombudsman
since last full survey January 6, 2023.
28 Pa. Code 201.29 (2) Resident rights
28 Pa. Code 201.14(a) Responsibility of Licensee
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395730
If continuation sheet
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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
12/07/2023
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 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of clinical records and select facility policy and staff interview, it was determined that the facility
failed to ensure that nursing services met professional standards of quality according to the Pennsylvania
Code Title 49, Professional and Vocational Standards, by failing to ensure licensed nursing staff were
knowledgeable in the necessary care and services for one resident with a Pleurex drain (Resident 1) and
failed to provide care and services according to accepted standards of clinical practice in the identification
of a resident's diagnosis of schizophrenia/schizoaffective disorder for one resident (Resident 12) out of 12
residents sampled.
Residents Affected - Few
Findings include:
According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State,
Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse)
requires the following: (a) The LPN is prepared to function as a member of the health care team by
exercising sound nursing judgement based on preparations, knowledge, skills, understandings, and past
experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of
nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the
therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes
codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring
safe and effective practice.
According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State,
Chapter 21 State Board of Nursing, Chapter 21.11 Functions of the RN (Registered Nurse) requires the
following: The registered nurse assesses human responses and plans, implements and evaluates nursing
care for individuals or families for whom the nurse is responsible. 21.18 A registered nurse shall undertake
a specific practice only if the registered nurse has the necessary knowledge, preparation, experience and
competency to properly execute the practice.
Review of clinical record revealed that Resident 1 was re-admitted to the facility on [DATE], following a
hospitalization for collapse of her left lung. Resident 1 returned to the facility with a Pleurex catheter (small,
flexible tube that is placed in the chest or abdomen to drain fluid) in her left chest.
A physician order dated December 1, 2023, indicated that the Pleurex catheter was to be drained three
times weekly, on Mondays, Wednesdays, and Fridays, and the amount drained was to be recorded. The
catheter was scheduled to be drained during the 3 PM to 11 PM shift. There were no physician orders
related to the care and maintenance of the catheter insertion site.
Interviews with Employee 1 (RN) and Employee 2 (LPN) on December 6, 2023, at approximately 9:30 AM
revealed that neither employee was provided education regarding Resident 1's Pleurex catheter. Employee
1 and Employee 2 had no knowledge of how to provide care and maintenance to the catheter site or how to
drain the catheter if the need arose during their shift of nursing duty.
Observation of the nursing unit on December 6, 2023, at approximately 9:45 AM, in the presence of
Employee 1 and Employee 2 revealed that there was no availability of a nursing policy and procedure
manual(s) for employees to reference, including care of a Pleurex catheter.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395730
If continuation sheet
Page 5 of 17
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
12/07/2023
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 0658
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview with the Director of Nursing on December 6, 2023, at approximately 1 PM, confirmed that there
was no education and/or competency evaluation provided to the licensed nursing staff upon Resident 1's
return to the facility with a Pleurex catheter.
There was no evidence that all the facility's licensed nursing staff had the knowledge and/or experience to
care for a resident with a Pleurex catheter should the need arise during their tour of duty.
Interview with the Nursing Home Administrator and the Director of Nursing on December 6, 2023, at 2 PM
confirmed that the facility did not have facility nursing policy and procedures readily available for access by
the nursing staff for reference.
According to the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders
(DSM-5), Fifth Edition, Schizophrenia, Diagnostic Criteria includes, but is not limited to:
A.
Two (or more) of the following, each present for a significant portion of time during a 1- month period (or
less if successfully treated). At least one of these must be (1), (2), or (3):
1.
Delusions
2.
Hallucinations
3.
Disorganized Speech (i.e., Frequent derailment or incoherence)
4.
Grossly disorganized or catatonic behavior.
5.
Negative symptoms (i.e., diminished emotional expression or avolition)
Someone with schizoaffective disorder meets the primary criteria for schizophrenia (listed above) and the
following DSM-5 criteria:
1.
A major mood episode (either major depression or mania) that lasts for an uninterrupted period of time.
2.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395730
If continuation sheet
Page 6 of 17
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
12/07/2023
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 0658
Delusions or hallucinations for two or more consecutive weeks without mood symptoms sometime during
the life of the illness.
