Kadima Rehabilitation & Nursing at Pottstown

In the surveyor’s words

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

• Immediate jeopardy, widespreadF600Nov 27, 2024

  Based on review of clinical records, facility documentation, observations, and interviews with staff, it was determined the facility failed to ensure residents were free from neglect by failing to provide sufficient nursing staff to ensure nursing care, safety, and related services for 39 residents on November 22, 2024, during the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts. The facility failed to provide necessary nursing services to 39 out of 39 residents due to the lack of appropriate nursing levels placing all 39 residents in the facility in an Immediate Jeopardy situation. […]

• Immediate jeopardy, widespreadF725Nov 27, 2024

  Based on clinical record review, review of facility documentation, observations, and staff interviews, it was determined the facility failed to maintain sufficient nursing staff to provide nursing care and related services to assure resident safety on one of one nursing units on November 22, 2024, during the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts. Residents did not receive care and services due to the lack of appropriate nursing levels placing all 39 residents in the facility in an Immediate Jeopardy situation. […]

• Immediate jeopardy, widespreadF584Nov 6, 2023

  Based on observations and staff and resident interviews it was determined that the facility failed to maintain a temperature range between 71 to 81 degrees Fahrenheit in random selection of rooms and common areas occupied by residents resulting in immediate jeopardy to the residents. Findings include: Interview conducted with Resident 4 on November 1, 2023, at 12:30 p.m. and Resident 11 on November 2, 2023, at 9:30 a.m. revealed the residents were cold. Observations of residents residing in the facility revealed residents had multiple layers of clothing, including blankets and hats. Observation of resident rooms revealed multiple blankets on residents' beds. Observation of facility staff revealed staff wearing long sleeves under working attire (scrubs). […]

• Immediate jeopardy, patternF689Feb 27, 2025

  Based on review of facility documentation, clinical records, and interviews with staff and residents it was determined the facility failed to ensure the transportation vehicle had a safety inspection from [DATE], until February 4, 2025, during which time the vehicle was used to transport seven residents on 11 separate occasions to medical appointments. Additionally, staff using the transport van had not been trained in safety procedures. This resulted in an Immediate Jeopardy which had the potential to cause residents discomfort or pain and to jeopardize the health and safety of residents. Findings include: Review of facility documentation revealed the facility's wheelchair accessible van had a state safety inspection completed on [DATE]. […]

• Actual harm, isolatedF689May 18, 2022

  Based on clinical record review, facility policy and staff interview it was determined that the facility failed to ensure that safety interventions were in place for Resident CL1 resulting in a fracture of the left rib, left femur, and three fractures in C1, 1 in the midline and 2 fractures in the posterior arch for one of two residents. Findings include: Review of facility policy titled Accidents and Incidents with a revision date of August 28, 2002 revealed under Guidelines Number 2 The occurrence of an incident will be recorded in the resident's clinical record. Further review of policy revealed Number 7 Staff will immediately notify family, attending physician, and other departments. […]