Health inspection·May 16, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, and staff interview, it was determined that the facility failed to provide reasonable accommodation of the needs of a bariatric resident for safe wheelchair equipment for one resident out of 9 residents observed (Residents M1). Residents Affected - Few Findings included Review of the clinical record revealed that Resident M1 was admitted to the facility on [DATE], with diagnoses to include morbid (severe) obesity, and polyosteoarthritis (swelling and tenderness causing joint pain or stiffness in five or more joints at the same time). Review of Resident M1's weight record revealed that the resident weighed 528.6 pounds on May 13, 2024. During an initial tour of the facility on May 16, 2024, at 9:05 AM, Resident M1 was observed seated in a bariatric wheelchair in the activities room. At 9:30 AM Resident M1 was observed self propelling the wheelchair down the hallway and into his room. Observation of the resident's wheelchair on May 16, 2024, at 10:27 AM, in the presence of the Nursing Home Administrator (NHA) and Director of Nursing, revealed that the manufacturer's maximum weight capacity for the wheelchair the resident was using was 500 pounds, which Resident M1 exceeded. The resident's weight record revealed the resident exceeded 500 pounds on February 8, 2024, weighing 508.2 pounds, which had increased to 528.6 lbs on May 13, 2024. At the time of the survey ending May 16, 2024, the facility was unable to provide documented evidence that the resident's wheelchair maximum capacity of 500 pounds was identified and addressed by the facility as the resident's current wheelchair did not accommodate his current bariatric weight. Interview with the NHA on May 16, 2024, at approximately 3:00 PM confirmed that Resident M1's current weight exceeded the wheelchair maximum weight capacity and that the facility failed to provide wheelchair equipment to accommodate the needs of a bariatric resident. 28 Pa. Code 205.75 Supplies Page 1 of 9 395730 395730 05/16/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and residents' financial account records and staff interview, it was determined that the facility failed to return resident funds within 30 days of discharge/death to the appropriate party for one of five residents sampled (Residents CR1 ). Residents Affected - Few Findings include: Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], and expired on [DATE]. A review of the resident's financial account statement provided by the facility dated [DATE], revealed a credit on his account for $9,520.00. On [DATE], an adjustment was noted with a revised credit amount of $6,584.48. The facility failed to refund the resident's personal funds within 30 days of the resident's discharge. A letter provided to the surveyor and signed by the Principal of the organization, confirmed that Resident CR1's account had not been issued a refund due to miscommunications within departments. During an interview on [DATE], at 11:00 AM, the Nursing Home Administrator verified that Resident CR1's personal funds were not refunded to the family within 30 days of his discharge/death from the facility. 28 Pa. Code: 201.18 (b)(2)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights 395730 Page 2 of 9 395730 05/16/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of the facility's abuse prohibition policy and clinical records, and staff interviews, it was determined that the facility failed to report multiple instances of resident abuse perpetrated by one of nine residents sampled to the State Survey Agency (Resident M1). Findings include: A review of the facility policy titled Abuse Protection, last revised by the facility on April 19, 2022, revealed that regardless of how minor an accident or incident may be, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information or such accident/incident is learned. An investigation is implemented, and witness statements are obtained. An accident or incident form must be completed for all reported accident or incidents. The reporting and filing of accurate documents relative to incidents of abuse, reporting to state agencies as required. In Pennsylvania, include PA Department of Health/Pennsylvania Department of Aging/Area Agency on Aging as appropriate. A PB-22 will be completed within five (5) days. A review of Resident M1's clinical record, revealed he was admitted to the facility on [DATE], with diagnoses to include morbid (severe) obesity due to excess calories, gastro-esophageal reflux disease (GERD), abnormalities of gait and mobility, and difficulty walking. A review of a nursing note dated December 8, 2023, at 1242 hours (12:42 PM), stating resident M1 yelling at another resident in the dayroom about how she is eating and