Level of Harm - Minimal harm
or potential for actual harm
3.
Residents Affected - Few
Mood symptoms are present for the majority of the illness.
4.
The symptoms are not caused by substance abuse.
A review of the Resident 12's clinical record revealed that the resident was admitted to the facility on
[DATE], with diagnoses which included hypertension (high blood pressure), hyperlipidemia (high
cholesterol), gastroesophageal reflux disorder (GERD - acid reflux), obsessive compulsive disorder,
generalized anxiety and depression.
Review of the resident's initial Minimum Data Set assessment (MDS- a federally mandated standardized
assessment completed at specific times to identify resident care needs) dated November 2, 2022, revealed
the resident had no psychiatric/mood disorders.
Review of the clinical record revealed that on October 20, 2022, Resident 12 was transferred to the
emergency department (ED) for a psychiatric evaluation due to agitation.
Review of a consult from the ED dated October 20, 2022, revealed the resident had been verbally
aggressive and confrontational toward staff and peers, requiring a psychiatric evaluation for threatening
behaviors. The resident was cleared by the crisis team and found to be appropriate during the consultation
with negative psychiatric symptoms and was diagnosed with acute reaction to situational stress and acute
urinary tract infection (UTI).
Review of Resident 12's progress notes dated October 21, 2022, revealed new orders for an antibiotic to
treat urinary tract infection (UTI), Ativan (acute agitation) for 14 days and Risperdal (antipsychotic) to treat a
new diagnosis of schizoaffective disorder. Target symptoms for treatment with the antipsychotic drug
included anxiety/apprehension, paranoia or delusions.
There was no documentation in the clinical record that Resident 12 had experienced hallucinations or
delusions and no further clinical findings to support the new diagnosis of schizophrenia.
Resident 12 was again transferred to the ED on October 22, 2022, related to agitation and received
Rocephin (antibiotic) and Tylenol and returned to the facility without any further treatment
recommendations.
Resident 12 was transferred to the ED on October 24, 2022, with complaints of chest pain and was
diaphoretic (sweaty). The resident was admitted for evaluation.
Review of 15-minute checks that were performed on the resident by staff from October 21, 2023, until
October 24, 2022, revealed the resident displayed no behaviors, to include delusions or hallucinations.
Review of a consult from the facility's Psychiatric Service provider dated December 8, 2022,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395730
If continuation sheet
Page 7 of 17
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
12/07/2023
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 0658
Level of Harm - Minimal harm
or potential for actual harm
revealed that the resident had chronic intermittent periods of mood disturbances, without hallucinations can
be delusional to environment. Risperdal (an antipsychotic) will be increased for positive symptoms of
paranoia, delusions, and agitation. Target symptoms for treatment with the antipsychotic drug included
anxiety/apprehension, paranoia or delusions. A GDR (gradual dose reduction) for Risperdal remained
clinically inadvisable according to the psychiatric service provider.
Residents Affected - Few
A review of Resident 12's comprehensive plan of care initially dated November 18, 2022, and most recently
reviewed August 28, 2023, revealed a diagnosis of schizoaffective disorder. The interventions included to
administer medications as prescribed and to observe for adverse effects.
A review of Resident 12's quarterly Minimum Data Set Assessment (MDS - a federally mandated
standardized assessment completed at specific times to identify resident care needs) dated September 9,
2023, revealed that the resident now had two (2) psychiatric/mood disorders, both depression and
schizophrenia.
There was no documented evidence in the resident's clinical record to demonstrate that a clinical
practitioner had diagnosed the resident with schizophrenia/schizoaffective disorder with documented
supporting clinical findings in the resident's clinical record from the time of the resident's admission to the
facility on October 14, 2022, through the current survey which ended on December 7, 2023.
Interview with the director of nursing on December 7, 2023, at 2:30 PM, confirmed that there was no
documented evidence of the clinical assessments and prescriber documentation identifying the resident's
diagnostic criteria supporting the diagnosis of schizoaffective disorder according to professional standards.
