Deficiency Records for Kadima Rehabilitation and Nursing at Luzerne
Updated as of March 01, 2024
A list of the most recent deficiencies for Kadima Rehabilitation and Nursing at Luzerne. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-11 | 2023-05-29 | N |
| Meet other general requirements. | Fire Safety | 2023-04-11 | 2023-05-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-04-11 | 2023-05-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-11 | 2023-05-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-11 | 2023-05-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-11 | 2023-05-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-11 | 2023-05-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-11 | 2023-05-29 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-04-20 | 2023-05-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-20 | 2023-05-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-20 | 2023-05-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-04-20 | 2023-05-22 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-04-20 | 2023-05-22 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-04-20 | 2023-05-22 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-04-20 | 2023-05-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-20 | 2023-05-22 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-04-20 | 2023-05-22 | N |
| Provide or arrange emergency care by a doctor 24 hours a day. | Health | 2023-04-20 | 2023-05-22 | N |
| Provide or obtain dental services for each resident. | Health | 2023-04-20 | 2023-05-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-20 | 2023-05-22 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-04-20 | 2023-05-22 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-04-20 | 2023-05-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-20 | 2023-05-22 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-04-20 | 2023-05-22 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-31 | 2023-02-08 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-11-01 | 2022-12-05 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-11-01 | 2022-12-05 | Y |
| Ensure a qualified health professional conducts resident assessments. | Health | 2022-11-01 | 2022-12-05 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-11-01 | 2022-12-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-01 | 2022-12-05 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-11-01 | 2022-12-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-01 | 2022-12-05 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-07-06 | 2022-08-04 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-06 | 2022-08-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-06 | 2022-08-04 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-26 | 2022-07-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-26 | 2022-07-06 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-05-26 | 2022-07-06 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-05-26 | 2022-07-06 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-05-26 | 2022-07-06 | N |
| Provide or obtain dental services for each resident. | Health | 2022-05-26 | 2022-07-06 | N |
| 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. | Health | 2022-05-26 | 2022-07-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-26 | 2022-07-06 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-05-26 | 2022-07-06 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-05-11 | 2022-05-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-05-11 | 2022-05-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-11 | 2022-05-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-12-21 | 2022-03-09 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-12-21 | 2022-03-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-21 | 2022-02-09 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-09 | 2021-12-21 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-11-09 | 2021-12-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-09 | 2021-12-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-01 | 2021-10-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-01 | 2021-10-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-07-01 | 2021-09-16 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-07-01 | 2021-08-18 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-07-01 | 2021-08-18 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-01 | 2021-08-18 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2021-07-01 | 2021-08-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-01 | 2021-08-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-01 | 2021-08-18 | N |
| Post nurse staffing information every day. | Health | 2021-07-01 | 2021-08-18 | N |
| 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. | Health | 2021-07-01 | 2021-08-18 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-07-01 | 2021-08-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-01 | 2021-08-18 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-07-01 | 2021-08-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-01 | 2021-08-18 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-07-01 | 2021-08-18 | Y |
| Meet other general requirements. | Fire Safety | 2021-07-13 | 2021-08-12 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2021-07-13 | 2021-08-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-07-13 | 2021-08-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-13 | 2021-08-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-13 | 2021-08-12 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-07-13 | 2021-08-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-07 | Not Fixed | Y |