was upsetting the other resident. The other resident stated leave me alone, however Resident M1 continued to verbally abuse the resident. A review of a behavior note, dated February 12, 2024, at 1415 hours (2:15 PM), indicated that Resident M1 was taunting a female resident, pulling his shirt up over his nose and teasing her because of her behaviors. He was making facial and hand gestures towards the female resident. Resident M1 was observed calling her A crazy bitch! Resident M1 confirmed he was mocking the other resident when staff asked. A review of a nursing note dated February 25, 2024, at 1651 hours (4:51 PM), revealed that Resident M1 was in the dayroom arguing with staff about television remote. Resident became irate cursing at staff stating, f*ck you, while throwing the middle finger stating, I pay you to take care of me and that is your job, anything that goes on in this building is my business so f*ck off. Other residents in dayroom voiced concerns about Resident M1's behavior and were kept safe at time, staff attempted to de-escalate with no effect. A nursing note dated March 18, 2024, at 1425 hours (2:25 PM), indicated that Resident M1 was verbally abusive with another resident in the dayroom. A review of a behavior note, dated March 21, 2024, at 2055 hours (8:55 PM), revealed that Resident M1 was in the dining room and loud and argumentative. The note indicated that Residen M1 Appears at times to intimidate the other residents. When asked to lower his voice a bit, he cursed. A review of a behavior note dated April 4, 2024, at 1105 hours (11:05 AM), revealed that Resident 395730 Page 3 of 9 395730 05/16/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some M1 was heard yelling at a resident in activities. When approaching area, he was yelling at another resident and said she's a f*cking retard. A review of a behavior note dated April 10, 2024, at 1212 hours (12:12 PM), revealed that Resident M1 was heard screaming at another resident in the dayroom. Resident continues to yell at resident causing other resident to leave area. A nursing note dated April 13, 2024, at 2236 hours (10:36 PM), indicated that there was a very loud verbal altercation in the hall and a Nursing Assistant (NA) was calling for help. Nursing noted I noticed several aides trying to restrain one of the residents who was yelling back at Resident M1 who was yelling at him. This yelling and verbal threats from Resident M1 continued and the other resident reacted in anger. Resident M1 would not go back in his room as the other resident did and continued the verbal threats. During an interview on May 16, 2024, at approximately 2:05 PM, the Nursing Home Administrator (NHA) confirmed that the facility did not report the instances of resident abuse perpetrated by Resident M1 against other residents to the State Survey Agency. 28 Pa Code 201.14 (c) Responsibility of licensee 28 Pa Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident rights 395730 Page 4 of 9 395730 05/16/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and the facility's abuse prohibition policy and staff interviews, the facility failed to investigate instances of resident abuse, protect residents from the potential for further abuse during the course of an investigation and submit the results of the completed investigations to the State Survey Agency within 5 working days of the incident for multiple instances of resident abuse perpetrated by one resident out of nine sampled (Resident M1). Residents Affected - Some Findings include: A review of the facility policy titled Abuse Protection, last revised by the facility on April 19, 2022, revealed the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. Residents must not be subject to abuse by anyone, including but not limited to facility staff and other residents. Abuse includes verbal abuse, and means the willful infliction of injury, unreasonable confinement, and intimidation, resulting in physical harm, pain or mental anguish. Regardless of how minor an accident or incident may be, an investigation is implemented, and witness statements are obtained. An accident or incident form must be completed for all reported accident or incidents. The reporting and filing of accurate documents relative to incidents of abuse, reporting to state agencies as required. In Pennsylvania, include PA Department of Health/Pennsylvania Department of Aging/Area Agency on Aging as appropriate, a PB-22 (Pennsylvania Bulletin 22- form used to detail investigation, findings and actions) will be completed within five (5) days. A review of Resident M1's clinical record, revealed he was admitted to the facility on [DATE], with diagnoses to include morbid (severe) obesity due to excess calories, gastro-esophageal reflux disease (GERD), abnormalities