Kadima Rehabilitation & Nursing at Harmony

Inspectors wroteBased on review of facility policy, resident records, facility documentation, incidents submitted to the local State field office, and staff interviews it was determined that the facility failed to submit a report of an allegation of staff to resident abuse and physical restraint for one of three residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, facility documents, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect by failing to provide incontinence care in a timely manner for one of four residents reviewed (Resident R105).

Inspectors wroteBased on review of facility policy, clinical record review and resident and staff interviews it was determined that the facility failed to provide Activities of Daily Living (ADL) assistance for three of four residents reviewed (Resident R1, R2, and R3).

Inspectors wroteBased on facility policy, clinical record review, observations and resident and staff interviews, it was revealed that the facility failed to prevent involuntary seclusion for one of six residents reviewed (Resident R5).

Inspectors wroteBased on review of facility policy, clinical records, facility documents, resident interview, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident (Resident R110), and failed to properly identify a resident's risk for elopement (Resident R54). This failure created an immediate jeopardy situation for two of 108 residents.

Inspectors wroteBased on observations, and staff interviews it was determined the facility failed to ensure that daily nutritional and special dietary needs for residents were met for one of four weeks (April/May 2025).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to properly label and date food products, monitor and maintain records of refrigeration/freezer temperature logs to make certain refrigeration/freezers function properly, and failed to maintain the cleanliness and sanitation of equipment in the Main Kitchen. (Main Kitchen).

Inspectors wroteBased on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to prevent the elopement of a resident (Resident R110), and failed to properly identify a resident's risk for elopement (Resident R54), which created an Immediate Jeopardy situation for two of 108 residents.

Inspectors wroteBased on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for four of ten residents (Residents R2, R55, R74, and R89).

Inspectors wroteBased on review of the clinical records and staff interviews, it was determined that the facility failed to provide sufficient and timely social services related to assistance in obtaining guardians for two of four residents (Resident R41 and R102).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to properly secure a medication cart while not in use for one of five medication carts (North Medication Cart), and failed to properly store medications on three of three medication carts (North Medication Cart, North [NAME] Medication Cart, and Split Hall Medication Cart).

Inspectors wroteBased on review of observations and staff interview, it was determined that the facility failed to protect and value residents' private space (South Wing Resident R18, and R63)

Inspectors wroteBased on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of five medication carts (North Medication Cart).

Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to maintain a clean, safe, and homelike environment for three of ten residents (Resident R106, R102, and R64). Findings Include: Review of the facility policy Resident Environment dated 4/25/25, indicated the facility will provide a safe, clean, comfortable, and homelike environment. During observations of the North nursing unit on 5/5/25, at 9:45 a.m. the following was observed: -Resident R106 in room [ROOM NUMBER]-D, indicated the perimeter of the wall to the left of the entrance door was dirty with built up grime, the floor mat beside the bed was dirty with white and gray markings and smudges, the perimeter of the wall under the heating element was corroded with built up grime, the bathroom had five visibly cracked floor tiles. [...]

Inspectors wroteBased on review of facility policies, facility provided documents, clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from mental abuse and threats of punishment or deprivation for one of three residents reviewed (Resident R64).

Inspectors wroteBased on review of facility policy, resident records, facility documentation, incidents submitted to the local State field office, resident council interview, resident and staff interviews it was determined that the facility failed to submit a report of an allegation of emotional abuse in a timely manner to the local State field office for one of five sampled residents (Resident R96).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of three residents sampled with facility-initiated transfers (Residents R3, and R110).

Inspectors wroteBased on review of facility policy, observation and interviews it was determined that the facility failed to provide care and services to meet the accepted standards of clinical practice two of four residents (Resident R14 and R16).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to follow a physician order for an edema (swelling) glove for one out of three residents (Resident R35).

Inspectors wroteBased on review of facility policies and clinical records and resident and staff interviews, it was determined that the facility failed to make certain that residents receive proper treatment and assistive devices to maintain visual ability for one of four residents (Resident R41).

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one of five residents (Resident R2).

Inspectors wroteBased on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for two of two residents (Residents R11 and R89).

