Inspection visit

InspectionDecember 2, 2022

KADIMA REHABILITATION & NURSING AT NORTH STRABANECMS #39607320 citations on this visit

20 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 20 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records reviews and staff interview, it was determined that the facility failed to sure residents maintain basic rights preserved in the Federal and State laws and regulations for five of seven residents (Residents R27, R43, R46, R47, and R49) by having residents sign an Assumption of the Risk and Waiver of Liability Relating to Coronavirus/Covid-19 (Covid-19 waiver). Findings Include: The facility form Assumption of the Risk and Waiver of Liability Relating to Coronavirus/Covid-19 states The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. NORTH STRABANE REHABILITATION AND WELLNESS CENTER (*the Facility*) has put in place preventative measures per state and federal guidelines to reduce or prevent the spread of COVID-19 in the Facility. Due to the nature of COVID-19, however, the Facility cannot guarantee that residents will not become infected with COVID-19. Indeed, admission to the Facility could increase a resident's risk of contracting COVID-19. By signing this agreement, I acknowledge and understand the contagious nature of COVID-19 and voluntarily assume the risk that I or my loved one that I am admitting to the Facility may be exposed to, or infected by, COVID-19. I acknowledge and understand that such exposure or infection may result in personal injury, illness, permanent disability, and death, and I voluntarily assume such risk. I understand that the risk of becoming exposed to or infected by COVID-19 at the Facility may result from the actions, omissions, or negligence of myself and others, including, but not limited to, other residents, Facility employees, contractors, volunteers, or others. I voluntarily agree to assume all of the foregoing risks and hereby accept sole responsibility for any injury to myself or loved one (including, but not limited to, personal injury. disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my loved one may experience or incur in connection with my or my loved one's admission to the Facility (Claims*). I hereby release, covenant not to sue, discharge, and hold harmless the Facility, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Facility, its employees. agents, and representatives, whether a COVID-19 infection occurs before, during, or after admission to the Facility. During an interview on 11/30/22, at 3:11 p.m. admission Director Employee E2 reported never seeing the form in the two months of his employment with the facility, and that it is not included in 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) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 29 Event ID: 396073 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0550 admission packet he had been using during his employment. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/30/22 at 3:29 p.m. the Corporate Compliance Nurse Employee E6 reported that she heard of a form a while back but had never seen one before. Upon inquiry, she confirmed that the form was very broad in limiting residents legal rights, and the form was attempting to absolve the facility of duties and obligations for which they were responsible for. Residents Affected - Some Review of the clinical records revealed Resident R27 was admitted to the facility on [DATE] and signed the Covid-19 waiver, undated by a personal representative. During a telephone interview on 12/1/22, at 2:38 p.m. Resident R27's personal representative reported that he may have signed the waiver, but really don't recall any of the paperwork. Resident R43 was admitted to the facility on [DATE] and signed the Covid-19 waiver form on 6/17/22. During an interview on 12/1/22 at 2:40 p.m. Resident R43 reported that she did not recall signing any waivers, but upon further discussion stated, I hope I didn't sign it. Upon asking if she had known what was involved would she have still signed it, she stated probably not. Review of the clinical records revealed Resident R46 was admitted to the facility on [DATE] and signed the Covid-19 waiver undated. Review of the clinical records revealed Resident R47 was admitted to the facility 5/9/22 and signed the Covid-19 waiver undated. Review of the clinical records revealed Resident R49 was admitted to the facility on [DATE] and signed the Covid-19 waiver dated 5/5/22. During the exit interview by telephone on 12/2/22, the Nursing Home Administrator and Director of Nursing reported that they were unaware the admissions representative was utilizing this form, that they did not feel the form had any legal merit, and agreed that it was an infringement on residents legal rights. 28 Pa Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.18 (b)(2) Management. 28 Pa. Code 201.18(e)(1) Mangement. 28 Pa. Code 201.24(b) admission policy. 28 Pa. Code 201.24(d) admission policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 2 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 facility policy, resident interview, resident observation, and staff interview, it was determined the facility failed to assess the clinical appropriateness of medication self-administration for two of 14 residents (Resident R1 and R259). Residents Affected - Few Findings include: Review of facility policy Medication Administration last reviewed 9/8/22, indicated residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration for medications. Review of the medical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included diabetes, and high blood pressure. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 11/14/22, indicated the diagnoses remain current. Review of Resident R1's physician orders dated 11/28/22, included medications of aspirin (fever/pain reducer), Eliquis (apixaban - a blood thinner/anticoagulant), ferrous sulfate (iron supplement), Lasix (furosemide - a diuretic for fluid retention), Jardiance (empagliflozin - used to lower blood sugar along with diet and exercise), Keppra (levetiracetam - used to treat seizures), and metformin (used to treat diabetes). Review of Resident R1 ' s November 2022, Medication Administration Record (MAR) indicated the medications were still active and marked as given. During an interview and observation on 11/28/22, at 10:25 a.m. Resident R1 was in the bathroom, the medication cup was observed sitting on the bedside table beside the bed with seven pills inside. Resident R1 ' s room mate was in the room sitting on her bed, and stated, Those are my mom ' s pills, I watch out for them when they leave them in the room like this. It happens a lot. Review of the clinical record failed to reveal an assessment done for self-administration of medications. Review of the physician's orders failed to include an order for self-administration. During an interview on 11/28/22, at 10:27 a.m. Licensed Practical Nurse Employee E1 confirmed the medications were left at the bedside. During an interview on 11/28/22, at 10:30 a.m. Registered Nurse Employee E2 stated she left the medications on the bedside table because: She was in the bathroom, and I was waiting for her to come out to take them. Review of the clinical record indicated Resident R259 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, and depression. Review of Resident R259's physician orders dated 11/25/22, included medications of Bupropion (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 3 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (anti-anxiety), docusate sulfate (stool softener), ferrous sulfate (iron supplement), metoprolol (high blood pressure, chest pain, and heart failure), multi-vitamin (supplement), prednisone (an anti-inflammatory and immunosuppressant), probiotic (digestive aid supplement), Venlafaxine (anti-depressant), vitamin C (supplement), and vitamin D3 (supplement), Review of Resident R259 ' s November 2022, MAR indicated the medications were still active and marked as given. Review of the clinical record failed to reveal an assessment done for self-administration of medications. Review of the physician's orders failed to include an order for self-administration. During an observation and interview on 11/28/22, at 10:29 a.m. Resident R259 was sitting in bed with her bedside table in front of her, with a medication cup containing multiple pills inside and an opened container of applesauce. Resident R259 stated I can take them myself, I like to take my time. During an interview on 11/28/22, at 10:35 a.m. Registered Nurse (RN) Employee E2 stated she left Resident R259's medications in her room because she likes to take her medicine with applesauce. During an interview on 11/28/22, at 2:20 p.m. the Director of Nursing confirmed that the facility failed to assess the clinical appropriateness of medication self-administration for Residents R1, and R259. 28 Pa. Code: 211.9(d) Pharmacy Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 4 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 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 review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide the opportunity 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) for six of eight residents reviewed (Resident R1, R26, R47, R52, R54, and R259). Findings include: A review of the facility policy Advanced Directive last reviewed 7/22/21 and 9/8/22, indicated that information will be provided upon admission of the policies and procedures, or at such time as may be appropriate. A review of the medical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included diabetes, and high blood pressure. A review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 11/14/22, indicated the diagnoses remain current. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R1 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R26 was admitted to the facility on [DATE], with diagnoses that included diabetes, and depression. A review of the MDS dated [DATE], indicated the diagnoses remain current. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R26 was given the opportunity to formulate an Advanced Directive. A review of the medical record indicated Resident R47 was admitted to the facility on [DATE], with diagnoses that included Covid-19, and hypertension (high blood pressure). A review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 10/6/22, indicated the diagnoses remain current. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R47 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R52 was admitted to the facility on [DATE], with diagnoses that included depression, and difficulty swallowing and speaking. A review of the MDS dated [DATE], indicated the diagnoses remain current. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R52 was given the opportunity to formulate an Advanced Directive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 5 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the clinical record indicated Resident R54 was admitted to the facility on [DATE], with diagnoses that included depression, anxiety, and high blood pressure. A review of the MDS dated [DATE], indicated the diagnoses remain current. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R54 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R259 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, and depression. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R259 was given the opportunity to formulate an Advanced Directive. During an interview on 11/30/22, at 10:00 a.m. Social Services Employee E3 confirmed that the clinical record did not include documentation that Resident R1, R26, R52, R54, and R259 were afforded the opportunity to formulate Advanced Directives. 