of gait and mobility, and difficulty walking. A review of a nursing note dated December 8, 2023, at 1242 hours (12:42 PM), stating resident M1 yelling at another resident in the dayroom about how she is eating and was upsetting the other resident. The other resident stated leave me alone, however Resident M1 continued to verbally abuse the resident. A review of a behavior note, dated February 12, 2024, at 1415 hours (2:15 PM), indicated that Resident M1 was taunting a female resident, pulling his shirt up over his nose and teasing her because of her behaviors. He was making facial and hand gestures towards the female resident. Resident M1 was observed calling her A crazy bitch! Resident M1 confirmed he was mocking the other resident when staff asked. A review of a nursing note dated February 25, 2024, at 1651 hours (4:51 PM), revealed that Resident M1 was in the dayroom arguing with staff about television remote. Resident became irate cursing at staff stating, f*ck you, while throwing the middle finger stating, I pay you to take care of me and that is your job, anything that goes on in this building is my business so f*ck off. Other residents in dayroom voiced concerns about Resident M1's behavior and were kept safe at time, staff attempted to de-escalate with no effect. A nursing note dated March 18, 2024, at 1425 hours (2:25 PM), indicated that Resident M1 was verbally abusive with another resident in the dayroom. 395730 Page 5 of 9 395730 05/16/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of a behavior note, dated March 21, 2024, at 2055 hours (8:55 PM), revealed that Resident M1 was in the dining room and loud and argumentative. The note indicated that Residen M1 Appears at times to intimidate the other residents. When asked to lower his voice a bit, he cursed. A review of a behavior note dated April 4, 2024, at 1105 hours (11:05 AM), revealed that Resident M1 was heard yelling at a resident in activities. When approaching area, he was yelling at another resident and said she's a f*cking retard. A review of a behavior note dated April 10, 2024, at 1212 hours (12:12 PM), revealed that Resident M1 was heard screaming at another resident in the dayroom. Resident continues to yell at resident causing other resident to leave area. A nursing note dated April 13, 2024, at 2236 hours (10:36 PM), indicated that there was a very loud verbal altercation in the hall and a Nursing Assistant (NA) was calling for help. Nursing noted I noticed several aides trying to restrain one of the residents who was yelling back at Resident M1 who was yelling at him. This yelling and verbal threats from Resident M1 continued and the other resident reacted in anger. Resident M1 would not go back in his room as the other resident did and continued the verbal threats. At the time of the survey ending May 16, 2024, the facility had completed investigations into the above episodes of resident abuse perpetrated by Resident M1. The resident victims were not identified in the documentation available. The facility failed to provide evidence of completed investigations, PB22's submitted to the State Survey Agency within five working days of the occurrence. During an interview on May 16, 2024, at approximately 2:05 PM, the Nursing Home Administrator (NHA) confirmed that the facility failed to investigate Resident M1's abuse of other residents and submit the completed investigations to the State Survey Agency within 5 working days of the incident. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident Rights 395730 Page 6 of 9 395730 05/16/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policy and clinical records, and staff interviews, it was determined that the facility failed to provide therapeutic social services to assess the psychosocial status and needs of residents following incidents of abuse perpetrated by Resident M1. Residents Affected - Some Findings include: According to regulatory guidance under §483.40(d) Medically-related social services means services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health, which include providing or arranging for needed mental and psychosocial counseling services and identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident. Situations in which the facility should provide social services or obtain needed services from outside entities include, but are not limited to the following: · Lack of an effective family or community support system or legal representative; · Expressions or indications of distress that affect the resident ' s mental and psychosocial well-being, resulting from depression, chronic diseases (e.g., Alzheimer ' s disease and other dementia related diseases, schizophrenia, multiple sclerosis), difficulty with personal interaction and socialization skills, and resident