28 Pa. Code 201.20 (a) Staff Development
28 Pa Code 211.12 (c)(d)(1)(2)(3)(5) Nursing services
28 Pa Code 211.2 (d)(3) Medical Director
28 Pa. Code 211.5 (f) Medical records
28 Pa. Code 211.10 (a) Resident care policies
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395730
If continuation sheet
Page 8 of 17
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
12/07/2023
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 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review and observations, it was determined that the facility failed to provide necessary staff
assistance with activities of daily living to maintain good personal grooming for residents dependent on staff
assistance with these activities for one of 12 residents sampled (Resident 2).
Residents Affected - Few
Findings include:
A review of the clinical record review revealed that Resident 2 was originally admitted to the facility on
[DATE], and had diagnoses which included dementia (group of symptoms affecting intellectual and social
abilities severely enough to interfere with daily functioning), rheumatoid arthritis, and pneumonia. The
resident was cognitively impaired, had functional limitation in range of motion on one side of her upper
extremities, and required staff assistance for activities of daily living which included bathing and personal
hygiene.
Observations conducted on December 5, 2023, at 10:57 AM and December 6, 2023, at 1:00 PM revealed
that the fingernails on both the resident's hands were dirty with a build-up of dark colored debris under the
nails.
Interview with the administrator on December 7, 2023, at approximately 2:30 PM confirmed that staff were
to provide residents' nail care to maintain good personal grooming and hygiene.
28 Pa Code 211.12 (d)(5) Nursing services
FORM CMS-2567 (02/99)
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Event ID:
Facility ID:
395730
If continuation sheet
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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
12/07/2023
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 0680
Ensure the activities program is directed by a qualified professional.
Level of Harm - Potential for
minimal harm
Based on review of facility employee personnel records and staff interview, it was determined that the
facility failed to ensure that the facility's activities program was directed by a qualified professional who is a
qualified therapeutic recreation specialist or an activities professional.
Residents Affected - Many
Findings included:
Interview with employee 3 (activities assistant) on December 5, 2023, at approximately 9:30 AM revealed
that she was currently acting as the facility activities director. Employee 3 confirmed she was not yet a
qualified activities professional and was hoping to complete a program to become a qualified activities
professional in six months.
Review of facility documentation revealed that the facility's former Activities Director was terminated from
employment with the facility on June 15, 2023.
Review of facility documentation revealed that Employee 3 (activities assistant) was hired at the facility on
August 28, 2023.
During an interview with the nursing home administrator (NHA) on December 7, 2023, at approximately
11:00 AM the NHA confirmed that the facility did not presently have a qualified Activities Director. The NHA
stated that the former Activities Director was terminated June 15, 2023, and that the facility had no
documented evidence of a qualified replacement from June 15, 2023, to the time of the survey ending
December 7, 2023. The NHA confirmed that employee 3 (activity assistant) has been running the activities
program since August 28, 2023 when she was initially hired.
28 Pa. Code 201.18 (b)(3)(e)(6) Management
28 Pa. Code 201.19 (3) Personnel policies and procedures
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395730
If continuation sheet
Page 10 of 17
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
12/07/2023
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of select facility policies and procedures and clinical records, observation, and staff
interviews, it was determined that the facility failed to provide supplemental oxygen administration care
consistent with professional standards of practice for one of 12 residents reviewed (Resident 2).
Residents Affected - Few
Findings include:
Observation of Resident 2 on December 5, 2023, at 10:57 a.m. revealed the resident was in her room with
oxygen in place via nasal cannula (attached to nose) with the liter flow set at 3.0 liters per minute (l/m).
Observation of Resident 2 on December 6, 2023, at 12:30 p.m. revealed the resident was in the dining area
with oxygen tubing in place via nasal cannula but not attached to an oxygen concentrator (bedside machine
that concentrates ambient air to supply an oxygen-rich gas stream), in the presence of Employee 1 RN and
was not receiving oxygen therapy.
Clinical record review for Resident 2 revealed nursing progress notes following the resident's return from
the hospital on December 2, 2023, until the end of this survey on December 7, 2023, that Resident 2 was
utilizing oxygen therapy via nasal cannula at 3 liters/minute for bronchitis (respiratory infection).
Clinical record review conducted during the survey ending December 7, 2023, revealed no current
physician order for supplemental oxygen administration and a prescribed rate and frequency for Resident 2.
