Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kadima Rehabilitation & Nursing At Irwin during CMS and state inspections, most recent first.
The facility failed to thoroughly investigate an allegation of sexual abuse when a resident reported that a CNA performed inappropriate and non-hygienic actions involving her hemorrhoid during incontinence care, leaving her feeling violated and assaulted. Although facility policy requires a comprehensive abuse investigation, the facility classified the allegation as unsubstantiated and did not interview the other residents cared for by the same CNA on that shift to determine whether there were additional victims or similar concerns. The Nursing Home Administrator later acknowledged that the investigation was incomplete and that resident statements about their care during that night were not obtained.
Food service failed to meet resident preferences and temperature expectations. Resident council minutes, grievances, and a resident group meeting showed complaints that meals were cold, late, not consistent with the posted menu, and lacked condiments or enough food. During tray line and test tray observations, dietary staff initially did not have sour cream available, the facility lacked enough bottom hot plate covers, and food temperatures were low, including meat at 80 degrees, beans at 90 degrees, and milk at 41 degrees. The NHA and DON confirmed the issues.
Delayed Meal Delivery and Missed Scheduled Meal Times Resident council minutes, grievances, and direct observations showed meals were repeatedly delivered late and not according to the posted tray schedule. Meal carts to the dining room and A/B wings arrived well after scheduled times, and the NHA confirmed the facility failed to provide at least three meals daily at regular times or in accordance with resident needs, preferences, and requests.
Kitchen equipment was not working properly and food service practices were observed during meal prep. The dish machine’s chemical level was below the indicated level, the stove did not heat properly and took too long to cook items, and the steam table had a drainage pipe touching the ground and placed within a drain to the sewage system. An aide was also observed handling food, removing gloves, wiping hands on clothing, and then continuing food prep.
Failure to respond to resident council concerns and grievances was identified after residents reported that the same issues were discussed at every meeting, including call bells, food and mealtimes, care, staff badges, and showers, and that they did not receive feedback. Review of council minutes showed multiple items of old business documented as ongoing or unresolved, and the NHA confirmed the facility failed to respond to ongoing resident group concerns.
The facility failed to document, resolve, and provide responses to residents and/or responsible parties for most grievances recorded in the grievance log. Review of the grievance policy showed residents have the right to voice grievances without discrimination or reprisal, and the log showed 16 of 18 grievances had no documented date that parties were informed of the findings or disposition. The NHA confirmed the missing documentation and responses.
The facility failed to provide enough nursing staff to meet resident needs, with residents reporting long call light response times, delays getting out of bed, and worse staffing on off shifts and weekends. Staff described frequent call offs and short staffing, especially on the 3-11 shift, and grievances and resident council minutes documented missed incontinence care, unanswered call bells, delayed assistance, and staff turning off call lights without returning.
Failure to maintain a clean, homelike environment was identified in one A wing shower room. Surveyors observed broken floor trim exposing broken drywall, with pieces of metal lifted and bent, and the Maintenance Director and NHA confirmed the condition of the room.
A resident with PTSD had no documented care plan goals or interventions for that diagnosis. The resident’s current care plan did not include person-centered instructions for PTSD, and the NHA confirmed the comprehensive care plan was incomplete for the resident’s care needs.
A resident with TIA, HTN, left-hand contracture, and left upper arm muscle wasting had an order for a resting hand splint while in bed, but surveyors repeatedly observed the splint was not applied. The resident's call bell was also found wrapped around a chair or on the floor near the bed during multiple observations, and the DON confirmed the facility failed to provide care and services as ordered.
Expired medications and biologicals were found stored in the A Wing medication room, including multiple boxes of influenza vaccine, Gvoke HypoPen, and 50% dextrose injection. Surveyors also found that no residents had received the expired influenza vaccine, and the NHA and DON confirmed the storage failure.
A resident who was sometimes understood was incorrectly marked as rarely/never understood in the MDS assessment, leading to the omission of required cognitive and mood interviews. Instead, a staff mood assessment was completed with an incorrect severity score, and the Nursing Home Administrator confirmed the MDS was not accurately or fully completed.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
A resident with multiple neurological and physical diagnoses was found outside the facility after being let out to the patio by staff. The medical record lacked follow-up documentation after the elopement, including care for scrapes, completion of an elopement risk assessment, and details about wander guard placement or subsequent wandering behaviors. The NHA confirmed these documentation deficiencies.
A resident with muscle weakness, debility, and dementia, who required assistance with bed mobility, was rolled away from a CNA during incontinence care, contrary to safe mobility guidelines and the care plan. This resulted in the resident rolling out of bed and experiencing an assisted fall, which was substantiated as neglect.
A resident with muscle weakness, debility, and dementia who required assistance with bed mobility experienced a fall when a CNA rolled the resident away from herself during incontinent care and sheet changing, contrary to safe bed mobility guidelines. The incident occurred because the aide did not follow the resident's care plan or established safety protocols, resulting in a substantiated finding of neglect.
A nurse aide was allowed to work without a current CNA certification after the facility failed to ensure timely renewal and verification of credentials. The lapse was discovered during an internal audit, and the administrator confirmed the deficiency. All other nurse aides were found to have current certifications.
The facility failed to monitor kitchen equipment temperatures, as required by their policies, potentially leading to food-borne illness. Temperature logs for refrigerators and freezers were missing on several days, and this was confirmed by the Nursing Home Administrator and Dietary Services Manager.
The facility failed to store insulin pens in a safe and sanitary manner, with six pens found unbagged in a medication cart, posing a risk of cross-contamination. This was confirmed by an LPN and the DON, highlighting a deviation from the facility's infection control policy.
Kadima Rehabilitation and Nursing at Irwin failed to provide required transfer notices to the Office of the Long-Term Care Ombudsman for four months. The facility's policy mandates timely notification to residents and their representatives, but this was not followed, as confirmed by the Nursing Home Administrator.
A facility failed to complete a significant change MDS assessment for a resident within 14 days after the resident was admitted to hospice care, as required by regulations. The resident, who had dementia, repeated falls, and anxiety, experienced a significant change in condition with the hospice admission. This deficiency was confirmed by an LPN Assessment Coordinator, highlighting a lapse in the facility's adherence to timely assessment protocols.
The facility failed to assess, document, and notify physicians of abnormal CBG levels for two residents, leading to a deficiency in care. Despite having policies in place, the facility did not follow protocols for managing diabetes-related complications. Both residents experienced abnormal CBG levels without proper assessment or physician notification, indicating a lapse in adherence to care plans and facility policies.