to resident altercations; · Abuse of any kind (e.g., alcohol or other drugs, physical, psychological, sexual, neglect, exploitation); · Difficulty coping with change or loss (e.g., change in living arrangement, change in condition or functional ability, loss of meaningful employment or activities, loss of a loved one); and · 395730 Page 7 of 9 395730 05/16/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0745 al support. Level of Harm - Minimal harm or potential for actual harm A review of the facility policy titled Abuse Protection, last revised by the facility on April 19, 2022, revealed verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms residents or their families or within their hearing distance, regardless of their age, or ability to comprehend or disability. Residents Affected - Some A review of Resident M1's clinical record, revealed he was admitted to the facility on [DATE], with diagnoses to include morbid (severe) obesity due to excess calories, gastro-esophageal reflux disease (GERD), abnormalities of gait and mobility, and difficulty walking. A review of a nursing note dated December 8, 2023, at 1242 hours (12:42 PM), stating resident M1 yelling at another resident in the dayroom about how she is eating and was upsetting the other resident. The other resident stated leave me alone, however Resident M1 continued to verbally abuse the resident. A review of a behavior note, dated February 12, 2024, at 1415 hours (2:15 PM), indicated that Resident M1 was taunting a female resident, pulling his shirt up over his nose and teasing her because of her behaviors. He was making facial and hand gestures towards the female resident. Resident M1 was observed calling her A crazy bitch! Resident M1 confirmed he was mocking the other resident when staff asked. A review of a nursing note dated February 25, 2024, at 1651 hours (4:51 PM), revealed that Resident M1 was in the dayroom arguing with staff about television remote. Resident became irate cursing at staff stating, f*ck you, while throwing the middle finger stating, I pay you to take care of me and that is your job, anything that goes on in this building is my business so f*ck off. Other residents in dayroom voiced concerns about Resident M1's behavior and were kept safe at time, staff attempted to de-escalate with no effect. A nursing note dated March 18, 2024, at 1425 hours (2:25 PM), indicated that Resident M1 was verbally abusive with another resident in the dayroom. A review of a behavior note, dated March 21, 2024, at 2055 hours (8:55 PM), revealed that Resident M1 was in the dining room and loud and argumentative. The note indicated that Resident M1 Appears at times to intimidate the other residents. When asked to lower his voice a bit, he cursed. A review of a behavior note dated April 4, 2024, at 1105 hours (11:05 AM), revealed that Resident M1 was heard yelling at a resident in activities. When approaching area, he was yelling at another resident and said she's a f*cking retard. A review of a behavior note dated April 10, 2024, at 1212 hours (12:12 PM), revealed that Resident M1 was heard screaming at another resident in the dayroom. Resident continues to yell at resident causing other resident to leave area. A nursing note dated April 13, 2024, at 2236 hours (10:36 PM), indicated that there was a very loud verbal altercation in the hall and a Nursing Assistant (NA) was calling for help. Nursing noted I noticed several aides trying to restrain one of the residents who was yelling back at Resident M1 who was yelling at him. This yelling and verbal threats from Resident M1 continued and the other resident reacted in anger. Resident M1 would not go back in his room as the other resident did and 395730 Page 8 of 9 395730 05/16/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0745 continued the verbal threats. Level of Harm - Minimal harm or potential for actual harm During an interview on May 16, 2024, at approximately 1:50 PM, the Director of Social Services, was unable to provide documented evidence of the facility's efforts to identify those residents affected by the above incidents of resident abuse perpetrated by Resident M1 and of the supportive social service interventions provided to assist the residents involved, directly, and indirectly (within hearing distance) following the incidents of abuse perpetrated by Resident M1. Residents Affected - Some During an interview on May 16, 2024, at approximately 2:10 PM, the NHA confirmed that there was no documented evidence of social service assessment of psychosocial status and needs and provision of social service interventions provided to residents following episodes of abuse perpetrated by Resident M1. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.16 (a) Social Services 395730 Page 9 of 9