Kadima Rehabilitation & Nursing at Luzerne

In the surveyor’s words

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

• Immediate jeopardy, widespreadF809Jun 11, 2025

  Based on a review of facility policies, observations, and staff and resident interviews, it was determined that the facility failed to provide meals in accordance with resident needs and preferences to ensure adequate nutrition and hydration and failed to consistently provide bedtime snacks as required for 3 of 36 residents. This deficient practice resulted in a lack of nutritionally adequate meals for 36 of 36 residents in the facility, created the potential for nutritional deficiencies, and placed all residents in Immediate Jeopardy to their health and safety. Findings include: A review of the facility's undated policy titled Frequency of Meals revealed that each resident shall receive three meals daily as well as snacks in between meals. […]

• Immediate jeopardy, widespreadF812Jun 11, 2025

  Based on a review of facility policies, manufacturer instructions for use, staff interviews, and observations, it was determined that the facility failed to follow safe and sanitary food handling practices during the washing, sanitizing, and preparation of cooking equipment, dishware, tableware, and utensils in the facility's kitchen. This failure resulted in the improper sanitization of food-contact surfaces, created an increased potential for foodborne illness, and placed 36 out of 36 residents in a condition of Immediate Jeopardy to their health and safety. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. […]

• Actual harm, isolatedF689Aug 13, 2026

  Based on clinical record review, facility policy review, facility provided investigative documentation, observation, and staff and resident interviews, it was determined the facility failed to maintain the resident environment as free of accident hazards as possible and failed to provide adequate supervision and appropriate equipment or other device for the safe transport of a hot liquid for one of 13 sampled residents (Resident 2) resulting in actual harm as evidenced by multiple first- and second-degree burns.Findings include:Resident 2 was admitted to the facility on [DATE], with diagnoses that included diabetes (a condition that causes elevated levels of sugar in the blood) and a recent above-the-knee amputation of the left leg. […]

• Actual harm, isolatedF686Feb 29, 2024

  Based on a review of clinical records, select facility policy, and investigation reports, and observation, and staff and resident interviews, it was determined that the facility failed to provide timely and consistent care, according to professional standards of practice, to prevent multiple facility acquired, unstageable pressure sores for one out of the 13 residents sampled (Resident 10). Findings include: A clinical record review revealed that Resident 10 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and schizophrenia (a chronic mental health disorder that involves problems with cognition, behavior, and… […]

• No harm, potential for more than minimal, widespreadF801Jun 11, 2025

  Based on staff interview and a review of employee credentials, it was determined the facility failed to ensure the registered dietitian (RD) provided the required on-site oversight of the food and nutrition services department. 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. […]