Inspectors wroteBased on review of facility policy, resident records, a facility tour, and staff interview it was determined that the facility failed to follow transmission based precautions and utilize enhanced barrier precautions (EBP) creating the potential for cross contamination for two out of five sampled residents (Residents R79 and R92).

Inspectors wroteBased on review of clinical records, facility policy and resident and staff interviews, it was determined that the facility failed to follow the policies established to assess one of twelve residents for safe smoking practices (Resident R64).

Inspectors wroteBased on observations and staff interview it was determined that the facility failed to have required postings for the facility in areas that are accessible to all residents throughout the facility for State Agency information, how to file a complaint with State Agency, Adult Protective Service information, and complete contact information for State Long-Term Care Ombudsman program posted at the facility.

Inspectors wroteBased on review of facility policy, shower schedule documents, resident clinical records, resident and staff interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of seven sampled residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify the physician of missed medication and increased behaviors for one of four residents (Resident CRR2) and failed to notify a resident's responsible party for an increase in medication dosage for one of three residents (Resident R1). Review of the facility's policy Notification Change in Condition Responsible Party dated 2/1/24, indicated the responsible party or guardian is to be notified of changes in condition or occurrences to ensure that the resident ' s responsible party or guardian is notified of changes and /or occurrences and action and pertinent information are documented. When any one of the following instances occurs, the resident's responsible party or guardian will be notified including but not inclusive to: [...]

Inspectors wroteBased on review of facility policy, clinical records, observations, and staff interviews it was determined that the facility failed to make certain each resident received adequate supervision which resulted in one elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of four residents (Resident CRR2) and failed to consistently document in the clinical record regarding post-incident response after an elopement for two of four residents (Resident R1 and CRR2).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to obtain a physician's order for a discharge and make certain that the necessary resident information was communicated to the receiving health care provider for one out of five residents sampled with facility-initiated transfers (Resident R1).

Inspectors wroteBased on review of facility documents and staff and resident interview it was determined that the facility failed to resolve concerns for 2 of 2 resident's reviewed.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to follow a physician order for one of seven residents (Resident R1).

Inspectors wroteBased on a review of facility menu, facility documents, observations, staff interviews, and resident interview, it was determined that the facility failed to comply with food safety regulations by failing to monitoring the proper cooling of foods for two days (4/27/24, and 4/28/24), and properly store utensils for one of two ice machines (Main Dining Room) creating the potential for food borne illness.

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide documentation of advanced directives or given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for eight of eight residents reviewed (Resident R8, R30, R50, R67, R75, R86, R87, and R311).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five out of seven residents sampled with facility-initiated transfers (Residents R30, R57, R59 R75, and R87).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident/resident representative and/or the representative of the Office of the State Long-Term Care Ombudsman of resident transfers, in writing, to include to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman for five of seven resident records reviewed (Resident R30, R57, R59, R75, and R87) Findings Include: Review of Title 42 Code of Federal Regulations §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; [...]

Inspectors wroteBased on review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for three of six sampled residents (Resident R3, R21, and R37).

Inspectors wroteBased on review of facility policies and job descriptions, clinical records, and staff interviews, it was determined that the facility failed to adhere to acceptable standards of practice related to participation in interdisciplinary meetings for 12 of 12 months, and completion of Nutrition Assessments by the Registered Dietitian for two of eight residents reviewed (Residents R21 and R59).

Inspectors wroteBased on review of facility policy, clinical record review, a resident council group interview, resident and staff interviews, it was determined that the facility failed to make certain that showers were consistently provided and failed to provide adequate hygienic care for eight out of 12 sampled residents (Resident R30, R50, R63, R67 R75, R87, R311, and R312 ).

Inspectors wroteBased on review of facility policies, clinical records, facility documents and staff interview, it was determined that the facility failed to ensure that residents received neurological assessment after an incident involving a fall for four of nine residents (Residents R8, R12, R30, and Resident R87).

