Health inspection·November 21, 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 resident and staff interview, it was determined the facility failed to provide reasonable accommodation of the needs of a dependent resident for safe wheelchair equipment for one resident out of 14 residents sampled (Resident 180). Residents Affected - Some Findings included: Review of the clinical record revealed that Resident 180 was admitted to the facility on [DATE], with diagnoses to include absence of the right leg below the knee (amputation), and history of falling. Further record review revealed the resident previously underwent a left leg below the knee amputation approximately 4 years ago. Review of Resident 180's care plan dated November 14, 2024, indicated the resident had self-care performance deficits due to impaired mobility with bilateral (both) below the knee amputations, diabetes, peripheral vascular disease, and pain. Interventions included physical and occupational therapy evaluation as ordered, provide two staff member assistance with transfers from the bed to the wheelchair and to transfer to and from the commode using a mechanical full body lift, provide total assistance for toilet use, provide total staff assistance for bathing, provide one staff assistance with dressing and one staff assistance for personal hygiene/oral care. During an interview with Resident 180 on November 19, 2024, at 10:50 AM the resident, with a BIMS score of 10 (BIMS -Brief Interview for Mental Status- a tool to assess cognitive status. A score between 8 to 12 suggests moderate cognitive impairment), reported that he had not been out of bed since he arrived at the facility on November 14, 2024, five days ago. Resident 180 revealed he had not left the room since he was admitted to the facility five days ago. He indicated that he had not been out of bed to attend activities, to dine in the dining room, or attend therapy in the therapy room. The resident stated that had to eat all his meals while in bed because he was not provided with a wheelchair when he entered the facility. Observation of Resident 180's room, conducted at the time of the interview, revealed the resident did not have a wheelchair or specialized seating equipment available for use. Interview with the Director of Nursing (DON) on November 19, 2024, at approximately 11:30 AM indicated that therapy was responsible for assessing Resident 180 for an appropriate wheelchair. Interview with Employee 1 (physical therapist) on November 19, 2024, at 12:40 PM revealed that Resident 180 was evaluated by Physical Therapy on November 15, 2024, and due to his bilateral leg amputations, the resident required front and rear anti-tipper devices (designed to prevent the wheelchair Page 1 of 17 395730 395730 11/21/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some from tipping forward and/or backwards) to be applied to the wheelchair to enhance the stability of the wheelchair. Employee 1 indicated that a maintenance work order was submitted on November 15, 2024. Interview with Employee 2 (nurse aide) on November 19, 2024, at approximately 1:30 PM confirmed that staff were unable to get Resident 180 out of bed for five (5) days because the resident did not have a wheelchair available for use. Review of the facility documentation titled Maintenance Repair Log revealed that a maintenance work order was submitted November 15, 2024, (no time indicated and no name of person filling out report was filled in) to apply front and rear tippers to the wheelchair. The Maintenance Repair Log description of the repairs made and the maintenance signature with time and date were not completed. Interview with the DON on November 21, 2024, at 10:57 AM revealed that Resident 180's wheelchair front and rear anti-tippers were applied by nursing staff on November 19, 2024, after surveyor inquiry, due to maintenance staff not being present in the facility since the work order was submitted on November 15, 2024. Interview with the Nursing Home Administrator and DON on November 21, 2024, at approximately 11:30 AM confirmed the facility failed to provide reasonable accommodations for a resident's positioning needs in a timely manner. 28 Pa. Code 205.75 Supplies 28 Pa. Code 211.12(d)(5) Nursing services. 395730 Page 2 of 17 395730 11/21/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0692 Provide enough food/fluids to maintain a resident's health. 