The facility failed to notify a doctor of a change in condition, document blood glucose interventions, and follow physician orders for two residents. Additionally, the facility did not maintain proper communication with a dialysis center for a resident with ESRD, as 34 out of 156 dialysis communication forms were incomplete. These deficiencies were confirmed by the DON.
The facility failed to store refrigerated medications properly, as observed in the B unit Short Hall medication cart, which contained 12 insulin pens and one insulin multi-dose vial not dated. An LPN was unsure why the insulin pens were not refrigerated, and the DON confirmed that medications should be dated and stored per policy.
The facility failed to meet the required nurse aide staffing levels, with shortages during day, evening, and night shifts over a 21-day period. The Nursing Home Administrator confirmed the facility's inability to provide the mandated minimum number of nurse aides, impacting care consistency.
The facility failed to meet the required LPN staffing levels on multiple occasions across different shifts. On several days, the actual LPN hours were below the required hours based on the resident census, leading to staffing shortages. The Nursing Home Administrator confirmed these findings, acknowledging the facility's failure to meet the staffing requirements on the specified days and shifts.
The facility did not provide the required 3.2 hours of direct resident care per resident in a 24-hour period on multiple occasions. The census ranged from 102 to 107 residents, with nursing hours per resident per day (PPD) falling short, reaching as low as 2.19. The deficiency was confirmed by the Nursing Home Administrator.
The facility did not maintain documentation for an annual fire alarm inspection, affecting the entire facility. This deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director, who acknowledged the lack of inspection documentation.
The facility failed to conduct the required annual preventive maintenance testing for its emergency generator over the past 12 months. Documentation review revealed the absence of records for this testing, and interviews with the Facility Administrator and Maintenance Director confirmed the deficiency.
The facility failed to maintain corridor doors as required, with a door to Room 22 on the first floor not latching properly. This was observed and confirmed by the Facility Administrator and Maintenance Director, indicating non-compliance with NFPA 101 standards for smoke resistance and positive latching hardware.
The facility failed to maintain proper documentation for kitchen fire safety, lacking records for a semiannual fire suppression inspection and kitchen hood cleanings over the past year. This was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain the automatic sprinkler system, affecting the entire facility. The sprinkler gauges in the maintenance shop were dated 2019, and the facility could not provide documentation of replacement or calibration within the last five years. This deficiency was confirmed by the Facility Administrator and Maintenance Director.
The facility did not conduct one of the twelve required fire drills, specifically missing the third shift fire drill for the fourth quarter. Documentation review revealed the absence of records for the drill between October and December 2024, and interviews with the Facility Administrator and Maintenance Director confirmed this deficiency.
The facility did not properly monitor food temperatures in the Main Kitchen, failing to record temperatures before meals on several occasions, as required by their policy. This oversight was confirmed by the Nursing Home Administrator and Registered Dietician, creating a potential risk for food-borne illness.
The facility did not employ a full-time qualified Food Service Director for six weeks. The current FSD is not certified and is only enrolled in classes to become a Certified Dietary Manager. The Registered Dietician works one day per week and does not manage the dietary department. The NHA confirmed the FSD's lack of qualifications.
The facility failed to monitor and address significant weight loss and nutritional needs for several residents. Despite physician orders for regular weight monitoring, documentation was inconsistent, and necessary nutritional supplements were not renewed. Residents experienced significant weight fluctuations, and some had to guess their weight for medication dosing. The Nursing Home Administrator confirmed these deficiencies, indicating a failure to identify and address nutritional needs timely.
A facility failed to provide sufficient nursing staff, resulting in unmet resident needs such as delayed call light responses, missed showers, and delayed pain medication. Observations showed call lights alarming for extended periods while staff were seated at the nurses' station. The Nursing Home Administrator confirmed the staffing inadequacy, affecting multiple residents.
The QAPI committee failed to address quality deficiencies in the dietary department over six weeks. The Food Service Director was unqualified, and the Registered Dietician, who worked only one day per week, did not manage the department. The Nursing Home Administrator confirmed the lack of effective corrective actions.
The facility did not employ a full-time qualified Food Service Director for two months. The current director, promoted from a dietary aide position, lacks the required certification and formal education. The facility's Registered Dietitian is present only one day per week, and the Nursing Home Administrator confirmed the director's lack of qualifications.
Failure to Thoroughly Investigate Alleged Sexual Abuse and Potential Additional Victims
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of sexual abuse involving one resident and did not determine the extent of potential abuse among other residents cared for by the same staff member. Facility policies on Abuse Protection and Abuse Reporting and Investigation, reviewed on 9/3/25, state that all residents have the right to be free from abuse and that the facility will conduct a thorough investigation of all abuse reports, including providing psychosocial support and protecting the resident during the investigation. The Nursing Home Administrator reported that an investigation had been conducted into an allegation of sexual abuse involving Resident R1 and Nurse Aide Employee E1, and the facility’s investigation concluded that the allegation was unfounded. However, the investigation did not include interviews with any of the other 12 residents who had been cared for by the same nurse aide on the night in question to identify possible additional victims. Resident R1 reported that the nurse aide entered her room to change her after an incontinent episode of urine, removed the front of her brief, wiped the sides of her front without cleaning her, then turned her onto her side, removed the brief, and pressed on her hemorrhoid in and out several times without using a rag or wipe. Resident R1 stated she did not have a bowel movement, that she was not cleaned, and that the aide simply applied a new brief and left. Resident R1 reported that she asked the aide to have the nurse come in and told the nurse she felt violated and later stated she felt assaulted, noting that this had never happened before and that she now feels safe because the aide no longer works there. The Nursing Home Administrator confirmed that the allegation was classified as unsubstantiated and acknowledged that no interviews were conducted with the other 12 residents cared for by the aide during that shift, and that the incident was not thoroughly investigated and resident statements regarding their care on the night shift were not obtained.
Food Service Not Meeting Resident Preferences or Temperature Standards
Penalty
Summary
The facility failed to serve food that was palatable, attractive, and at a safe and appetizing temperature, as well as according to resident preferences. Review of seven months of resident council minutes and grievance logs showed residents reporting that food was cold, meals were often not provided according to the posted menu, condiments were not available, and some food items were not available. During a resident group meeting, residents stated that food was often served cold and late, condiments were not provided, and they did not always receive enough food or what was posted. During lunch tray line observation, dietary staff did not place sour cream on trays until the surveyor asked where it was, at which point a box of sour cream packets was brought to the tray line, and the facility did not have enough bottom hot plate covers for all residents. A test tray observation showed meat at 80 degrees, beans at 90 degrees, rice with no temperature able to be obtained, and milk at 41 degrees. The NHA and DON confirmed that the facility failed to serve food that was palatable, with all item availability and condiments per resident preferences, and confirmed there were not enough bottom hot plate covers for all residents.