Inspectors wroteBased a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that weights were monitored for two of nine residents (Resident R21, and R50), failed to timely assess the nutritional status for two of four residents (Resident R21, and R59), and failed to provide nutritional supplements as ordered for weight loss for one of two residents ( Resident R50).

Inspectors wroteBased on review of facility policy, observations, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care and maintain respiratory equipment for three out of four sampled residents (Resident R3, R12, and R66).

Inspectors wroteBased on staff interviews, and review of the Food Service Director's Job description, it was determined that the facility failed to employ a full-time qualified Food Service Director for six of six months (November and December 2023, and January through April 2024).

Inspectors wroteBased on review of clinical records, facility policies, facility documents, and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential clinical duties for six out of 12 months (November and December 2023, and January through April 2024).

Inspectors wroteBased on review of facility policy, facility documents, resident interviews, meal tray observations and staff interviews, it was determined that the facility failed to provide menu selections according to the resident's preference for five out of nine residents (Resident R21, R58, R59, R88, and R210).

Inspectors wroteBased on review of facility in-service documentation, personnel records, and staff interviews it was determined that the facility failed to implement and maintain an effective training program for six out of eight personnel records (LPN Employee E11, LPN Employee E12, Nurse aide Employee E7, Nurse aide Employee E13, Nurse aide Employee E14, and Nurse aide Employee E15).

Inspectors wroteBased on review of facility in-service documentation, personnel records, and staff interviews it was determined that the facility failed to ensure that nurse aide staff received annual inservice training on resident rights for four out of four personnel records (Nurse aide Employee E7, Nurse aide Employee E13, Nurse aide Employee E14, and Nurse aide Employee E15).

Inspectors wroteBased on review of facility in-service documentation, personnel records, and staff interviews it was determined that the facility failed to ensure that all nurse aide staff received a minimum of twelve hours of inservice education training each year for four out of four personnel records (Nurse aide Employee E7, Nurse aide Employee E13, Nurse aide Employee E14, and Nurse aide Employee E15).

Inspectors wroteBased on facility policy, clinical record review and staff interviews, it was determined the facility failed to notify the physician of a change in condition for one of six residents. (Resident R30).

Inspectors wroteBased on review of facility policy, clinical record review, staff interview, and facility submitted documents, it was determined that the facility failed to provide services to create an environment free from neglect for one of four residents (Resident R99).

Inspectors wroteBased on review of facility policy, newly hired personnel records and staff interviews it was determined that the facility failed to conduct an FBI background check on an employee prior to working on the nursing unit for one out of five personnel records (Registered Nurse Employee E6) and failed to properly screen an employment by completing a State background check prior to hire for one out of five personnel records (Dietary Aide Employee E17).

Inspectors wroteBased on review of facility policy, resident clinical record, reports submitted to the State, and staff interview it was determined that the facility failed to report two allegations of abuse for one of three sampled residents (Resident R67).

Inspectors wroteBased on review of facility policy, clinical records, reports submitted to the state, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse for one of three residents (Resident R67).

Inspectors wroteBased on review of facility documents, clinical records, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of seven resident hospital transfers (Resident R57). Findings Include: Review of the admission Packet which is provided to residents upon admission, it was indicated that before the facility transfers a resident to the hospital or the resident goes on therapeutic leave, the facility shall provide written notice to Resident or Resident Representative. Review of the clinical record indicated Resident R57 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on facility policy, clinical record review, resident observation, and staff interviews, it was determined that the facility failed to follow physician's orders for one of two residents (Resident R311).

Inspectors wroteBased on review of facility policy, resident clinical records and staff interview it was determined that the facility failed to obtain laboratory results and promptly report those results as per order for one out of two sampled residents (Resident R17).

Inspectors wroteBased on observations, facility menu, resident interviews, and staff interviews it was determined that the facility failed to follow the displayed menu for one of four observed meals (lunch meal 4/30/24).

Inspectors wroteBased on a review of facility policy, observation, resident interview, and staff interview, it was determined that the facility failed to serve food products that appeared palatable for one of four meals observed (lunch meal on 4/29/24).