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, select facility policy, and staff interview, it was determined the facility failed to assess, evaluate, and monitor nutritional parameters and develop and implement individualized nutritional interventions to maintain nutritional parameters for two residents (Resident 1 and Resident 22) and deter weight loss for one resident (Resident 17) out of 14 residents sampled. Residents Affected - Some Findings include: The Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards: Responsibilities of the Licensed Dietitian/ Nutritionist Section 21.711 Professional Conduct indicated that the Licensed Dietitian/ Nutritionist shall provide information which will enable patients to make their own informed decisions regarding nutrition and dietetic therapy, including the reasonable expectations of the professional relationship. Review of the Facility assessment dated [DATE], indicates that the facility will have two dietitians or other qualified nutrition professional to serve as the director of food and nutrition services. During interview with the foodservice director on November 19, 2024, at 8:45 AM the food service director (FSD) stated that he has been the full-time food service director since March 8, 2024, but does not meet the minimum qualifications to be the food and nutrition services supervisor. The FSD stated that he is currently enrolled in a class to become a certified dietary manager. The FSD stated that he does not interact with the facility's part-time registered dietitian who works remotely. The FSD stated that he does visit residents to obtain food preferences which are added to each resident's meal ticket and attends plan of care meetings for residents but does not document in the clinical record. A review of the facility's Nutrition Assessment Policy last reviewed February 2024 indicated that a nutrition assessment shall be completed for each resident admitted to the facility. The dietitian or the dining services manager under the guidance of the dietitian is responsible for developing a nutrition assessment for each resident admitted to the facility. A nutrition assessment will be conducted, and such information will include at least the following information: Weight Height Hematological data Nutritional intake Eating habits Food preferences and dislikes Dietary restrictions Diagnoses 395730 Page 3 of 17 395730 11/21/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0692 Other information deemed necessary and appropriate. Level of Harm - Minimal harm or potential for actual harm Nutrition assessments shall be initiated within 72 hours of admission to the facility and completed prior to developing the resident's MDS 3.0 assessment and care plan. Residents Affected - Some Nutrition assessments will be reviewed quarterly and revised as necessary. A review of the facility Resident Weights policy last reviewed February 2024 indicated weights must be obtained routinely to monitor the parameters of nutrition over time and identify residents at risk for significant weight change. Upon admission/readmission, the resident will be weighed each day for the first 2 days. The first weight will be within 24 hours of admission or readmission. After admission weights are obtained, the individual will be weighed weekly for 4 weeks. After the first 4 weeks, the interdisciplinary team will determine the need for continuation of weekly weights or a change to monthly weights. All monthly weights will be completed by the seventh of the month. Re-weights will be obtained within 72 hours of monthly weight if a weight change greater than 3%. If the weight change is validated, the licensed nurse will notify the physician and dietitian. The licensed nurse will notify the interdisciplinary team for further assessment if the weight change is significant (a weight loss or gain of 5% in a month, 7.5% in 90 days, or 10% in 6 months), the family will be notified. All weights will be transcribed (including weekly weights and any reweigh) in the resident's medical record. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnosis to include diabetes and dementia (chronic persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of Resident 1's admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated April 19, 2024, revealed the resident had a BIMS score of 14 (Brief Interview for Mental Status- a tool that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact), weighed 163 pounds, 64 inches tall, had no significant weight loss or weight gain, and was on a regular diet. Further review of the clinical record revealed no documented evidence that a nutritional assessment was completed and documented within 72 hours of Resident 1's admission to the facility to ensure timely assessment, evaluation, and monitoring of nutritional parameters and to establish individualized nutritional goals for Resident 1. A review of the facility's policy entitled Nutrition Assessment for Enteral Feeds, last reviewed February 2024, revealed that a nutrition assessment shall be completed for each resident admitted to the facility with an enteral feed order. The dietician is responsible for developing a nutrition assessment for each resident with enteral feed admitted to the facility. Further review of the policy indicated that a nutrition assessment will be conducted, and include at least the following information: weight, height, hematological data (blood work results), enteral feed order, water flush order, oral intake if any, dietary restrictions