Delayed Meal Delivery and Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to provide at least three meals daily at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. Review of resident council minutes from September through the current period and grievances from the same timeframe showed complaints that meals were not delivered in a timely manner and did not follow the posted tray delivery schedule. During observation on 12/16/25, the last cart to the A nursing unit was being delivered at 1:45 p.m., although the schedule showed a 12:35 p.m. delivery time, making it 1 hour and 10 minutes late. During observation on 12/17/25, meal delivery times were also delayed: the dining room cart scheduled for 12:00 p.m. arrived at 12:20 p.m., the A wing first cart scheduled for 12:10 p.m. arrived at 12:43 p.m., the B wing first cart scheduled for 12:20 p.m. arrived at 12:55 p.m., the A wing second cart scheduled for 12:35 p.m. arrived at 1:10 p.m., and the B wing second cart scheduled for 12:45 p.m. arrived at 1:20 p.m. In interview on 12/17/25 at 1:45 p.m., the NHA confirmed the facility failed to provide meals at regular times or in accordance with resident needs, preferences, and requests.
Kitchen Equipment Not Working Properly and Unsafe Drainage Setup
Penalty
Summary
The facility failed to ensure essential kitchen equipment was working safely in the Main Kitchen. During an observation of the dish room on 12/16/25 at 9:50 a.m., the dish machine was identified as a low temperature chemical machine, and a chemical verification strip placed during the cleaning process showed the chemical level at 10 ppm when it was indicated to be at least 50 ppm. During an interview on 12/16/25 at 10:15 a.m., the Nursing Home Administrator confirmed he was not aware that the dishwasher was inoperable. During meal service observation on 12/17/25 from 12:00 p.m. through 1:35 p.m., Dietary Aide Employee E4 was observed plating food items, leaving the area, making grilled cheese using gloved hands, removing gloves, wiping her hands on her pants and shirt, then putting on new gloves and beginning to label a container for sandwiches. She then opened a bun bag, cut bread, and returned to making grilled cheese, which had been holding up the tray line. Staff in the kitchen stated that the stove does not heat properly and takes a long time to heat to cook items in a timely manner. During an observation and interview on 12/17/25 at approximately 2:00 p.m., the Nursing Home Administrator and Maintenance Director Employee E1 confirmed that the steam table had a draining system in place with a drainage pipe touching the ground and placed within a drain to the sewage system.
Failure to Respond to Resident Council Concerns
Penalty
Summary
The facility failed to respond to resident concerns and grievances identified during resident council meetings. During the resident group meeting on 12/18/25 at 2:00 p.m., residents stated that they discussed the same concerns at every meeting, specifically call bells, food and mealtimes, care, staff badges, and showers, and that they did not receive feedback on their concerns. Review of resident council minutes from July 2025 through November 2025 showed 30 areas of old business, with interventions documented as staff educated or manager aware and outcomes listed as resolved no, ongoing in 19 of 30 items, or yes, resolved in 11 of 30 items. During an interview on 12/19/25 at 11:30 a.m., the Nursing Home Administrator confirmed that call bells, food, mealtimes, staff badges, and showers were discussed with grievance files and that the facility failed to respond to resident groups on-going concerns.
Failure to Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to document, resolve, and provide responses to residents and/or their responsible parties regarding grievances. Review of the facility’s grievance policy showed that residents have the right to voice grievances without discrimination or reprisal and that the facility must make prompt efforts to resolve grievances, including concerns related to treatment furnished or not furnished and the behavior of other residents. Review of the facility grievance log for June 2025 through November 2025 showed 18 resident grievance entries, and as of 12/19/25, 16 of the 18 had no documented date that parties were informed of the findings or disposition. During interview on 12/19/25, the Nursing Home Administrator confirmed that the facility failed to document, resolve, and provide responses to residents and/or responsible parties for 16 of the 18 grievances.
Insufficient Nursing Staffing and Delayed Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs and to maintain the highest practicable physical, mental, and psychosocial well-being of 8 of 13 residents. During interviews, residents reported long call light response times, delays in getting out of bed, and worse staffing on the off shifts and weekends. One resident stated call light response takes a long time, and another stated there was not enough staff and that it was worse on the 3-11 shift. Staff interviews also described frequent call offs, short staffing, and difficulty getting residents up and out of bed, with one staff member stating there was not enough help and another stating the facility was short staffed more than not. Grievances and resident council records documented concerns related to incontinence care, grooming, fresh water availability, protective booties not being applied, call light availability, and staff not answering call bells or turning them off without returning. A grievance on behalf of two residents reported that one resident was not put back into bed until the 11 p.m. to 7 a.m. shift and another reported nobody was answering the call bell and that she was soaked. Resident council minutes from multiple months also reflected complaints that staff on the 3-11 shift were not answering call bells, gave residents attitude, did not introduce themselves, and had wait times that were too long. The Nursing Home Administrator and DON confirmed the facility failed to have sufficient nursing staff to provide nursing and related services for the affected residents.
Failure to Maintain a Clean, Homelike Shower Room Environment
Penalty
Summary
The facility failed to maintain a clean, homelike environment in one of two resident shower rooms on the A wing nursing unit hall. During observation, the A wing shower room was found with broken floor trim exposing broken drywall, and pieces of metal were lifted and bent. The deficiency was confirmed during interview by the Maintenance Director and the Nursing Home Administrator, who acknowledged that the facility failed to maintain a homelike environment for the A wing shower room.
Incomplete Care Plan for PTSD
Penalty
Summary
The facility failed to develop a complete care plan that included instructions for person-centered care for Resident R1. Review of the facility policy on MDS/RAI/Care Planning indicated that the facility was to develop a written, individualized plan of care identifying each resident’s strengths, problems, and needs through an assessment process. The clinical record showed that Resident R1 was admitted to the facility and had diagnoses including PTSD, as reflected in the MDS dated 10/15/25 and a psychiatry note dated 11/10/25. However, review of Resident R1’s current care plan dated 10/9/25 failed to reveal a care plan with goals and interventions for PTSD. During an interview on 12/19/25 at 11:30 a.m., the Nursing Home Administrator confirmed that the facility failed to ensure a comprehensive resident care plan was complete for the resident’s care needs.