28 Pa. Code: 201.29(b)(d)(j) Resident rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 6 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, incident reports, and staff interview, it was determined that the facility failed to make certain residents were free from neglect by not providing appropriate assistance and assistive devices for two of four residents (Resident R25 and R12). Findings include: The facility's Abuse Protection policy dated 9/8/22, and updated 7/22/21, indicated that neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety adequate, and appropriate services. A review of the clinical record revealed that Resident R12 was admitted to the facility on [DATE]. The Minimum Data Set (MDS - periodic assessment of care needs) dated 8/2/22, and 11/2/22, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), osteoarthritis (degeneration of the joint causing pain and stiffness), and age-related physical debility. A review of Resident R12's plan of care for potential for falls updated 10/14/22, indicated for staff to ensure that Resident R12 ' s wheelchair has right elevating leg rest on it. A review of the physician order dated 2/3/22, indicated that Resident R25 is required to be transferred with a sit to stand lift with two-person assistance. A review of a progress note dated 9/4/22, at 3:35 p.m. indicated Resident R25 received a skin tear 3 cm (centimeters) x1 cm on the upper top of her right-hand during morning care. Resident R25 complained of a burning pain to the injured area. A review of an incident report dated 9/4/22, at 6:50 a.m. indicated that Resident R25 sustained a skin tear to her right had during a transfer, edges not well approximated. The wound was cleansed, and steri strips (wound closure strips) applied. Staff educated on proper transfer techniques. The incident further documented that the sit to stand was not utilized as ordered. A review of the clinical record revealed that Resident R12 was admitted to the facility on [DATE]. The MDS dated [DATE], included diagnoses of spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness), osteoarthritis, and muscle weakness. Review of Section G: Activities of Daily Living (ADL) Assistance indicated Resident R12 required extensive assistance of two or more persons for transfers on both assessments. A review of Resident R12's plan of care for ADL self-care performance deficit, initiated 9/10/18, and revised on 8/12/22, revealed that Resident R12 was required to be transferred with a sit to stand lift with two-person assistance. A review of the physician order dated 9/30/22, indicated that Resident R12 is ordered a manual wheelchair with foam cushion and right elevating leg rest at all times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 7 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of a progress note dated 10/17/22, at 11:04 p.m. indicated Resident was being pushed by staff member and slid off front of w/c (wheelchair), she indicated that her shoe got stuck, complete assessment provided with negative findings noted, education provided with understanding expressed. A review of an incident report dated 10/17/22, at 8:25 p.m. indicated that Resident R12 was being pushed in wheelchair in the hallway to go outside to smoke by nurse in when she slid off the front of her wheelchair. The incident further indicated that the Resident was educated on the importance of keeping feet/legs in an extended position when being pushed by staff to prevent any further incidences and explained that further injuries could have occurred. During an interview on 11/30/22, at 1:30 p.m. the Interim Director of Nursing, the Nursing Home Administrator, and the Corporate Compliance Nurse Employee E6 confirmed that residents are never to be pushed without leg rests, and education should have been directed to staff to utilize leg rests, not to instruct an aged resident with musculoskeletal deficits to hold her legs up unsupported for an extended time. During an interview on 12/2/22, at 3:00 p.m. the Interim Director of Nursing and the Nursing Home Administrator confirmed that the facility failed to make certain residents were free from neglect by not providing appropriate assistance and assistive devices for two of four residents. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.29(a) Resident Rights 28 Pa. Code 201.29(c)(d) Resident Rights. 28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code 211.10(c) Resident Care Policies. 28 Pa. Code 211.10(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 28 Pa. Code 211.12(d)(3) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 8 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy and clinical records, and resident and staff interviews, it was determined that the facility failed to assess residents for appropriate use of an alarming device for one of three residents (Resident R49). Residents Affected - Few Findings include: The facility's policy entitled Resident Rights dated 9/8/22, previously dated 7/22/21, stated that residents have the right to be free from chemical and physical restraints. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 5/10/22, indicated that Resident R49 had diagnoses that included repeated falls, muscle weakness and thyroid disorder and had a Brief Interview of Mental Status (BIMS) score of 14, indicating little to no cognitive impairment. Review of the elopement risk assessment dated [DATE], identified poor decision-making skills, Resident is independently mobile, and Resident has the ability to leave the facility has risk factors prompting Resident R49 as at risk for elopement. Review of the physician orders dated 5/24/22, indicated a wanderguard (personal alert bracelet which alarms if a resident attempts to leave the facility) was ordered. Review of the clinical progress notes indicated that on 5/24/22, a wanderguard was placed to the left lower extremity. Review of the clinical progress note dated 8/8/22, indicated Resident R49 removed the ankle bracelet. Review of the MDS dated [DATE], indicates Resident R49 BIMS remained at 14. Review of the physician orders indicated the wander guard was discontinued on 09/04/22. Review of the clinical progress note dated 9/4/22, states wanderguard discontinued due to resident being of sound mind and not an elopement risk at this time. Review of the clinical progress notes from 5/4/22, to 9/4/22, failed to identify any clinical documentation of Resident R49 attempting to leave, or verbalizing any wishes to leave the facility. During an interview on 12/1/22, at 3:11 p.m. Resident R49 stated that she was unaware why the facility placed the wanderguard on her, they told me it was for my protection, and she removed it several times because the doors would lock when the ambulances would attempt to transfer her to the hospital for treatment. During an interview on 12/2/22, at 3:00 p.m. the Director of Nursing confirmed the facility placed the wanderguard restraint on Resident R49 without a valid rationale for doing so. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 9 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0604 28 Pa. Code 211.8(d)(e)(f) Use of restraints. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(5) Nursing services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 10 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 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 review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate injuries of unknown origin for three of six residents (Residents R310, R9, R25). Residents Affected - Some Findings include: A review of the facility's policy Abuse Protection dated 9/8/22, previously dated 7/22/21, stated the facility will complete timely and thorough investigations of all reports and allegations of abuse to include injuries of unknown origin. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed that Resident R310 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 11/14/21, included diagnoses of dementia and history of a stroke. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R310's score to be 05, severely impaired. Review of a progress note dated 11/23/21, at 5:23 p.m. indicated NA was doing care on resident and called me into the room to look at her left foot. I noted a bruised area to the top of resident's left foot measuring 5.3 cm x 6.8 cm. Resident was unable to give a description of how it happened. Resident verbally denied pain and no signs or symptoms pain were noted. Review of the facility provided incident report dated 11/23/21, reiterated the progress note. Review of the clinical record revealed that Resident R9 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], and 11/23/22, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R9's score to be 6, severe impairment for both assessments. Review of a progress note dated 2/1/22, at 4:00 p.m. indicated NA (Nurse Aide) came and got this nurse and stated that resident (R9) had a skin tear on left elbow. Resident unable to give description on how skin tear happened. This nurse assessed resident and cleaned skin tear. Review of the facility provided incident report dated 2/1/22, indicated the skin tear measured 1.5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 11 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0610 inches x 1 inch. Level of Harm - Minimal harm or potential for actual harm Review of a progress note dated 7/13/22, at 9:58 a.m. indicated This nurse was called to resident's room (R9) to assess LFA. A large purple bruise with a raised knot like area. Expresses pain when touched. This nurse notified RN to assess. Residents Affected - Some Review of the facility provided incident report dated 7/13/22, indicated the skin tear measured 14 cm (centimeters) x 6 cm, with a small hematoma (pooling of blood) that measured 3 cm x 3 cm. Review of the clinical record revealed that Resident R25 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diagnoses of traumatic brain injury (a disruption in the normal function of the brain)and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R25's score to be 04, severely impaired. Review of a progress note dated 6/1/22, at 11:50 a.m. indicated Resident (R25) acquired new skin tear to left knee. When asked what occurred, resident stated that she was not aware of her having one. Resident is baseline alert to self and sometimes situation. The skin tear was c-shaped measuring 1.7 cm x 0.5 cm. Review of the facility provided incident report dated 6/1/22, indicated a skin tear was identified to Resident R9's left knee and bleeding was present. During an interview on 12/1/22, at 1:15 p.m. the Director of Nursing confirmed that the facility was unable to provide documentation that these of investigations into injuries of unknown origin for three of six residents. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.14 (c)(e) Responsibility of licensee. 28 Pa. Code: 201.18 (e)(1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 12 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, facility policy, and staff interview, it was determined that the facility failed to develop a baseline care plan that includes smoking and interventions needed to provide effective and person-centered care for one of 14 residents (Resident R54). Findings include: The facility policy Care Plans-Baseline dated 9/8/22, indicated the admitting nurse will complete the baseline care plan upon admission and includes any services and treatments to be administered by the facility. A review of the clinical record indicated Resident R54 was admitted to the facility on [DATE], with diagnoses that included depression, anxiety, and high blood pressure. A review of the MDS dated [DATE], indicated the diagnoses remain current and the resident is a current tobacco user. During a review of Resident R54 baseline care plan completed on 11/14/22, did not include a baseline care plan indicating interventions for smoking. During an interview on 11/29/22, at 9:20 a.m. the Director of Nursing confirmed that the baseline care plan for Resident R54 did not include her immediate care needs. 28 Pa. Code: 211.11 (a)(c) Resident care plan. 28 Pa. Code: 211.11 (d) Resident care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 13 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to assess a resident for signs and symptoms of hypoglycemia and notify a physician of a change in condition for one of six residents with high glucose (blood sugar) levels (Resident R10),. Residents Affected - Few Findings include: Review of the facility Nursing care of the Diabetic Resident policy last reviewed 7/22/21 and 9/8/22, indicated the facility will recognize, assist, and document the treatment of complications commonly associated with diabetes. Additionally, it states to obtain physician orders for testing including parameters for intervention; and documentation should reflect the carefully assessed diabetic resident and include interventions to stabilize blood glucose levels and response to same, and notification to the physician and of significant variances from baseline per physician ' s order. A review of the clinical record revealed that Resident R10 was admitted to the facility on [DATE]. The Minimum Data Set (MDS-a periodic assessment of care needs) dated 8/17/22 included diagnoses of diabetes mellitus (a chronic condition that affects the way the body processes blood sugars), heart failure and hypertension. Review of Resident R10 physician orders dated 11/7/22, indicated that R10 was to receive Humalog Solution (insulin) as per sliding scale (blood sugar levels) three times daily with meals: 150-200=3 units 201-300=5 units 301-400= 7 units 401+=10 units >401 administer 10 units, notify the physician. Review of Resident R10's care plan revised 5/24/22, indicated to monitor blood sugars, notify the physician per orders, administer insulin as ordered and to report signs or symptoms of hyperglycemia. Review of Resident R10 ' s vitals summary for blood sugars found the following: 11/7/22 4:12 p.m.