if any, diagnoses, and other information deemed necessary and appropriate. Additionally, nutritional assessments shall be initiated within 72 hours of admission to the facility and completed prior to developing the resident's MDS 3.0 assessment and care plan. Nutrition assessment will be reviewed quarterly and revised as 395730 Page 4 of 17 395730 11/21/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0692 necessary. Level of Harm - Minimal harm or potential for actual harm Reviewed of Resident 22's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses which included dysphagia, (difficulty swallowing), surgical aftercare following surgery for a ruptured appendix, and malnutrition, and required a feeding tube for nutritional support following surgery. Residents Affected - Some Clinical record review revealed that Resident 22 had a PEG tube (Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate for feeding) which was placed during hospitalization. A physician order dated October 29, 2024, was noted for the resident to receive the tube feeding formula of Osmolite 1.5 Cal (liquid feeding administered via feeding tube) at 55 ccs per hour continuous for 24-hours daily with 200 ccs of sterile water every 4 hours for hydration, and a puree diet with thin liquids. A review of Resident 22's admission MDS dated [DATE], revealed the resident had a BIMS score of 14, weighed 167 pounds, 67 inches tall, had no weight loss/weight gain, received nutrition via a feeding tube and a mechanically altered diet. Further review of the MDS indicated that Resident 22 received 25% or less of total calories through enteral feedings and 500mL/day or less of average fluid intake per day through tube feeding despite receiving tube feeding continuously 24 hours a day and routine water flushes of 200mL every 4 hours. Review of Resident 22's weights documented in the clinical record revealed that on October 29, 2024, the resident weighed 167 pounds. On November 4, 2024, the resident weighed 158.6 pounds, an 8.4 pound or 5% weight loss in 6 days. There was no evidence that a reweight was obtained upon admission or that a reweight was obtained after the identified significant weight loss. Upon surveyor request, a weight was obtained on November 21, 2024, and Resident 22 weighed 149.4 pounds, losing an additional 9.2 pounds from the last weight obtained on November 4, 2024. According to documentation, Resident 22 lost a total of 17.6 pounds or 10.5% in 24 days. At time of survey ending on November 21, 2024, there was no evidence that Resident 22's nutritional requirements were evaluated. There was no evidence that Resident 22's significant weight loss was identified and evaluated or that the physician and/or family was made aware. Interview with the nursing home administrator (NHA) on November 20, 2024, at 9:30 AM confirmed that since January 5, 2024, the facility has not had an onsite registered dietitian. The NHA confirmed the current part-time registered dietitian who also works for sister facilities works remotely and completes nutritional assessments and nutritional progress notes offsite, without face-to-face interaction with the residents. The NHA confirmed that nutritional assessments were to be timely completed to ensure nutritional parameters are maintained to the extent possible for each resident. Review of Resident 17's clinical record revealed the resident was originally admitted to the facility on [DATE], with diagnoses which included dysphagia, and dementia. 395730 Page 5 of 17 395730 11/21/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0692 Level of Harm - Minimal harm or potential for actual harm Further review of the resident's clinical record revealed that the resident was hospitalized on [DATE], and readmitted to the facility on [DATE]. Review of Resident 17's weights documented in the clinical record revealed that a weight was not obtained upon readmission to the facility on June 25, 2024. Residents Affected - Some The next documented weight was obtained on July 10, 2024, and the resident weighed 122.6 pounds. Review of the clinical record revealed that on August 28, 2024, the resident weighed 112 pounds, a 10.6 pound or 8.6% weight loss in 50 days. A reweight was not obtained until September 1, 2024, which revealed that the resident weighed 111.4, losing an additional 0.6 pounds. Review of the clinical record revealed a dietary note dated September 15, 2024, which identified Resident 17's significant weight loss of August 28, 2024, with recommendations for health shakes twice a day for weight maintenance. There was no evidence that Resident 17's physician and/or responsible party was notified of the significant weight loss. Interview with the Nursing Home Administrator on November 21, 2024, at approximately 11:00 AM confirmed that the facility failed to timely identify Resident 17's significant weight loss and implement the facility's weight policy. Refer F693, F801, F838 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services. 