Inspectors wroteBased on facility policy, observation, and staff interview it was determined that the facility failed to properly contain and dispose of garbage in one of one outside dumpsters to prevent the potential for rodent and insect infestation.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to maintain and complete accurate documentation for two of nine residents (Resident R3 and R12).

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interviews, it was determined the facility failed to obtain a physician order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for one of four residents (Resident R30).

Inspectors wroteBased on policy review, observations, and staff interview, it was determined that the facility failed to maintain a clean, comfortable, homelike environment in seven out of 12 sampled resident rooms (Residents R1, R2, R3, R4, R5, R6, and Resident R7).

Inspectors wroteBased on review of facility policy, clinical records, facility investigation, resident and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent injuries for two of four residents (Resident R3 and R1). This failure caused Resident R3 to have an unsupervised fall causing head trauma, abrasion of nose and fracture of nasal bone and Resident R3 was unsupervised smoking and suffered a burn. Resident R1suffered a fall during care and sustained blunt force injuries of the head and cervical spine from the fall which resulted in the death of Resident R1. This failure created an Immediate Jeopardy situation for two of four residents (Resident R3 and R1).

Inspectors wroteBased on a review of facility policies, documents, resident council minutes and staff interviews it was determined that the facility failed to implement the grievance process in accordance with Federal regulations for five of five residents (Resident R4, R5, R6, R7, and R8).

Inspectors wroteBased on review of facility policy, resident observations, resident interviews and confidential staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of seven of ten residents (Resident R2, R4, R5, R6, R7, R8, and R9). Findings Include: Review of the undated, Certified Nursing Assistant job description indicated it is the responsibility of nurse aides to assist residents with bath functions, nail care, and bladder and bowel functions. During an interview on 1/24/24, at 9:57 a.m. Nurse Aide (NA), Employee E17 stated there can be an improvement with staffing. She stated she is unable to provide care to the residents and is often overwhelmed. [...]

Inspectors wroteBased on review of facility policy, resident clinical record, investigation documentations, resident and staff interviews, it was determined that the facility failed to report an allegation of neglect within 24 hours for one out of four sampled residents (Resident R2).

Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate allegations of abuse or neglect for two of five residents reviewed (Resident R2 and Resident R3).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to provide wound dressing treatment as ordered for one out of two residents (Resident R6).

Inspectors wroteBased on a review of facility policy, clinical records and staff interviews it was determined that the facility failed to ensure that a resident's drug regimen was free of unnecessary medication for one of two residents. (Resident R2)

Inspectors wroteBased on observations, review of clinical records, facility policies and documentation, and staff interviews, it was determined that the facility failed to maintain an effective infection prevention and control program by failing to follow infection control guidelines from the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections. This failure resulted in seven of ten residents not positive for COVID-19 remaining in room with a resident with a COVID-19 positive resident (Residents R2, R4, R6, R8, R10, R12, and R14) and two of seven residents who remained in a room with a COVID-19 positive resident becoming positiveand symptomatic of COVID-19 (Residents R2 and R4).

Inspectors wroteBased on review of facility financial documents, interviews with vendors and staff, it was determined that the facility failed to pay bills in a timely manner for services without which the residents' health and safety are potentially impacted.

Inspectors wroteBased on review of facility policy, personnel files and staff interviews it was determined that the facility failed to complete annual performance evaluations for three out of eight personnel files (Nurse Aide Employee E5, Nurse Aide Employee E6, and Nurse Aide Employee E7).

Inspectors wroteBased on review of facility documentation and staff interview it was determined that the facility failed to employ qualified staff to oversee the kitchen for six out of 12 months (January of 2023 to June of 2023).

Inspectors wroteBased on review of facility policy, resident clinical record, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of neglect for one out of three sampled resident records (Resident R30).

Inspectors wroteBased on review of facility policy, clinical record review, staff interview it was determined that the facility failed to implement a care plan for assistance with eating for one of four residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as per order for one out of three residents (Resident R37).

Inspectors wroteBased on review of facility policy, clinical record and staff interview it was determined that the facility failed to provide a diagnosis for a psychotropic medication for one of five Residents (Resident R54).