Failure to Provide Ordered Splint and Accessible Call Bell
Penalty
Summary
Facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for Resident R66. The resident was admitted with diagnoses including transient cerebral ischemic attack, hypertension, contracture of the left hand, and muscle wasting and atrophy of the left upper arm. The clinical record showed an order dated 8/12/25 for a resting hand splint on the left hand while in bed, to be removed for skin integrity checks and activities of daily living, and the facility policy on splint/brace management indicated residents are to be assessed to determine a splint/brace device program to attain, maintain, and prevent decline in joint mobility. During multiple observations on 12/16/25, 12/17/25, 12/18/25, and 12/19/25, Resident R66's left hand brace was never placed on the resident. During multiple observations on 12/16/25, 12/17/25, and 12/19/25, the resident's call bell was observed wrapped around a chair behind the head of the bed, on the floor behind the bed, or on the floor next to the bed. On 12/19/25 at 11:30 a.m., the DON confirmed the facility failed to provide care and services as needed with assisted devices as ordered for Resident R66.
Expired Medications Found in Medication Room
Penalty
Summary
The facility failed to properly store medications and biologicals in one of two medication rooms, the A Wing Medication Room. During an observation of the room, surveyors found 16 boxes of Influenzae Vaccine 2024-2025 formula expired 6/30/25, 1 additional box of the same expired influenza vaccine, 2 boxes of Gvoke HypoPen (glucagon injection pen) expired 6/2025, and 4 boxes of 50% Dextrose Injection expired 5/2025. A review of resident clinical records for influenza vaccine administration found no residents had received the expired medications. The facility policy on storage of medication stated medications are to be stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. The NHA and DON confirmed the facility failed to properly store medication and/or biologicals in one of the medication rooms.
Failure to Accurately Complete Comprehensive MDS Assessment
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were accurate and fully completed for one of eight residents. According to the facility's policy and the Resident Assessment Instrument (RAI) User's Manual, assessments such as the Brief Interview for Mental Status (BIMS) and the Resident Mood Interview should be conducted if the resident is at least sometimes understood. For the resident in question, clinical records indicated that the individual was not in a persistent vegetative state and was sometimes understood, both verbally and nonverbally. However, the MDS assessment marked the resident as rarely/never understood in the cognitive section, and as a result, the BIMS and Resident Mood Interview were not completed as required. Further review of the resident's MDS assessment showed inconsistencies, such as marking the resident as having a memory problem and being severely impaired in daily decision-making, but failing to complete the necessary cognitive and mood interviews. Instead, a staff assessment of mood was completed, which resulted in a severity score outside the expected range. During an interview, the Nursing Home Administrator confirmed that the facility did not ensure the accuracy and completeness of the MDS assessments for this resident.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Incomplete Documentation Following Resident Elopement
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented following an incident of elopement. The resident, who had diagnoses including aphasia, muscle wasting and atrophy, vascular dementia, and a history of transient ischemic attack and cerebral infarction, was found outside the facility after being let out to the front patio by a staff member. The resident, who is non-verbal, was discovered approximately 75 feet down the parking lot and was unable to explain the wandering event. The clinical record for this resident did not contain a follow-up note or any documentation after the day of the elopement. The only note present from the day of the incident included a basic assessment and vital signs, as well as mention of scrapes to the right leg, but lacked documentation regarding care provided for the scrapes, completion of an elopement risk assessment, or placement and documentation of a wander guard. There was also no documentation regarding any subsequent wandering behaviors or attempts since the incident. The Nursing Home Administrator confirmed these documentation gaps, indicating that the facility did not maintain complete and accurate medical records as required.
Failure to Protect Resident from Neglect During Bed Mobility Assistance
Penalty
Summary
The facility failed to protect a resident from neglect during the provision of incontinence care. According to the clinical record and staff statements, a resident with diagnoses of muscle weakness, debility, and dementia, who required assistance with bed mobility, was being assisted by a nurse aide. The aide rolled the resident away from herself while changing the sheets, contrary to published safe bed mobility guidelines and the resident's care plan, which resulted in the resident rolling out of bed and experiencing an assisted fall. The aide attempted to prevent injury by grabbing the resident's gown, allowing the resident to slide gently to a sitting position on the floor. Facility documentation and staff interviews confirmed that the resident was an assist x1 for bed mobility and that the aide did not follow proper procedures for repositioning. The incident was substantiated as neglect, as the facility's policy defines neglect as the failure to provide necessary goods and services to a resident. The deficiency was identified through review of facility policy, clinical records, and staff interviews, which established that the resident was not protected from neglect during the incident.
Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident who required assistance with bed mobility due to muscle weakness, debility, and dementia. According to the clinical record and staff statements, the resident was being assisted by a nurse aide with incontinent care and sheet changing when the aide rolled the resident away from herself, contrary to published safe bed mobility guidelines. As a result, the resident rolled out of bed and experienced an assisted fall, coming to rest in a sitting position on the floor. The resident's care plan indicated the need for assistance with changing position in bed, and the aide's actions did not align with the recommended procedure for such assistance. Facility documentation and staff interviews confirmed that the aide involved rolled the resident in a manner inconsistent with both the resident's care plan and established safety protocols. The incident was substantiated as neglect, as the transfer status and required supervision were not properly followed during the provision of care. The deficiency was identified through review of facility documents, clinical records, and staff interviews, which collectively demonstrated a lapse in supervision and adherence to safe care practices for residents requiring assistance with bed mobility.
Nurse Aide Worked Without Current Certification
Penalty
Summary
The facility failed to ensure that a nurse aide maintained an active certification, resulting in one of five nurse aides reviewed working without a current certification. Review of personnel files and facility documentation revealed that the nurse aide's certification had expired, and the lapse was identified during a routine internal audit. The facility's job descriptions require nurse aides to possess an active Certified Nursing Assistant Certification, having completed a state-approved training program and examination. However, the expired certification was not detected prior to the audit, allowing the individual to continue working without the necessary credentials. Interviews with staff and review of records confirmed that, at the time of the deficiency, all other nurse aides had current certifications and had received appropriate education. The Nursing Home Administrator acknowledged that the facility failed to ensure timely renewal of the nurse aide's registration, which resulted in the individual working without a valid certification. This deficiency was cited under 28 Pa. Code 201.29 Personnel Policies and Procedures.