395730 Page 6 of 17 395730 11/21/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, and staff interview it was determined that the facility failed to implement physician's orders and provide appropriate treatment and services to one resident out of 14 residents sampled (Resident 22). Findings include: Reviewed of Resident 22's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses which included dysphagia, (difficulty swallowing), surgical aftercare following surgery for a ruptured appendix, and malnutrition. Clinical record review revealed that Resident 22 had a PEG tube (Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate for feeding) which was placed during hospitalization. A physician order dated October 29, 2024, was noted for the resident to receive the tube feeding formula of Osmolite 1.5 Cal (liquid feeding administered via feeding tube) at 55 ccs per hour continuous for 24-hours daily with 200 ccs of sterile water every four hours for hydration, and a puree diet with thin liquids. A physician order dated October 30, 2024, was noted for Resident 22 to receive dysphagia therapy 3 to 5 times a week for 4 weeks to increase toleration to mechanical soft diet. A review of documentation dated November 2, 2024, revealed that Resident 22 continued to receive Osmolite 1.5 Cal at 55mL an hour continuously with 200mL sterile water flush every 4 hours for hydration, a regular diet, puree consistency with thin liquids, and that the resident's appetite remained poor. A review of physician documentation dated November 5, 2024, revealed that Resident 22's spouse inquired about gradually decreasing the tube feeding. According to the documentation, the physician stated, we have to see the patient make some gains with nutrition before we talk about decreasing tube feeding. A review of the resident's clinical record failed to provide evidence that dysphagia therapy intended to advance the resident's diet was provided. Interview with the Nursing Home Administrator on November 20, 2024, at approximately 10:45 a.m., confirmed that there was no evidence the facility provided treatment and services to restore oral eating skills for a resident receiving a tube feeding. Refer F825, F692 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. 395730 Page 7 of 17 395730 11/21/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and a review of personnel files and employee credentials, it was determined the facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian and failed to ensure frequently scheduled consultations from a qualified dietitian or other clinically qualified nutritional professional. Findings include: According to current federal regulatory guidance the facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. In the absence of a full-time qualified dietitian the director of food and nutrition services the facility must designate a person to serve as the director of food and nutrition services. (i) The director of food and nutrition services must at a minimum meet one of the following qualifications(A) A certified dietary manager; or (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a national certifying body; or D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or (E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and must receive frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. During initial tour of the food and nutrition services department on November 19, 2024, at 8:45 AM the food service director (FSD) stated that he has been the food service director since March 8, 2024. The FSD stated that he is currently enrolled in a class to become a certified dietary manager. The FSD stated that the facility has a part-time registered dietitian who works remotely but does not provide any in person oversight to the operation of the department. The FSD noted that there is a regional certified dietary manager who provides some oversight support for the department. Review of the Facility assessment dated [DATE], indicates the facility will have two dietitians or other qualified nutrition professional to serve as the director of food and nutrition services. 395730 Page 8 of 17 395730 11/21/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0801 Level of Harm - Minimal harm or potential for actual harm Review of documentation provided by the facility revealed the facility's onsite registered dietitian's last day of employment was on January 5, 2024. Review of documentation provided by the facility revealed the previous full-time qualified director of food and nutrition service's last day of employment was on March 8, 2024. Residents Affected - Many Interview with the nursing home administrator (NHA) on November 20, 2024, at 9:30 AM confirmed the current part-time registered dietitian who also works for sister facilities works remotely and does not provide in person oversight or consultation to the food and nutrition services department. The NHA confirmed the facility has not had an onsite registered dietitian since January 5, 2024. The NHA confirmed the facility has been without a full-time qualified food and nutrition services director in the absence of a full- time qualified dietitian since March 8, 2024. Refer F692, F804, F838 28 Pa Code 201.18(e)(1)(6) Management. 