= 403 11/9/22 4:39 p.m.= 597 11/10/22 7:22 a.m.= 574 11/11/22 8:41a.m.= 502 11/11/22 11:12 a.m.= 531 11/11/22 4:25 p.m. = 440 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 14 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0684 11/12/22 8:06 a.m. = 447 Level of Harm - Minimal harm or potential for actual harm 11/13/22 4:36 p.m.= 464 11/13/22 8:19 p.m. = 442 Residents Affected - Few 11/15/22 8:46 a.m. = 546 11/15/22 4:36 p.m. = 415 11/16/22 11:28 a.m.= 438 11/17/22 8:14 p.m.= 483 11/18/22 4:16 p.m. = 515 11/19/22 11:21a.m. = 402 11/19/22 5:41p.m.= 415 11/21/22 8:40 a.m.= 417 11/21/22 12:45 p.m.= 547 11/21/22 4:13p.m. = 457 11/21/22 8:22 p.m.= 431 11/22/22 3:55 p.m.= 488 11/24/22 9:38 a.m.= 421 11/24/22 11:49 a.m. = 416 11/24/22 5:34 p.m.= 437 Review of Resident R10' s nurse progress notes from November 7-24, 2022 did not include a notification to the physician pertaining to high blood sugars for the dates/times noted above. During an interview on 12/1/22, at 10:53 a.m. Licensed Practical Nurse (LPN) Employee E5 stated that the physician was aware that Resident R10 ' s blood sugars were running high due to an infection, but she failed to follow the physician orders and contact the physician at those times. During an interview on 12/2/22 at 3:15 p.m. the Director of Nursing confirmed that the physician was aware that Resident R40's blood sugars were running high, but that staff failed to follow the order as written by notifying the physician, and that the facility failed to make certain that residents were provided appropriate treatment and services to maintain bowel function for two of four residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 15 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0684 28 Pa. Code 201.14(a) Responsibility of Licensee. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(1) 28 Pa. Code 201.29(a) Resident rights. Residents Affected - Few 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code:211.12(d)(1) Nursing services. 28 Pa Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 16 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to assess a resident for smoking safety for one of three residents (Resident R54). Findings include: A review of the facility Smoking Policy last reviewed 9/8/22, indicated that upon admission residents who smoke will be reviewed for safety with independence in smoking A review of the clinical record indicated Resident R54 was admitted to the facility on [DATE], with diagnoses that included depression, anxiety, and high blood pressure. A review of the MDS dated [DATE], indicated the diagnoses remain current and the resident is a current tobacco user. A review of the clinical record indicated an admission assessment was completed on 11/12/22, and indicated Resident R54 was a current smoker. A review of the clinical records failed to reveal a smoking assessment was completed for Resident R54. A review of the progress notes dated 11/20/22, revealed medical staff were aware of resident R54 going outside to smoke cigarettes. A review of the care plan revealed smoking interventions added on 11/17/21, that included to monitor for smoking. During an interview on 11/29/22, at 9:20 a.m. the Director of Nursing confirmed the facility failed to complete smoking safety assessments on admission, annually, and quarterly for Resident R54. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.11(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 17 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, clinical record review, and professional standards, the facility failed to ensure respiratory services were provided according to physician orders and professional standards for one of two residents reviewed (Resident R34). Residents Affected - Few [NAME] Respironics, manufacturer of respiratory devices recommends mechanical ventilator (A mechanical ventilator is a machine that helps a patient breathe when he or she cannot breathe on his or her own for any reason) equipment including tubing, masks and headgear should be cleaned weekly to prevent growth of bacteria and mold in equipment. A review of the clinical record revealed that R34 was admitted to the facility on [DATE]. The Minimum Data Set (MDS-a periodic assessment of care needs) dated 10/8/22 indicates Resident R34 was admitted to the facility on [DATE], with diagnoses that included shortness of breath while lying flat, cerebral infarction (stroke), epilepsy (neurological condition causing seizures), and Chronic Obstructive Pulmonary Disease (chronic lung disease). During an observation on 11/29/22, at 9:34 a.m. of the CPAP tubing and mask, were sitting inside a bag dated 11/14/22. Closer inspection of the mask revealed a film of debris stuck to the inside of the mask, and no dates on the tubing or mask to indicate when it had been last cleaned or changed. During an interview on 11/29/22, at 10:21 a.m. LPN Employee E2 confirmed the above findings. During a review of Resident R34's physician orders on 11/30/22, it was noted there were orders for wipe outside of CPAP with alcohol-based cloth-tubing and reservoir soak in 1 part vinegar and 3 parts hot water let soak for 30 mins and air-dry weekly, scheduled day shift Wednesdays. It was noted the order was documented as completed on 11/30/22. During an observation on 11/30/22, at 1:52 p.m. Resident R34's CPAP tubing was still noted to be sitting inside a bag dated 11/14/22, failed to identify a date indicating the equipment had been cleaned or changed, and a film of debris was still stuck to the inside of the mask. During an interview on 11/30/22, at 1:57 p.m. LPN Employee E5 confirmed the above findings. Upon questioning, LPN Employee E5 admitted she was unaware of the procedure to clean the equipment and had just signed off the order as completed without cleaning the equipment. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1) Nursing services. 28 Pa. Code: 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 18 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility document review and interviews with residents and staff, it was determined that the facility failed to maintain sufficient nursing staff levels to provide nursing care and services for one of eleven residents (Resident R45). Findings include: Review of facility assessment dated [DATE], indicated the facility will provide services by sufficient numbers of staff provide nursing care to all residents in accordance with resident care plans. Review of a progress note dated 11/28/22, at 1:32 a.m. indicated Resident R45 was having exit seeking behaviors and did make it outside through an fire exit door and was found squatting in the bushes. Progress notes also stated that once the resident Resident R45 was back in the facility, Resident R45 fell and hit her head needing a transfer to the hospital. During an interview on 11/30/22, at 1:05 p.m. Maintenance Director Employee E13 indicated that the door Resident R45 exited through does have a beeping audible alarm at five seconds, then a solid audible alarm when the door is open at 30 seconds. Maintenance Director Employee E13 demonstrated the function of the door lock and activation alarm types two times. Maintenance Director Employee E13 also demonstrated the force that is needed to break the seal and set the alarm off. During an interview on 11/30/22, at 2:31 p.m., Licensed Practical Nurse (LPN) Employee E14 reported that there was only two nurses on staff for the whole building that evening, giving Resident R45 the opportunity and the time to get to the door and break the seal for 30 seconds and making it outside and develop into an elopement situation. LPN Employee E14 indicated that if there was more staff in the facility at the time of Resident R45 incident, the incident would have possibly not happened. During an interview on 11/30/22, at 2:45 p.m., LPN Employee E15 reported that there was only herself and LPN Employee E14 in the building at the time of Resident R45 elopement situation. LPN Employee E15 stated that when it was happening she was up the hall and was trying to follow the Resident R45 but was to far away and had called for LPN Employee E14 to go to the main door to unlock it because if the Resident R45 and the LPN Employee R15 was outside and the door closes they would be locked outside. LPN Employee E15 also stated that when Resident R45 was outside and was trying to be redirected into the building both LPN Employee E14 and E15 were outside, leaving no staff in the building. Review of the staffing log for the night of 11/27/22 showed only LPN Employee E14 and E15 on duty until 4:00 a.m. Interview on 12/1/22 , at 11:00 a.m. the Nursing Home Administrator and the Director of Nursing confirmed that there was only two employees on duty at the time of the incident, and confirmed the facility failed to maintain sufficient nursing staff levels to provide nursing care and services for one of eleven residents (Resident R45). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 19 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record reviews, and staff interviews, it was determined the facility failed to make certain monthly Medication Regimen Reviews (MRR) were conducted for four of nine residents (Residents R8, R36, R40, and R46). Findings include: Review of facility policy titled Medication Regimen Review last reviewed by the facility on 7/22/21 and 9/8/22, indicated the consultant pharmacist will perform a comprehensive review of each resident's medication regimen at least monthly. A review of the clinical record revealed that Resident R8 was admitted to the facility on [DATE]. The Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/26/22 included diagnoses of lymphedema (swelling in the arm or leg due to a blockage in the lymphatic system), major depression disorder (a mental health disorder characterized by depressed mood or loss of interest in activities), osteoarthritis (a condition when flexible tissue at the end of the bones wears down), and anxiety. There was no documented evidence in Resident R8's clinical record that the required monthly medication reviews were completed by the pharmacist in 1/22, 2/22, 3/22, 4/22, 5/22, 6/22, 7/22, 8/22, 9/22, or 10/22. A review of the clinical record revealed that Resident R36 was admitted to the facility on [DATE]. The Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/28/22 included diagnoses of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), anxiety, depression, and schizophrenia (a mental disorder in which people interpret reality abnormally). There was no documented evidence in Resident 36's clinical record that the required monthly medication reviews were completed by the pharmacist in 12/21, 2/22, 3/22, 4/22, 5/22, 6/22, 7/22, 9/22, or 11/22. A review of the clinical record revealed that Resident R40 was admitted to the facility on [DATE]. The MDS dated [DATE] included diagnoses of high blood pressure, anxiety, depression, and schizophrenia. There was no documented evident in Resident 40/s clinical record that the required monthly medication reviews were completed by the pharmacist in 12/21, 2/22, 4/22, 5/22, 6/22, 7/22, 8/22, 9/22, 10/22, or 11/22. A review of the clinical record revealed that Resident R46 was admitted to the facility on [DATE]. The MDS dated [DATE] included diagnoses of coronary artery disease (condition where the major blood vessels supplying the heart are narrowed), dementia, depression, and malnutrition. There was no documented evidence in Resident 46's clinical record that the required monthly medication reviews were completed by the pharmacist since admission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 20 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0756 