Failure to Monitor Kitchen Equipment Temperatures
Penalty
Summary
The facility failed to properly monitor equipment temperatures in the Main Kitchen, which could potentially lead to food-borne illness. A review of the facility's policies, specifically the 'Equipment Temperature Logs' dated 9/18/24, indicated that the Dietary Services Manager is responsible for recording the temperatures of all refrigerators and freezers daily. These logs are to be posted in the Dining Services Department and maintained for one year. However, documentation from 12/1/24 to 1/27/25 revealed that temperatures were not recorded on several specific days for the walk-in and reach-in coolers and freezers, as well as the milk cooler. During an interview on 1/27/25, the Nursing Home Administrator and the Dietary Services Manager confirmed the findings, acknowledging the failure to monitor equipment temperatures. This lapse in monitoring created the potential for food-borne illness, as the facility did not adhere to its own policies regarding food safety and equipment temperature logging. The specific dates on which temperature logs were missing were 1/6/25, 1/13/25, 1/16/25, and 1/18/25.
Plan Of Correction
The facility will properly monitor equipment in the Main Kitchen in order to prevent the potential for food-borne illness. The facility is unable to correct that temperatures were not recorded on the following dates for the walk in and reach in coolers and freezers, and milk cooler: 1/6/25, 1/13/25, 1/16/25, and 1/18/25. The facility will record temperatures for the walk in and reach in coolers and freezers, and milk cooler. The facility will maintain the temperature logs in the Dining Services Department and kept on file for a period of one year. The Dietary Manager will educate dietary staff, including new hires, on the facility's "Temperature Recording Policy" which states that the Dietary Department will use the Refrigeration and Freezer Temperature Log to record the temperatures of all refrigerators and freezers daily. The forms will be posted in the Dining Services Department and kept on file for a period of one year. The Dietary Manager will audit Refrigeration and Freezer temperature logs five times a week for four weeks and then weekly for three months to ensure temperatures for the walk in and reach in coolers and freezers, and milk cooler. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
Improper Storage of Insulin Pens
Penalty
Summary
The facility failed to store medications in a safe and sanitary manner, specifically concerning the storage of insulin pens. During an observation, it was noted that six insulin pens were stored unbagged in the medication cart on A unit Short Hall. This improper storage method posed a risk of cross-contamination, as confirmed by an LPN present during the observation. Further confirmation of this deficiency was provided by the Director of Nursing, who acknowledged that the facility did not prevent the risk of cross-contamination by storing insulin pens unbagged in the medication carts for A unit Long Hall. The facility's policy on infection control, which was reviewed, indicated a structured program focused on infection prevention and management, yet the observed practices did not align with these standards.
Plan Of Correction
The facility will ensure that all insulin pens in compartments will be stored appropriately in bags to prevent cross contamination in accordance to state and federal regulations. The insulin pens identified in survey that were not stored appropriately were discarded and replaced and stored in bags to prevent cross contamination. The facility will conduct a house audit on residents with insulin pens to ensure that all residents with insulin pens are bagged and stored appropriately to prevent cross contamination. The Director of Nursing or designee will re-educate all licensed nurses, including new hires and agency on Federal Regulation F0880 detailing facility policy on proper bagging of insulin pens. The Director of Nursing or designee will complete an audit 3 times weekly for 4 weeks and then monthly for 3 months to ensure insulin pens are bagged appropriately. Results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement committee for review and frequency of audits.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
Kadima Rehabilitation and Nursing at Irwin was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the notice requirements before transferring or discharging residents. The facility failed to provide transfer notices to the representatives of the Office of the Long-Term Care Ombudsman Division for four months, from January 2024 through April 2024. This deficiency was identified during a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and an Abbreviated survey in response to four complaints. The facility's policy on 'Admission Transfer and Discharge' was reviewed, and it indicated that no resident would be discharged without timely notification to the resident, responsible party, or authorized representative. However, the facility did not adhere to this policy, as confirmed by the Nursing Home Administrator during an interview. The federal regulations require that a copy of the transfer or discharge notice be sent to a representative of the Office of the State Long-Term Care Ombudsman, which was not done for the specified period.
Plan Of Correction
The facility will provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division. The facility cannot retroactively correct the concern identified during the annual survey. The facility will send the discharge/transfer list to the state Ombudsman monthly. The Nursing Home Administrator or Designee will re-educate the Director of Social Services on federal tag F0623. The Nursing Home Administrator or Designee will complete an audit monthly for three months to validate the transfer/discharge list is completed and sent to the state Ombudsman monthly. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
Failure to Complete Timely MDS Assessment After Significant Change
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident, identified as R97, within the required 14-day period following a significant change in the resident's condition. The resident was admitted to the facility with diagnoses including dementia, repeated falls, and anxiety. On June 14, 2024, the resident was admitted to hospice care, which constitutes a significant change in condition requiring a comprehensive assessment. However, the facility did not complete the necessary MDS assessment to reflect this change. The deficiency was confirmed during an interview with the Licensed Practical Nurse Assessment Coordinator, who acknowledged that the facility did not conduct the MDS significant change assessment within the mandated timeframe. The facility's policy requires that such assessments be completed within 14 days of determining a significant change in a resident's condition, which was not adhered to in this case. This oversight indicates a lapse in the facility's adherence to regulatory requirements for timely assessments following significant changes in a resident's health status.
Plan Of Correction
The facility will complete a significant change Minimum Data Set (MDS) assessment for residents with a change in condition. Resident R97 MDS will be updated to reflect the significant change in Hospice services. The Facility will complete a house audit on residents receiving hospice services to validate the MDS was completed and indicates a significant change related to Hospice. The Regional Clinical Consultant or designee will re-educate the Licensed Practical Nurse Assessment Coordinator (LPNAC) on federal regulation 0623, detailing completing a significant change MDS for Hospice residents. The Director of Nursing or designee will complete an audit weekly for four weeks then monthly for three months to validate residents receiving hospice services has a MDS to reflect the significant change. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
Failure to Manage Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to properly assess, document, and notify physicians of abnormal Capillary Blood Glucose (CBG) levels for two residents, leading to a deficiency in the quality of care. The facility's policies require timely communication with physicians and documentation of changes in a resident's condition, but these were not followed. Specifically, the facility did not adhere to its own protocols for managing diabetes-related complications, such as hypoglycemia and hyperglycemia, which are critical for residents with diabetes. Resident R51, who was admitted with diagnoses including hypoglycemia and diabetes, had several instances of abnormal CBG levels that were not properly managed. On multiple occasions, the resident's CBG levels were either too low or too high, yet there was no evidence of assessment for hyper-/hypoglycemia, monitoring of treatment effectiveness, or physician notification. The care plan interventions, which included monitoring for signs and symptoms of glucose level abnormalities and notifying the physician, were not followed. Similarly, Resident R66, who also had a diagnosis of diabetes, experienced numerous instances of elevated CBG levels. Despite the care plan's directives to perform Accuchecks and notify the physician of abnormal results, the facility failed to assess for hyperglycemia, recheck blood sugar levels, or notify the physician. This lack of adherence to the care plan and facility policies contributed to the deficiency in providing quality care to the residents.