Interview with Nursing Home Administrator (NHA) on December 7, 2023, at 2:30 p.m. confirmed that there
was no physician order for oxygen administration for Resident 2. Further confirmed that nursing staff
administered oxygen therapy without a physician order since the resident's return from the hospital on
December 2, 2023.
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395730
If continuation sheet
Page 11 of 17
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
12/07/2023
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 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, a review of clinical records, and staff interview it was determined that the facility failed to plan
individualized care for resident receiving hemodialysis and failed to ensure the ready availability of
necessary emergency supplies for three residents out of three sampled receiving hemodialysis (Residents
1, 11, and 10).
Residents Affected - Some
Findings include:
According to the National Kidney Foundation patients receiving hemodialysis should keep emergency care
supplies on hand.
A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with
diagnoses to include diabetes end stage renal disease with dependence on dialysis.
A review of physician orders dated December 1, 2023, indicated that the resident was to receive
Hemodialysis (HD), Monday, Wednesday, and Friday.
The resident was receiving hemodialysis (process of removing waste products and excess fluid from the
body when the kidneys are not able to adequately filter the blood), every Monday, Wednesday, and Friday.
A review of Resident 1's current plan of care in effect at the time of the survey ending December 7, 2023,
revealed no indication of emergency procedures, and or location, presence of an emergency kit available
for the resident's dialysis access site.
Observations of Resident 1's room were conducted on December 5, 2023, at approximately 10:30 AM, and
December 6, 2023, at approximately 10:20 AM, revealed no emergency supplies available for use.
A review of the clinical record revealed that Resident 11 was admitted to the facility on [DATE], with a
diagnosis to include diabetes end stage renal disease with dependence on dialysis.
A review of physician orders dated June 9, 2023, indicated the resident is to receive HD, Monday,
Wednesday, and Friday.
The resident was receiving HD every Monday, Wednesday, and Friday.
A review of Resident 11's current plan of care revealed no indication of emergency procedures, and or
location, presence of an emergency kit available.
Observations of Resident 11's room were conducted on December 5, 2023, at approximately 12:03 p.m.,
and December 6, 2023, at approximately 10:20 AM, revealed no emergency supplies available for use.
Interview with Employee 1, Registered Nurse (RN), and Employee 2, Licensed Practical Nurse (LPN), on
December 7, 2023, at approximately 10:45 a.m. revealed that both nurses were unaware that emergency
supplies were to be readily available in the event of an emergency involving a dialysis access site.
Employee 1 and Employee 2 confirmed that there were no emergency supplies readily available at the
bedside for any resident receiving dialysis.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395730
If continuation sheet
Page 12 of 17
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
12/07/2023
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 0698
Level of Harm - Minimal harm
or potential for actual harm
A review of the clinical record revealed that Resident 10 was admitted to the facility on [DATE], with a
diagnosis to include diabetes end stage renal disease with dependence on dialysis.
A review of physician orders dated November 17, 2023 indicated the resident is to receive Hemodialysis
(HD), Monday, Wednesday, and Friday.
Residents Affected - Some
The resident was receiving hemodialysis (process of removing waste products and excess fluid from the
body when the kidneys are not able to adequately filter the blood), every Monday, Wednesday, and Friday.
A review of Resident 10's current plan of care revealed no indication of emergency procedures, and or
location, presence of an emergency kit available.
Observations of Resident 10's room on December 5, 2023, at approximately 11:00 AM, and December 6,
2023, at approximately 10:45 AM, revealed no emergency supplies available for use.
Interview with the Director of Nursing on December 7, 2023, at approximately 2 p.m., confirmed the facility
failed to assure an emergency kit was readily available and that the resident's plan of care addressed
emergency procedures, and or the emergency kit for each resident's specific type of dialysis access site.
28 Pa. Code 211.12 (d)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395730
If continuation sheet
Page 13 of 17
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
12/07/2023
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 0741
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the
behavioral health needs of residents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, a review of clinical records and the facility assessment and resident and staff interview, it was
determined that the facility failed to provide sufficient staff who provide direct services to residents with the
appropriate competencies and skills sets to provide nursing and related services to assure resident safety
and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each
resident and failed to develop effective non-pharmacological approaches to care for one resident (Resident
26) with behaviors out of 12 sampled residents.
