Kadima Rehabilitation & Nursing at Washington

In the surveyor’s words

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

• Actual harm, isolatedF600Aug 23, 2023

  Based on review of facility policy, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from neglect for three of six residents (Resident R1, R2 and R3), that resulted in actual harm for Resident R1 of facial abrasions and a subarachnoid hemorrhage. Findings include: Review of the United States Code of Federal Regulations (CFR), 42 CFR S483.12. Freedom from Abuse, Neglect, and Exploitation defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. […]

• Actual harm, isolatedF689Aug 23, 2023

  Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision for the bed mobility needs for one of six residents (Resident R1), which resulted in actual harm of facial abrasions and a subarachnoid hemorrhage for Resident R1. Findings include: Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual effective October 2019, indicated that bed mobility is defined as how resident moves to and from lying position, turns side or side, and positions body while in bed or alternate sleep furniture. […]

• No harm, potential for more than minimal, widespreadF838Jan 30, 2026

  Based on review of the facility's facility assessment, staff interview, professional standards, and facility documentation, it was determined the facility failed to conduct and document a comprehensive, evidence-based facility assessment to ensure licensed nursing staff possessed the required training and competencies necessary to provide care and services for residents and Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care as required. […]

• No harm, potential for more than minimal, widespreadF880Jan 30, 2026

  Based on review of facility policy, documentation, staff interview and review of Centers for Disease Control (CDC) guidelines for Legionella (bacteria that causes disease found in contaminated water) control, and staff interviews it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for twelve of twelve months (January 2025 through January 2026). Findings include:Review of the facility policy Legionella Policy dated 1/7/26, with a previous review date of 1/9/25, indicated specific actions should be taken for prevention of Legionella and for investigation should a case occur. […]

• No harm, potential for more than minimal, widespreadF945Jan 30, 2026

  Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Infection Control for ten of ten staff members (Employee E9, E10, E11, E12, E13, E14, E15, E16, E17 and E18).Findings include:Review of the Facility Assessment most recently reviewed 1/7/26, listed under the training topics Infection Control Training is identified.Review of the facility policy Staff Development Program last reviewed on 1/7/26, with a previous review date of 1/9/25, identified Infection Prevention and Control as a topic for orientation and annual trainings required.Physical Therapy Aide Employee E9 had a hire date of 9/15/16, failed to have Infection Control training in-service between 1/17/25, and… […]