395730 Page 9 of 17 395730 11/21/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of select facility policy, test tray results, and resident and staff interviews, it was determined the facility failed to serve meals at safe and palatable temperatures. Residents Affected - Some Findings include: According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. A review of the facility Food Temperature Recording Policy last reviewed February 2024 indicated that food temperatures will be taken and recorded by the dining services staff prior to the start of each meal service to ensure that food items are at proper temperatures. All hot foods will be served and held at or above 135 degrees Fahrenheit and all cold foods will be held and served at or below 41 degrees Fahrenheit. During a group interview with seven alert and oriented residents on November 20, 2024, at 10:00 AM, all seven residents in attendance (Residents 25, 12, 5, 6, 18, 1, and 8) stated the food temperatures are frequently cold. Resident 6 stated I don't expect it to be hot, but it would be nice to get it at least warm. A test tray performed on the Nursing Unit on November 20, 2024, revealed the test tray arrived on the Nursing Unit at 12:15 PM. The hot meal was Swedish meatballs, mashed potatoes, mixed vegetables, and coffee. At 12:30 PM, at the time the last resident was served, the test tray was completed and yielded the following results: Swedish meatballs 115 degrees Fahrenheit, mashed potatoes were 115 degrees Fahrenheit, mixed vegetables were at 105 degrees Fahrenheit, and coffee was 107 degrees. The hot food tasted cold and was not palatable at the temperatures served. Interview with the nursing home administrator (NHA) on January 10, 2024, at 1:15 PM, confirmed that food was to be served at safe and palatable temperatures. Refer F801 395730 Page 10 of 17 395730 11/21/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, review of facility scheduled mealtimes, select facility policy, and resident and staff interview the facility failed to ensure the provision of a nourishing (satisfying to the resident) evening snack when greater than 14 hours elapsed from the supper meal to breakfast the next day for residents including eight residents of 17 sampled (Residents 4, 25, 12, 5, 6, 18, 1, and 8). Findings include: Review of the facility's policy titled Frequency of Meal last reviewed by the facility in February 2024, indicated it is the facility's policy to provide three meals daily with not more than a fourteen (14) hour span between a substantial evening meal and breakfast unless a nourishing bedtime snack is provided. Bedtime snacks are routinely offered to all residents per preference. Review of the facility's scheduled (not exact times may fluctuate plus or minus 15 minutes) mealtimes revealed 14.25 hours between the evening meal and the next day's breakfast meal. During an interview on November 19, 2024, at 11:20 AM Resident 4 stated that staff do not provide or offer a nighttime snack. She stated that her husband brings her food, so she has something to snack on. During a group interview with seven alert and oriented residents on November 20, 2024, at 10:00 AM, all seven residents in attendance (Residents 25, 12, 5, 6, 18, 1, and 8) stated that snacks are not routinely offered to them in the evenings. The residents stated they would like to receive an evening/bedtime snack. Resident 25 reported the snacks are in a tin at the nurse's station, and staff will provide a snack if you come to the nurse's station in the evening. Resident 6 reported that he would like to receive a bedtime snack however he does not come to the nurse's station in the evening and is not offered a snack when he is in bed. Resident 18 reported she would like to receive a bedtime snack however she does not self-propel her wheelchair and is unable to bring herself to the nurse's station for a bedtime snack. During an interview on November 21, 2024, at approximately 2:15 PM the Nursing Home Administrator was unable to explain why the residents were not routinely offered and provided with a bedtime/evening snack. 