Plan Of Correction
The facility will assess, document and notify the physician of increased and decreased Capillary Blood Glucose (CBG) levels for all residents. The facility cannot retroactively correct the concerns identified for residents R51 and R66; however, in the future, any increased or decreased CBG, the physician will be notified. All diabetic residents' orders will be reviewed to ensure accuracy/need for physician notification. The facility will complete a two-week look back of diabetic residents to validate the physician was notified of increased or decreased CBG, and the resident was assessed for hypoglycemia and documented. The Director of Nursing or designee will re-educate licensed nurses on the facility policy and procedures for Notifying the Physician with resident change in condition, detailing notification of increased or decreased CBG. The Director of Nursing or designee will complete an audit three times a week for four weeks, then monthly for three months to validate physicians are notified of any increased or decreased blood sugars and residents are assessed for hypoglycemia. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
Failure in Communication and Documentation for Dialysis and Resident Care
Penalty
Summary
The facility failed to notify the doctor of a change in condition, document an assessment or interventions related to blood glucose, and follow physician orders for two residents. These deficiencies were confirmed by the Director of Nursing during an interview. Additionally, the facility did not maintain ongoing communication with the dialysis center for a resident with end-stage renal disease, high blood pressure, and depression. This resident was supposed to receive dialysis three times a week, with vital signs taken before and after each session. The facility's policy required that residents receiving dialysis be monitored and documented in their medical records, with assessments conducted before and after dialysis treatments. However, a review of the dialysis communication forms revealed that 34 out of 156 scheduled treatments were not fully completed, either before or after treatment. This lack of documentation was confirmed by the Director of Nursing, indicating a failure to ensure proper communication between the facility and the dialysis center.
Plan Of Correction
The facility will ensure ongoing communication with the dialysis centers for residents. The facility cannot retroactively correct the concern identified for resident R2. The facility will complete a house audit on all residents who receive dialysis to validate that a dialysis communication form is completed pre and post treatment between the facility and dialysis center. The Director of Nursing or Designee will re-educate licensed nurses, including new hires and agency staff, on the facility policy and procedures for dialysis care, detailing the importance of ensuring the communication form is completed pre and post dialysis treatment between the facility and dialysis center for each scheduled dialysis day. The Director of Nursing or Designee will complete an audit three times a week for four weeks, then monthly, to validate the dialysis form is completed for residents who receive dialysis. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
Improper Storage of Refrigerated Medications
Penalty
Summary
The facility failed to properly store refrigerated medication in one of the medication carts observed, specifically the B unit Short Hall medication cart. The facility's policy requires that medications needing refrigeration be stored in the refrigerator located in the drug room at the nurses' station. However, during an observation, it was found that the medication cart contained 12 insulin pens and one insulin multi-dose vial that were not dated. These included various types of insulin such as Novolog, Lantus, Humulin R, and Humalog, which require specific storage conditions to maintain their efficacy. During interviews, an LPN expressed uncertainty about why so many insulin pens were in the drawer instead of being stored in the refrigerator. The Director of Nursing confirmed that the medications should have been dated upon opening and that any extras not in use should have been stored in the refrigerator according to the facility's policy. This oversight indicates a failure to adhere to the established protocols for medication storage, potentially compromising the safety and effectiveness of the medications.
Plan Of Correction
The facility will ensure insulin is stored in a safe, secure and orderly manner in accordance with federal and state regulations and facility policies. The insulin pens identified during survey without dates were discarded and immediately replaced. The facility will complete a house audit on all five medication carts to make certain all insulin is stored and dated appropriately. The Director of nursing or Designee will re-educate all licensed nurses, including new hires and agency of the facility policy and proper storage and labeling of insulin. The Director of nursing or Designee will complete an audit three times a week for four weeks and once weekly for three months to ensure insulin pens are stored and dated as indicated. The results of the audit will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide staffing levels as mandated by the regulation effective July 1, 2024. Specifically, the facility did not provide the minimum number of nurse aides per residents during various shifts over a period of 21 days. During the day shift, the facility was short of the required nurse aide hours on nine days, with a consistent shortfall of 3.92 hours each day for a census of 106 residents. Similarly, the evening shift experienced a shortage on 13 days, with the required hours not met on multiple occasions. The night shift also faced deficiencies on 12 days, with significant discrepancies between the actual and required hours, particularly on days with a census of 107 residents. The nursing schedules and census information reviewed for specific weeks revealed these staffing shortages. The Nursing Home Administrator confirmed these findings during an interview, acknowledging the facility's failure to provide the mandated minimum number of nurse aides on the specified days and shifts. This deficiency highlights a systemic issue in maintaining adequate staffing levels to meet regulatory requirements, impacting the facility's ability to provide consistent care to its residents.
Plan Of Correction
The facility will ensure state-required nurse aide ratios are met for all shifts. The facility cannot correct that nurse aide staffing ratios were not met on the cited dates. The facility will ensure that nurse aide staffing ratios are met every shift. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5520 and ensuring nurse aide staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist as needed. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure nurse aide staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
LPN Staffing Shortages in Facility
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) on multiple occasions across different shifts. Specifically, the facility did not provide the minimum number of LPNs per residents as mandated by regulations on 5 out of 21 days for both the day and evening shifts, and on 3 out of 21 days for the night shift. The review of nursing schedules and census information revealed that on certain days, the actual LPN hours were below the required hours based on the resident census. For instance, on the day shift of 11/09/24, with a census of 106 residents, only 32 actual LPN hours were provided against the required 33.92 hours. Similar shortages were noted on other specified dates for the evening and night shifts. The Nursing Home Administrator confirmed these findings during an interview, acknowledging the facility's failure to meet the staffing requirements on the specified days and shifts.
