Kadima Rehabilitation & Nursing at Palmyra

In the surveyor’s words

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

• Immediate jeopardy, widespreadF802Jul 3, 2025

  Based on clinical record review and observation, it was determined that the facility failed to employ sufficient support personnel who were competent to carry out the functions of dietary services which included safe food preparation for all resident meals, proper sanitation of resident dishes and cookware, and proper preparation of a mechanically altered diet for one of 16 sampled residents. (Resident 17) This failure resulted in an Immediate Jeopardy situation for all residents. Findings include: Observation of the kitchen on July 1, 2025, at 10:51 a.m., revealed that the only two staff members working were a nurse aide (NA) 1 and activities aide (AA) 1. NA 1 and AA 1 were the only two staff members present in the kitchen. […]

• Immediate jeopardy, widespreadF812Jul 3, 2025

  Based on observation, review of facility documentation, and staff interview, it was determined that the facility failed to serve food under sanitary conditions in the kitchen. This failure resulted in an Immediate Jeopardy situation for all residents. Additionally, the facility failed to prepare and store food under sanitary conditions in the kitchen and dry storage areas. Findings include: Observation of the kitchen on July 1, 2025, at 10:51 a.m. revealed the following: The two staff members working were a nurse aide (NA) 1 and an activities aide (AA) 1. In an interview, NA 1 and AA 1 were the only two staff members present in the kitchen. They were preparing resident meals, meal trays, and washing resident dishes. […]

• Actual harm, isolatedF684Sep 1, 2021

  Based on clinical record review, review of facility incident report investigations, and staff interview, it was determined that the facility failed to ensure that one of 21 sampled residents received the appropriate care for removal of cerumen (ear wax) which resulted in actual harm to the resident. (Resident 21) Findings include: Clinical record review revealed that Resident 21 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident 21 had cognitive impairment (memory disorder), minimal difficulty with ability to hear, usually understood others, and required extensive assistance from staff with support from two people for personal hygiene. […]

• No harm, potential for more than minimal, widespreadF692Jul 3, 2025

  Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess the nutritional status of six of six sampled residents at nutritional risk. (Residents 2, 9, 15, 19, 20, and 28) Findings include: Review of the facility policy entitled, Resident Weights, last reviewed May 16, 2025, revealed that reweighs would be obtained within 72 hours for a weight change of three percent (%) or greater in one month. All weights, which included reweights, would be transcribed into the resident's electronic medical record. […]

• No harm, potential for more than minimal, widespreadF725Jul 3, 2025

  Based on group interview, and review of facility documentation, it was determined that the facility failed to provide sufficient nursing staff to meet resident needs. Findings include: During a group interview on July 2, 2025, at 10:23 a.m., seven of seven residents reported that staff typically did not respond to call bells for an extended period of time due to low staffing levels. Review of facility staffing documentation from June 11, 2025, through July 1, 2025, revealed that the facility failed to meet the minimum nurse aide to resident ratios on 17 of 21 days reviewed. Review of facility staffing documentation from June 11, 2025, through July 1, 2025, revealed that the facility failed to meet the minimum licensed practical nurse ratios on 18 of 21 days reviewed. […]