Kadima Rehabilitation & Nursing at Lakeside

In the surveyor’s words

From the most serious findings on record at Kadima Rehabilitation & Nursing at Lakeside, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 26, 2023

  Based on review of clinical records and select resident incident/accident reports, and staff interview, it was determined that the facility failed to provide supervision and assistance with ambulation and implement planned measures to deter falls and prevent serious injury, a fractured hip, for one resident (Resident 1) out of four sampled and failed to maintain an environment free of potential accident hazards on one of one nursing units. Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (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) and difficulty… […]

• Actual harm, isolatedF689Jun 15, 2021

  Based on a review of clinical records and select incident reports and staff interview, it was determined that the facility failed to provide effective individualized fall prevention measures to address a resident's known risk factors for falls to prevent an avoidable fall and serious injury, a neck fracture, for one out of 8 sampled residents (Resident CR 1). Findings include: A review of Resident CR 1's clinical record revealed that the resident was readmitted to the facility May 31, 2019, with diagnoses to include muscle weakness, lack of coordination, [CONDITION(S)] (chronic [CONDITION(S)] lung disease that causes obstructed airflow), and abnormalities of gait and mobility. […]

• No harm, potential for more than minimal, widespreadF812Sep 4, 2025

  Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth , which increased the risk of food-borne illness in the food and nutrition services department. Findings include: Food safety and inspection standards for safe food handling indicate that everything that encounters food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. […]

• No harm, potential for more than minimal, widespreadF801Nov 21, 2024

  Based on staff interview and a review of personnel files and employee credentials, it was determined the facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian and failed to ensure frequently scheduled consultations from a qualified dietitian or other clinically qualified nutritional professional. Findings include: According to current federal regulatory guidance the facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. […]

• No harm, potential for more than minimal, widespreadF838Nov 21, 2024

  Based on a review of professional literature, the facility's assessment, facility documentation, a review of the medical, nutritional, and rehabilitative needs of the resident census, and staff interview it was determined the facility failed to conduct and document a facility-wide assessment, using evidence-based methods, which identified and accurately reflected the specific resources necessary and available to care for its specific resident population. Findings include: Review of the Centers for Medicare and Medicaid Services Memorandum, Revised Guidance for Long-Term Care Facility Assessment Requirements (QSO-24-13-NH) dated June 18, 2024, revealed the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population,… […]