Findings include:
Review of the Facility Assessment last reviewed December 1, 2023, indicated that the facility practices an
admission process that revolves around intensive review of each resident's individual needs before offering
admission to the facility. In cases where a less common diagnosis or condition is present, an
interdisciplinary review is conducted to ensure the facility can meet the prospective resident's needs.
Education on clinical competencies occurs before the resident enters the facility and necessary supplies
are made available timely. When current resident develops a new condition, an immediate interdisciplinary
review is conducted and educational needs are provided. Mental health and behavior care manages the
medical conditions and medication-related issues causing psychiatric symptomatology and behavioral
outbursts, identification triggers and develop interventions to support the resident. In addition to nursing
staff, social services is provided for behavioral healthcare and services.
Review of Resident 26's clinical record revealed that the resident was admitted to the facility on [DATE],
with diagnoses, which include paranoid schizophrenia (a pattern of behavior where a person feels
distrustful and suspicious of other people and acts accordingly, delusions and hallucinations are two
symptoms) and major depressive disorder.
Review of Resident 26's care plan initially dated October 16, 2023, revealed that the resident is resistive to
care and medication due to a diagnosis of paranoid schizophrenia. The planned intervention is to educate
the resident, family, and caregivers of the possible outcomes of not complying with care and medication.
The care plan also noted the resident receives psychotropic medications. The planned interventions to
prevent side effects of the psychotropic medication included follow-up psych consult as needed, monitor for
side effects of medications, and social services as needed.
There were no non-pharmacological interventions planned in response to the resident's diagnoses of
paranoid schizophrenia and major depression.
During interview with Resident 5, a cognitively intact resident, on December 6, 2023, at 10:30 AM the
resident revealed that Resident 26 had a loud outburst the night before, that included yelling, cursing, and
threatening staff. Resident 5 stated that she keeps her room door closed because of Resident 26's behavior
and stated that she is fearful of the resident because of his temper.
A behavior note dated November 21, 2023, indicated that the resident was having increased violent
behaviors. Threatening to hit and kill staff members. Continues to scream in staff members faces. The
resident walked up to the nurses station and screamed you better get out of my f******* house I'm going to
kill you. The resident proceeded to slam his fists on the nurses station desk. The resident
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395730
If continuation sheet
Page 14 of 17
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
12/07/2023
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 0741
continued to scream throughout the night causing residents not to sleep and scaring residents.
Level of Harm - Minimal harm
or potential for actual harm
Interview with Resident 15, a cognitively intact resident, on December 7, 2023 at approximately 11:00 AM
also confirmed that Resident 26 has verbal outbursts that mostly happen at night, which are disturbing to
other residents and that the other night he could not even sleep because Resident 26 was so loud.
Residents Affected - Few
Further review of Resident 26's clinical record failed to provide documented evidence that staff documented
Resident 26's behaviors as reported by Residents 5 and Resident 15 on the night of December 5, 2023, in
the resident's clinical record.
A behavior note dated December 7, 2023, indicated that from 7:00 PM until 10:30 PM the resident was
nasty towards staff. He refused to take medication including insulin, and he was calling staff members
various disrespectful names.
Interview with the social services director on December 7, 202,3 at 11:00 AM failed to provide documented
evidence of the interventions used by staff to manage or modify Resident 26's verbal outbursts and threats.
Interview with the administrator on December 7, 2023 at 12:00 PM failed to provided evidence that
interdisciplinary reviews were completed based on Resident 26's disruptive and threatening behaviors. The
administrator confirmed the facility was aware of Resident 26's behaviors prior to admission but failed to
provide documented evidence that the facility employed sufficient staff with the necessary competencies
and skills sets to provide nursing and related services to assure resident safety and attain or maintain the
highest practicable physical, mental, and psychosocial well-being of Resident 26 and other residents
including Residents 5 and 15 who reside at the facility. The administrator failed to provide documented
evidence that the facility developed individualized non-pharmacological interventions to address Resident
26's behaviors.