Plan Of Correction
The facility will ensure state-required LPN ratios are met for all shifts. The facility cannot correct that LPN staffing ratios were not met on the cited dates. The facility will ensure that LPN staffing ratios are met every shift. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist as needed. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure LPN staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on 14 out of 21 days. This deficiency was identified through a review of nursing time schedules and staff interviews. Specific dates where the facility did not meet the required nursing hours include 11/08/24, 11/09/24, 12/22/24, 12/23/24, 12/24/24, 12/25/24, 12/26/24, 12/27/24, 12/28/24, 01/26/25, 01/29/25, 01/30/25, 01/31/25, and 02/01/25. The facility's census on these dates ranged from 102 to 107 residents, with the provided nursing hours per resident per day (PPD) falling short of the required 3.2 hours, with PPDs as low as 2.19 on some days. The Nursing Home Administrator confirmed these findings during an interview on 1/29/25.
Plan Of Correction
The facility will ensure that the state minimum staffing requirement of 3.2 PPD is met in order to ensure the health and safety of all residents. The facility is unable to retroactively correct the concern of the minimum staffing requirement not being met on dates: 11/08, 11/09, 12/22, 12/23, 12/24, 12/25, 12/26, 12/27, 12/28, 1/26, 1/29, 1/30, 1/31, and 2/1. The facility will continue to ensure all efforts are exhausted to maintain the minimum staffing requirement of 3.2 PPD on a daily basis to ensure the health and safety of all residents. The facility will continue to acquire agency staff as needed to meet the 3.2 PPD requirement. Recruitment efforts are underway, and a plan is in place. Bonuses will be offered to all staff to pick up shifts. Facility admissions will be limited if the staffing requirement cannot be met. The Regional Clinical Consultant will re-educate the Administrator, Director of Nursing, and staffing coordinator on the "Nursing Department Staff" policy, which outlines the minimum staffing requirements and steps that are to be taken in order to ensure staffing requirements are met to ensure the health and safety of all residents. The Administrator or designee will audit staffing levels five times a week for four weeks and then monthly for three months to ensure the minimum staffing requirement of 3.2 PPD is met to ensure the health and safety of all residents. Findings of audits will be reported to the monthly Quality Assurance & Performance Improvement (QAPI) for review, recommendations, and frequency of audits.
Failure to Maintain Fire Alarm System Documentation
Penalty
Summary
The facility failed to maintain the fire alarm system as required, affecting the entire facility. During a documentation review on January 28, 2025, it was discovered that the facility did not have documentation for an annual fire alarm inspection. This deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director, who acknowledged the absence of the necessary inspection documentation at the time of the survey.
Plan Of Correction
The facility will ensure the fire alarm system is maintained at all times. The facility will complete its annual fire alarm inspection as required. Documentation will be stored and maintained by the facility. The administrator will audit monthly to ensure fire alarm inspections are completed as required. The maintenance director will be educated on federal tag F0345.
Failure to Perform Annual Emergency Generator Maintenance Testing
Penalty
Summary
The facility failed to perform the required emergency generator maintenance testing over the past 12 months. During a documentation review on January 28, 2025, it was discovered that the facility did not have records of an annual preventive maintenance (PM) test for the emergency generator. This lack of documentation indicates that the facility did not conduct the necessary testing to ensure the generator's functionality and compliance with NFPA standards. An interview with the Facility Administrator and Maintenance Director confirmed that the documentation for the annual generator testing was not available at the time of the survey. This deficiency highlights a lapse in the facility's adherence to the maintenance and testing protocols required for emergency power systems, as outlined by NFPA 101, NFPA 110, and NFPA 111 standards.
Plan Of Correction
The facility will perform emergency generator maintenance testing annually as required. The facility will schedule and complete annual emergency generator PM. Documentation of the PM will be stored and maintained by the facility. The administrator will audit emergency generator PM logs to ensure PM is being completed as required. Maintenance director will be educated on federal tag F0918.
Corridor Door Latching Deficiency
Penalty
Summary
The facility failed to maintain corridor doors in compliance with NFPA 101 standards, specifically in one instance affecting one of ten smoke compartments. During an observation on January 28, 2025, at 9:40 a.m., it was noted that the door to Room 22 on the first floor did not latch when tested. This deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director at 10:00 a.m. on the same day. The report highlights that the corridor doors are required to resist the passage of smoke and have positive latching hardware, as per CMS regulations. The failure of the door to Room 22 to latch properly indicates a non-compliance with these requirements, potentially compromising the safety measures intended to prevent the spread of smoke in the event of a fire.
Plan Of Correction
The facility will maintain all corridor doors in the facility. Hardware for the door of RM 22 was adjusted for the door to properly latch. An audit was completed of all corridor doors in the facility and no concerns were noted.
Deficiency in Kitchen Fire Safety Documentation
Penalty
Summary
The facility failed to maintain its cooking facilities as required by NFPA 101 standards. During an observation and document review, it was found that the facility did not have documentation for the semiannual kitchen fire suppression inspection that was due in March 2024. Additionally, there was no documentation of any kitchen hood cleanings in the past 12 months. These deficiencies were confirmed through an interview with the Facility Administrator and Maintenance Director.
Plan Of Correction
The facility will maintain all cooking facilities. The facility will complete semiannual kitchen fire suppression inspections and kitchen hood cleanings as required. Documentation will be stored and maintained by the facility. The NHA will audit fire suppression inspections and hood cleaning logs monthly to ensure they are completed as required. The maintenance director will be educated of Federal Tag F0324.
Failure to Maintain Automatic Sprinkler System
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, which affected the entire facility. During an observation on January 28, 2025, at 9:10 a.m., it was noted that the automatic sprinkler gauges located in the rear of the maintenance shop in the basement were dated 2019. The facility was unable to provide documentation that these gauges had been replaced or calibrated within the last five years. This deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director on the same day at 10:00 a.m.
Plan Of Correction
The facility will maintain the automatic sprinkler system at all times. The automatic sprinkler gauges in the rear of the maintenance shop in the basement will be replaced or calibrated within as part of the facility's five-year internal sprinkler system inspection. Documentation will be stored and maintained by the facility.
Failure to Conduct Required Fire Drill
Penalty
Summary
The facility failed to conduct one of the twelve required fire drills, specifically the third shift fire drill for the fourth quarter. This deficiency was identified during a documentation review on January 28, 2025, at 8:30 a.m., which revealed the absence of documentation for the fire drill that should have occurred between October and December 2024. An interview with the Facility Administrator and Maintenance Director confirmed the lack of documentation for this drill, indicating that it was not performed as required by the NFPA 101 standards.
Plan Of Correction
The facility will perform all fire drills as required. The facility will schedule an additional 11-7 fire drill that was missed for the fourth quarter of 2024 and will complete fire drills quarterly for all three shifts as required. Documentation will be stored and maintained by facility.
