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Deficiency Records for Kadima Rehabilitation and Nursing at Luzerne

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.

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?
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 2024-07-23 2024-08-18 Y
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Health 2024-07-23 2024-08-18 Y
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. Health 2024-02-29 2024-04-29 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2024-02-29 2024-04-29 N
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 2024-02-29 2024-04-29 N
Protect each resident from the wrongful use of the resident's belongings or money. Health 2024-02-29 2024-04-29 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2024-02-29 2024-04-29 N
Ensure each resident receives an accurate assessment. Health 2024-02-29 2024-04-29 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-02-29 2024-04-29 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-02-29 2024-04-29 N
Provide enough food/fluids to maintain a resident's health. Health 2024-02-29 2024-04-29 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-02-29 2024-04-29 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 2024-02-29 2024-04-29 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 2024-02-29 2024-04-29 N
Dispose of garbage and refuse properly. Health 2024-02-29 2024-04-29 N
Provide and implement an infection prevention and control program. Health 2024-02-29 2024-04-29 N
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2024-02-29 2024-04-29 N
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Health 2024-02-29 2024-04-29 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 2024-02-21 2024-03-01 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-02-21 2024-03-01 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-02-21 2024-03-01 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2024-02-21 2024-03-01 N
Have simulated fire drills held at unexpected times. Fire Safety 2024-02-21 2024-03-01 N
Meet requirements for the installation and maintenance of electrical systems. Fire Safety 2024-02-21 2024-03-01 N
Provide activities to meet all resident's needs. Health 2023-10-26 2023-12-28 Y
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2023-10-26 2023-12-28 Y
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2023-10-26 2023-12-28 Y
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 2023-09-07 Not Fixed Y

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