28 Pa Code 211.12 (d)(3)(4)(5) Nursing services
28 Pa. Code 201.18 (e)(1)(3) Management
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395730
If continuation sheet
Page 15 of 17
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
12/07/2023
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation and staff interview, it was determined that the facility failed to ensure adherence to
medication expiration/use by dates on one of one medication carts.
Findings include:
Observation of the facility's medication cart on December 7, 2023, at 9:00 AM, in the presence of Employee
4 (LPN) revealed one two Lantus Solostar insulin medication pens, one Basaglar insulin pen, and one
Novolog insulin pen were opened without a date of when they were initially opened.
Further review of the medication cart revealed an additional Novolog insulin pen that was opened without a
date of when it was initially opened, and the medication did not have a resident identification label.
According to manufacturer instructions, the Lantus Solostar unopened pen is to be stored in the
refrigerator. If the Lantus pen is stored outside of the refrigerator, it should be used or thrown away within
28 days. A Basaglar insulin pen should be discarded 28 days after opening, and Novolog insulin pen should
be discarded after 28 days once opened.
Interview with the Director of Nursing on December 7, 2023, at approximately 2 PM confirmed that the
facility failed to properly store and label the insulin medication pens.
28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services
28 Pa. Code 211.12 (d)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395730
If continuation sheet
Page 16 of 17
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
12/07/2023
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, review of the facility's infection control tracking logs and policy and staff interviews
it was determined that the facility failed to maintain a comprehensive program to monitor the development
and spread of infections within the facility and plan preventative measures accordingly.
Residents Affected - Many
Findings include:
A review of the current facility policy Infection Control Program Overview, last reviewed by the facility
January 4, 2023, revealed that the purpose of the facility Infection Control Program is to provide a safe,
sanitary and comfortable environment, to help prevent the development and transmission of communicable
infections and to improve antibiotic use. The facility adheres to the mission and goals set forth in the
infection control plan. The infection prevention and control plan is a comprehensive process that addresses
preventing, identifying, reporting, investigating and controlling infections and communicable diseases and
monitoring judicious use of antibiotics to individuals.
A review of the facility's infection control data available during the survey ending December 7, 2023,
revealed that the facility's infection control tracking did not reflect evidence of a functioning tracking system
to monitor and investigate causes of infection and manner of spread. There was no documented evidence
of a system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in
the rate of infection in a timely manner.
The facility's infection control tracking log revealed no documented evidence of detailed data collection that
could be used by the facility to track these infections and to identify any potential trends contained in the
tracking data. The data did not include resident room location or the infectious organism. There was no
documented evidence at the time of the survey ending December 7, 2023, that based on the available
tracking data that the facility had identified any possible trends to implement specific interventions to
prevent the spread of any of the infections.
There was no documentation by the facility of the any of the infections listed of the resolution date,
symptoms, complete culture information for any of the infections noted in the facility's monthly infection
control tracking logs and the treatments required, if any. It could not be determined if any of the noted
infections required the implementation of isolation protocols.
There was no indication that the limited data that was compiled was then evaluated to determine what
could be done to prevent the spread or recurrence of infection.
During an interview conducted on December 7, 2023, at approximately 11 AM, the facility's Infection
Preventionist confirmed that the facility's infection control tracking was incomplete and failed to include the
necessary details to conduct routine, ongoing, and systematic collection, analysis, interpretation, and
dissemination of surveillance data to identify infections (i.e., HAI and community-acquired), infection risks,
communicable disease outbreaks, and to maintain or improve resident health status and to track staff for
adherence to infection control policies and procedures and the potential need to for corrective action.
28 Pa Code 211.12 (d)(1)(3)(5) Nursing services
28 Pa. Code 211.10 (a)(d) Resident care policies
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395730
If continuation sheet
Page 17 of 17
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Back to topCitations
11 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F680 - The activities program must be directed by a qualified professional
Ensure the activities program is directed by a qualified professional.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F741 - The facility must have sufficient staff who provide direct services to
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the December 7, 2023 survey of KADIMA REHABILITATION & NURSING AT LAKESIDE?
This was a inspection survey of KADIMA REHABILITATION & NURSING AT LAKESIDE on December 7, 2023. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at KADIMA REHABILITATION & NURSING AT LAKESIDE on December 7, 2023?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.