28 Pa. Code 211.12 (d)(3)(5) Nursing Services 395730 Page 11 of 17 395730 11/21/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, the facility's admission agreement, the facility's assessment, and resident and staff interview, it was determined the facility failed to provide specialized occupational therapy and speech therapy services according to the professional standards of practice for two out of three residents reviewed for rehabilitation services (Residents 180 and 22). Residents Affected - Some Findings include: Review of the facility's admission Agreement, Section 2 Services Provided by the Facility revealed the facility agrees to provide nursing and personal care services, subacute services and physician and ancillary services. Ancillary services are physician ordered services which include pharmacy services, physical therapy, audiology services, occupational therapy, speech therapy, podiatry services, psychiatric or psychological treatment, optometric services, laboratory services, x-ray services, special nurse or companion services, oxygen therapy, dental services, and transportation services. Review of the Facility's Assessment (process used to thoroughly assess the needs of facility resident population and required resources to provide care and needed services using evidence-based, data-driven methods), last reviewed by the facility on September 30, 2024, Section 2.1 stated the types of resident care provided at the facility include the following therapies: PT (physical therapy), OT (occupational therapy), ST (speech therapy), and Respiratory Therapy. Review of the clinical record revealed that Resident 180 was admitted to the facility under Aetna Medicare PDPM (patient-driven payment model. The PDPM Medicare model was created to reduce administrative burdens for health providers by focusing on each patient's unique needs) insurance coverage on November 14, 2024, with diagnoses to include absence of the right leg below the knee (amputation), history of falling, and altered mental status. Further record review revealed the resident previously underwent a left leg below the knee amputation approximately 4 years ago. Review of Resident 180's care plan dated November 14, 2024, indicated the resident had self-care performance deficits due to impaired mobility with bilateral (both) below the knee amputations, diabetes, peripheral vascular disease, and pain. Interventions included physical and occupational therapy evaluation as ordered, provide 2 staff assistance with transfers from the bed to the wheelchair and to transfer to and from the commode using a mechanical full body lift, provide total assistance for toilet use, provide total staff assistance for bathing, provide one staff member assistance with dressing and one staff assistance for personal hygiene/oral care. Review of the physician progress note/history and physical dated November 19, 2024, revealed the assessment and plan for Resident 180 included surgical aftercare for the right below the knee amputation, wound care, supportive care by staff, fall risk, PT (physical therapy), OT (occupational therapy) and strengthening. Review of a physician order dated November 15, 2024, revealed an order for PT evaluation and treatment 3-5 times per week for therapeutic exercises, therapeutic activities, and wheelchair management training. During an interview with Resident 180 on November 19, 2024, at 10:50 AM the resident, with a BIMS score of 10 (BIMS -Brief Interview for Mental Status- a tool to assess cognitive status. A score between 8 to 12 suggests moderate cognitive impairment), reported he had not been out of bed since he 395730 Page 12 of 17 395730 11/21/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some arrived at the facility on November 14, 2024, five days ago and he had not left the room since he was admitted to the facility. He indicated that he had not been out of bed to attend activities, to dine in the dining room, or attend therapy in the therapy room. When asked about receiving therapy the resident replied therapy, what therapy? I barely see those people. Interview with Employee 1 (physical therapist) on November 19, 2024, at 12:40 PM verified that Resident 180 was receiving physical therapy services. However, upon further inquiry, Employee 1 revealed that Resident 180 had not received occupational therapy services since admission to the facility on November 14, 2024, as the facility did not currently have an occupational therapist on staff. Employee 1 also revealed the facility did not currently have a speech therapist on staff. Interview with the Nursing Home Administrator (NHA) on November 19, 2024, at 2:35 PM confirmed the facility currently does not have a Director of Rehabilitation, Speech Therapist, or Occupational Therapist. The NHA revealed the last day the facility had a speech therapist was November 1, 2024, and the last day of having an occupational therapist, who was also the Director of Rehab, was November 6, 2024. Review of the clinical record revealed that Resident 22 was admitted to the facility under Medicare A insurance coverage on October 29, 2024, with diagnoses to include surgical aftercare following surgery of the digestive system, peritonitis (inflammation of the lining of the abdominal call and covering of the abdominal organs) after a ruptured abscessed appendix, mild protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of protein and nutrients needed for health), and dysphagia (a condition with difficulty in swallowing