Failure to Monitor Food Temperatures in Kitchen
Penalty
Summary
The facility failed to properly monitor food temperatures in the Main Kitchen, which created the potential for food-borne illness. A review of facility policies and documents, specifically the Dietary Services Administration and Food Temperature Recording policy dated 9/18/24, indicated that food temperatures should be taken and recorded by dining service staff prior to each meal, with hot foods held and served above 135 degrees Fahrenheit. However, the Daily Temperature Log from 12/7/24 through 1/7/25 showed missing documentation of temperature checks before meals on several specific dates. During an interview on 1/7/25, the Nursing Home Administrator and Registered Dietician confirmed these findings, acknowledging the failure to monitor food temperatures as required by the facility's policy.
Plan Of Correction
The facility will properly monitor food temperatures in the Main Kitchen in order to prevent the potential for food-borne illness. Facility is unable to retroactively correct concerns for food temperatures not being recorded on 12/24/24, 12/29/24, 12/30/24, 1/1/25, and 1/3/25. The Dietary Manager or designee will educate dietary staff on dietary manual's "Food Temperature Recording" policy that explains the process for food temperature recording prior to the start of each meal service. The Dietary Manager or designee will audit 10 resident meals per week for four weeks and then monthly for three months to ensure food temperatures are being properly recorded in order to prevent the potential for food-borne illness. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
Failure to Employ Qualified Food Service Director
Penalty
Summary
The facility failed to employ a full-time qualified Food Service Director for a period of six weeks. The job description for the Food Service Director requires the individual to be a graduate of an accredited course in dietetic training approved by the American Dietetic Association and to be registered as a Food Service Director in Pennsylvania. However, the current Food Service Director, Employee E1, is not certified and is only enrolled in classes to become a Certified Dietary Manager. Additionally, the Registered Dietician, Employee E2, works only one day per week and does not participate in the operation or management of the dietary department. The Nursing Home Administrator confirmed that Employee E1 did not meet the necessary qualifications as required by the facility's job description and state regulations.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss and nutritional needs for eight out of eleven residents. The Registered Dietitian's responsibilities included developing dietary care plans and reviewing nurses' notes to ensure adherence to these plans. However, the facility's policy on weight monitoring and intervention was not effectively implemented, as evidenced by the lack of consistent weight documentation and failure to renew necessary nutritional supplements for residents. Resident R1 experienced an 8.9% weight loss over 13 days, with multiple physician orders for daily and weekly weight monitoring not being followed. Additionally, a liquid protein supplement order was not renewed upon the resident's return from the hospital, despite dietician notes indicating its necessity. Similarly, Resident R2 had a physician order for weekly weight monitoring, but weights were not consistently documented, and the resident's moderate protein energy malnutrition was not adequately addressed. Other residents, including R3, R4, R5, R6, R7, and R8, also experienced issues with weight monitoring and nutritional management. For instance, Resident R3 had significant weight fluctuations due to inaccurate documentation, and Resident R4 had no weights recorded during a specified period. Resident R5's weight was not documented for several months, and Resident R6 experienced drastic weight changes without consistent monitoring. Resident R7's inconsistent weights were not addressed with timely nutrition notes, and Resident R8 had to guess her weight for medication dosing due to lack of documentation. The Nursing Home Administrator confirmed these deficiencies, highlighting the facility's failure to identify and address weight loss and nutritional needs in a timely manner.
Inadequate Nursing Staff Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by observations and interviews with residents and staff. The facility's policy, dated 11/30/23, mandates adequate staffing of licensed nurses and other nursing personnel on a 24-hour basis to ensure proper care in accordance with resident care plans. However, multiple residents reported insufficient staffing, leading to unmet needs such as being left in soiled clothing and linens, delayed response to call lights, and missed scheduled showers. Observations on 7/30/24 revealed that call lights were left unanswered for extended periods, with some residents waiting over an hour for assistance. Interviews with residents further highlighted the impact of inadequate staffing, with reports of delayed pain medication and unmet personal care needs. During the observation period, four staff members were seen seated at the nurses' station while call lights continued to alarm. The Nursing Home Administrator confirmed the facility's failure to provide sufficient nursing staff, affecting 13 of 16 residents. This deficiency violates several Pennsylvania Code regulations, including those related to the responsibility of the licensee, management, staff development, and nursing services.
QAPI Committee Fails to Address Dietary Department Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to effectively address quality deficiencies over a six-week period. The deficiency was identified through a review of facility documents, staff interviews, and survey results. The Food Service Director (FSD), Employee E1, was found to be unqualified as she was not yet certified, despite being enrolled in classes to become a Certified Dietary Manager (CDM). This issue was previously cited in a survey ending on 6/18/24, and the facility's plan of correction included the oversight of a Registered Dietician. However, the Registered Dietician, Employee E2, only worked one day per week and did not participate in the management or operation of the dietary department. During interviews, it was confirmed that the QAPI committee did not make a good faith attempt to correct these deficiencies, as required by 42 CFR 483.75(a)(2)(h)(i) and 28 Pa. Code 201.18(e)(1)(2)(3)(4). The Nursing Home Administrator acknowledged the failure to implement effective plans to improve care and services. The lack of a qualified Food Service Director and insufficient involvement of the Registered Dietician contributed to the ongoing quality deficiencies in the dietary department.
Lack of Qualified Food Service Director
Penalty
Summary
The facility failed to employ a full-time qualified Food Service Director for two months, from April to June 18, 2024. The Food Service Director's job description requires the individual to be a graduate of an accredited dietetic training course approved by the American Dietetic Association and registered as a Food Service Director in Pennsylvania. However, the current Food Service Director, Employee E1, stated during an interview that she is not a Certified Dietary Manager and lacks formal education or certificates in food service management. She was promoted from a dietary aide position approximately two months ago and is not enrolled in any classes to become a Certified Dietary Manager. Additionally, the facility employs a Registered Dietitian who is present only one day per week. The Nursing Home Administrator confirmed that Employee E1 does not possess the necessary qualifications as required by the facility's job description and state regulations.
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What surveyors actually found near you
We read the 1,227 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near North Huntingdon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Transitions Healthcare North Huntingdon | 2.8 mi | ★★★★★ | 11 | 0 |
| Woodhaven Health & Rehab Center | 6.5 mi | ★★★★★ | 17 | 0 |
| Monroeville Post Acute | 6.8 mi | ★★★★★ | 18 | 0 |
| John J Kane Regional Center-mc | 6.8 mi | ★★★★★ | 3 | 1 |
| Riverside Health & Rehab Center | 6.8 mi | ★★★★★ | 31 | 0 |
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