During an interview on 11/30/22, at 2:05 p.m. the Nursing Home Administrator confirmed the facility failed to make certain that monthly MRRs were conducted for Residents R36, R40 and R46. Level of Harm - Minimal harm or potential for actual harm 28 Pa. 211.9(k) Pharmacy services. Residents Affected - Some 28 Pa. 211.12(c)(d)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 21 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 - Some 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 review of facility policies, observations, and staff interviews, it was determined that the facility failed to date multi-dose over the counter (OTC) medication bottles in one of four medication carts (Avalon Hall Med Cart). Findings include: The facility policy Storage of Medication last reviewed 7/22/21 and 9/8/22, indicated medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. During an observation on 11/29/22, at 8:35 a.m. of the Avalon Hall medication cart revealed the following OTC medications were observed open without a date of opening: One bottle- Vitamin D 10 microgram (mcg) (vitamin supplement) Two bottles - Melatonin 3 milligrams (mg; sleep aid) One bottle - Melatonin 1 mg One bottle - Melatonin 5 mg Two bottles - Antacid tablets (stomach acid relief) Three bottles - Aspirin 81 mg (fever/pain reducer) One bottle - Magnesium oxide 400 mg (supplement) One bottle - Polyethylene Glycol 3350 (laxative) One bottle - Ibuprofen 200 mg (fever/pain reducer) One bottle - Optimum probiotic (supplement) One bottle - Florastor (supplement) One bottle - Aspirin 325 mg One bottle - Famotidine 20 mg (stomach acid reducer) Two bottles - Docusate sodium 200 mg (stool softener) One bottle - Calcium/Vitamin D3 600mg (supplement) One bottle - Diphenhydramine 25 mg (allergy relief) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 22 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 One bottle - Cranberry 425 mg (supplement) Level of Harm - Minimal harm or potential for actual harm One bottle - Folic acid 1 mg (supplement) One bottle - Thiamin/Vitamin B1 100 mg (supplement) Residents Affected - Some One bottle - Ocular vitamin (supplement) One bottle - Guaifenesin 400 mg (cough/mucus relief) One bottle - Mucus relief 600mg One bottle - Omeprazole 10 mg (stomach acid reducer) One bottle - Omeprazole 20 mg Two bottles - Multi-vitamin (supplement) One bottle - Loratadine 10 mg (allergy relief) One bottle - Senna 8.6 mg (stool softener) One bottle - Bisacodyl 5 mg (laxative) One bottle - Vitamin C 250 mg (supplement) One bottle - Vitamin B12 100 mg (supplement) One bottle - Vitamin B12 500 mg One bottle - Iron 325 mg (supplement) During an interview on 11/29/22, at 8:45 a.m. Licensed Practical Nurse Employee E1 confirmed the OTC medication bottles should have been dated when opened as required. During an observation on 11/29/22, at 8:55 a.m. of the 300's Hall medication cart revealed the following OTC medications were observed open without a date of opening: One bottle - Senna 8.6 mg One bottle - Famotidine 20 mg One bottle - Diphenhydramine 50 mg One bottle - Omeprazole 20 mg One bottle - Aspirin 81 mg x3 bottles One bottle - Ibuprofen 200 mg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 23 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 One bottle - Multivitamin Level of Harm - Minimal harm or potential for actual harm Two bottles - Folic acid 1000 mcg x2 Three bottles - Vitamin B12 x3 Residents Affected - Some One bottle - Vitamin C One bottle - Zinc 50 mg One bottle - Vitamin D25 mg One bottle - Calcium D3 600 mg During an interview on 11/29/22, at 9:15 a.m. Licensed Practical Nurse Employee E5 confirmed the OTC medication bottles should have been dated when opened as required. During an interview on 11/30/22, at 10:00 a.m., the Director of Nursing confirmed the OTC medications should have been dated when the bottle was opened. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 24 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on a review of the facility's infection control policies and procedures, documents, and staff interview, it was determined the facility failed to implement an antibiotic stewardship program for eleven of twelve months (January, February, March, April, May, June, July, August, September, October, and November 2022). Residents Affected - Some Findings include: Review of the facility policy entitled Antibiotic Stewardship Program dated 9/8/22, previously reviewed 7/22/21, indicated the facility Antibiotic Stewardship Program will track or delegate the tracking of antibiotic days, number of residents on prescribed antibiotics, prescribing practice as they relate to antibiotic usage, antibiotic usage in residents that did not meet the criteria for active infection, types of antibiotics prescribed, overall infection rages, and antibiotic resistant organisms within the facility. Review of the facility provided Infection Control Monthly Data Analysis documentation forms (form that tracks number of infection, , facility tracking maps, and infection ling-listings from January 2022, through November 2022, revealed the following: January 2022: Form was incomplete, map and line list were blank. February 2022: Form was incomplete, map and line list were blank. March 2022: Form was incomplete, no map, and the line list only contained resident's name and antibiotic name. April 2022: Form was incomplete and the line list only contained resident's name and antibiotic name. May 2022: Form was incomplete, map and line list were blank. June 2022: Form was incomplete, map and line list were blank. July 2022: Form was incomplete. August 2022: Form was incomplete. September 2022: Form was incomplete. October 2022: No information was provided. November 2022: No information was provided. During an interview on 12/1/22, at 1:15 p.m. the Director of Nursing confirmed that the facility failed to implement an Antibiotic Stewardship program for eleven of twelve months. 28 Pa. Code: 201.14(a) Responsibility of licensee. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 25 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0881 28 Pa. Code 201.18(b)(1) Management. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 26 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on review of facility documentation, clinical records, and staff interview it was determined that the facility failed to provide accurate and timely documentation related to the COVID-19 vaccine for 15 of 56 residents (Resident R4, R10, R13, R18, R24, R32, R38, R43, R45, R47, R48, R52, R53, R54, and R259). During an interview on 11/30/22, at 1:00 p.m. the Director of Nursing confirmed that all vaccination information for residents was maintained in the electronic medical record. Review of the electronic medical record for Residents R4, R10, R13, R18, R24, R32, R38, R43, R45, R47, R48, R52, R53, R54, and R259 failed to include documentation if the COVID-19 vaccine was provided, previously received, or refused. During an interview on 12/1/22, at 11:15 a.m. the Interim Director of Nursing confirmed that no further documentation of COVID-19 vaccine status was available for the above residents. During an interview on 12/1/22, at 11:15 a.m. Nursing Home Administrator confirmed that the facility failed to provide accurate and timely documentation related to the COVID-19 vaccine for 15 of 56 residents. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code: 211.12(d)(1) Nursing services. 28 Pa. Code: 211.12(d)(3) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 27 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Minimal harm or potential for actual harm Based on a review of observations, clinical records, facility employee vaccination data, and staff interviews, it was determined that the facility failed to implement policies and procedures to ensure that all staff were vaccinated for COVID-19 four six of 46 staff members (Therapy Employees E7, E8, E9, E10, E11, and E12). Residents Affected - Some Findings include: The Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality/Quality, Safety and Oversight Group memo (QSO-22-07-ALL) dated 12/28/21, revised 04/05/22, indicated the facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. Regardless of clinical responsibility or resident contact, the policies and procedures must apply to the following facility staff, who provide any care, treatment, or other services for the facility and/or its residents: facility employees, licensed practitioners, students, trainees, and volunteers, and individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement. Review of the facility, COVID 19 Vaccination Policy dated 9/8/22, previously reviewed 7/21/22, indicated this policy will comply with all applicable laws and is based on guidance from the CDC (Centers for Disease Control and Prevention) that all employees are required to receive vaccinations as determined by CMS (the Centers for Medicare and Medicaid Services) unless a reasonable medical or religious accommodation is approved, that the COVID-19 vaccination program applies to all employees, that the facility is responsible for maintaining an accurate record of COVID-19 vaccinations. Review of the facility provided documentation of staff and agency nursing staff COVID-19 vaccination statuses failed to include Therapy Employees E7, E8, E9, E10, E11, and E12. Additionally, medical providers, hospice providers, and other outside vendor staff were not included. During an interview on 12/1/22, at 1:15 p.m. the Interim Director of Nursing confirmed that the facility failed to implement policies and procedures to ensure that all staff were vaccinated for COVID-19. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.14(c) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a) Resident Rights. 28 Pa. Code: 211.12(d)(1) Nursing services. 28 Pa. Code: 211.12(d)(1) Nursing services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 28 of 29 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 396073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317 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 0888 28 Pa. Code: 211.12(d)(2) Nursing services. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 211.12(d)(5) Nursing services. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396073 If continuation sheet Page 29 of 29

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Citations

20 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.

0550GeneralS&S Epotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0554GeneralS&S Dpotential for harm
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
0578GeneralS&S Epotential for harm
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.
0610GeneralS&S Epotential for harm
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
0655GeneralS&S Dpotential for harm
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0689GeneralS&S Epotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0725GeneralS&S Dpotential for harm
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
0756GeneralS&S Epotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0761GeneralS&S Epotential for harm
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.
0887GeneralS&S Epotential for harm
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
0888GeneralS&S Epotential for harm
Ensure staff are vaccinated for COVID-19
0600GeneralS&S Dpotential for harm
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
0604GeneralS&S Dpotential for harm
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
0881GeneralS&S Epotential for harm
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
0912GeneralS&S Dpotential for harm
F912 - Measure at least 80 square feet per resident in multiple resident
Have power receptacles that are properly grounded.
0920GeneralS&S Epotential for harm
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.

FAQ · About this visit

Common questions about this visit

What happened during the December 2, 2022 survey of KADIMA REHABILITATION & NURSING AT NORTH STRABANE?

This was a inspection survey of KADIMA REHABILITATION & NURSING AT NORTH STRABANE on December 2, 2022. The surveyor cited 20 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at KADIMA REHABILITATION & NURSING AT NORTH STRABANE on December 2, 2022?

Yes, 20 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

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 June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·December 2, 2022