liquid or food). Review of Resident 22's care plan dated October 30, 2024, indicated the resident was at risk for functional decline in ADLs (activities of daily living) related to immobility, abdominal surgery, g-tube (an endoscopic medical procedure in which a tube, gastrostomy tube, is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding/fluid when oral intake is not adequate), hypertension, weakness, history of deep vein thrombosis (blood clot), depression, and anxiety. Interventions included evaluate the resident for pain, medications as ordered, OT/PT screens as needed, out of bed to wheelchair with pressure relieving cushion with leg rests, and transfer with assistance of two staff using a mechanical lift. Review of the physician progress note/history and physical dated November 5, 2024, revealed the assessment and plan for Resident 22 included (but not limited to): 1. a very ill patient recovering from peritonitis after a ruptured abscessed appendix, nutrition is poor being supplemented by tube feeding, pain control is an issue. 2. status post C. difficile enterocolitis (bacterium that causes an infection in the colon) - no reports of continued diarrhea but malnutrition and strength are continued issues. 3. concern for skin breakdown and immobility. Wound precautions, PT/OT and good nursing care, air mattress in place. Review of a physician order dated October 29, 2024, revealed an order for PT evaluation and treatment 3-5 times per week for 30 days for therapeutic exercises therapeutic activities, neuromuscular re-education, gait training and manual therapy. Review of a physician order dated October 30, 2024, revealed an order for dysphagia evaluation, and 395730 Page 13 of 17 395730 11/21/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0825 therapy 3-5 times per week for 4 weeks to increase toleration to a mechanical soft diet. Level of Harm - Minimal harm or potential for actual harm Review of a physician order dated October 30, 2024, revealed an order for OT evaluation and treatment 8-15 times in 30 days to provide therapeutic exercises, therapeutic activities, manual therapy, wheelchair management and self-care to increase safety and independence with functional tasks. Residents Affected - Some Review of speech therapy documentation revealed a speech therapy evaluation was conducted on October 30, 2024, with goals established for a 4-week duration of services. The note indicated Resident 22 was provided with 15 minutes of speech therapy treatment for dysphagia therapy. At the time of the survey ending November 21, 2024, there were no additional speech therapy notes. The facility was unable to provide documented evidence that continued speech therapy services were provide to Resident 22 as prescribed. Review of occupational therapy documentation revealed an occupational therapy evaluation was conducted on October 30, 2024, with goals established for a 30-day duration of services. Continued review of occupational therapy documentation revealed one (1) daily treatment note dated October 31, 2024, indicating that Resident 22 was provided with occupational therapy treatment consisting of therapeutic activities and therapeutic exercises. At the time of the survey ending November 21, 2024, there were no additional occupational therapy notes. The facility was unable to provide documented evidence that continued occupational therapy services were provide to Resident 22 as prescribed. During an interview with the NHA on November 20, 2024, at 9:00 AM it was confirmed that facility failed to adhere to the facility's admission agreement and facility's assessment and failed to provide specialized occupational and speech therapy services to Resident 180 and Resident 22. Refer F 838 28 Pa. Code: 201.18 (a)(1)(e)(1)(4)(6) Management 28 Pa. Code: 211.12(d)(3)(5) Nursing Services 395730 Page 14 of 17 395730 11/21/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on a review of professional literature, the facility's assessment, facility documentation, a review of the medical, nutritional, and rehabilitative needs of the resident census, and staff interview it was determined the facility failed to conduct and document a facility-wide assessment, using evidence-based methods, which identified and accurately reflected the specific resources necessary and available to care for its specific resident population. Findings include: Review of the Centers for Medicare and Medicaid Services Memorandum, Revised Guidance for Long-Term Care Facility Assessment Requirements (QSO-24-13-NH) dated June 18, 2024, revealed the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions), and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. Further review revealed the assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess in order to deliver the necessary care required by the residents being served. Review of the Facility Assessment, last reviewed by the facility on September 30, 2024, indicated that the average daily census of the facility is 25-30 residents. The facility's admissions range from 1-2 per week with discharges ranging from 1-2 per week. The facility practices an admission process that revolves around an 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 a current resident develops a new condition, an immediate interdisciplinary review is conducted, and educational needs are provided. Further review of the Facility Assessment revealed types of resident care provided at the facility are to include Physical Therapy, Occupational Therapy, Speech Therapy, and Respiratory Therapy, and Nutrition services for liberal diets, specialized diets, IV nutrition, tube feeding, cultural dietary needs, assistive devices, and fluid monitoring. The facility assessment stated the facility employs a variety of department heads such as Director of Rehabilitation, Dietitian, and Food Service Director. Additional support staff titles include Physical Therapist, Physical Therapy Assistant, Occupational Therapist, Occupational Therapy Assistant, and Speech Therapist. Review of the facility's Resident Matrix (list of all residents in the facility), dated November 19, 2024, revealed a total census of 26 residents. Of the 26 residents, the Matrix identified one resident (Resident 22) receiving enteral feeding who would require services of a dietitian. Further review of the facility Resident Matrix revealed that at time of survey ending on November 21, 2024, two new residents were admitted to the facility in the last 30 days who would require services by the rehabilitation department. 395730 Page 15 of 17 395730 11/21/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During initial tour of the food and nutrition services department on November 19, 2024, at 8:45 AM, the food service director (FSD) stated that he has been the food service director since March 8, 2024. The FSD stated that he is currently enrolled in a class to become a certified dietary manager. The FSD stated that the facility has a part-time registered dietitian who works remotely but does not provide any oversight to the operation of the department. The FSD noted that there is a regional certified dietary manager who provides some oversight support for the department. An interview with the Nursing Home Administrator (NHA) on November 19, 2024, at 2:35 PM, revealed that the facility currently does not have a Director of Rehabilitation, Speech Therapist, Occupational Therapist, or Occupational Therapy Assistant onsite. The NHA revealed that the facility has been without a speech therapist since November 2, 2024, and without an occupational therapist, who was also the Director of Rehabilitation since November 7, 2024. An interview with the NHA on November 20, 2024, at 9:30 AM, revealed since January 5, 2024, the facility has not had an onsite registered dietitian. The NHA confirmed the current part-time registered dietitian who also works for sister facilities works remotely and completes nutritional assessments and nutritional progress notes offsite, without face-to-face interaction with the residents. The Facility Assessment failed to accurately reflect the current staff employed in the facility to ensure a sufficient and competent number of qualified staff are available to meet each resident's needs. An interview with the Nursing Home Administrator on November 21, 2024, at 9:30 AM, confirmed that the facility failed to provide rehabilitative services and nutrition services as outlined in the Facility Assessment. Refer F692, F801 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(3) Management 395730 Page 16 of 17 395730 11/21/2024 Kadima Rehabilitation & Nursing at Lakeside 245 Old Lake Road Dallas, PA 18612

F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on a review of select facility policy and staff interview, it was determined the facility did not have one or more individuals serving as the Infection Preventionist (IP) responsible for the facility's infection prevention plan that worked at least part time at the facility. Findings included: The Centers for Medicare and Medicaid Services regulation §483.80(b)(3) states the facility must designate one or more individuals as the infection preventionist who are responsible for the facility's Infection Prevention and Control Program. The IP (infection preventionist) must work at least part-time at the facility, physically work onsite in the facility, have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field, cannot be an off-site consultant or perform the IP work at a separate location. During an interview with the Nursing Home Administrator (NHA) on November 21, 2024, at 10:00 a.m., it was confirmed that there was currently no designated IP since the previous IP left on October 17, 2024. The NHA further confirmed that the facility did not currently have a qualified staff member credentialed as an infection Preventionist. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 395730 Page 17 of 17