Inspection·April 27, 2024

F 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to provide necessary equipment to a resident on admission for one of five sampled residents. (Resident CL1) Findings include: Review of the the facility policy entitled, Pre-admission Process Procedure, last reviewed July 1, 2023, revealed that when a referral was received the Clinical Director of Admissions and Marketing would pre-screen the referral. The Director of Nursing would review the referral clinically for staff education needs and to ensure all necessary equipment was ordered. If there were additional needs identified, they would be communicated to the Clinical Director of Admissions and Marketing so they could be addressed before admission. Clinical record review revealed that Resident CL1 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease, dependence on supplemental oxygen, and morbid obesity. Review of pre-admission documentation received by the facility from the hospital revealed that the resident was dependent on four liters of continuous oxygen and used an average volume-assured pressure support (AVAPS) machine (a machine that facilitates non-invasive ventilation to support people with respiratory failure) daily prior to admission and during her hospitalization. Review of Resident CL1's admission assessment and nurse's notes revealed that the resident was admitted to the facility on [DATE], and the facility did not have an AVAPS machine for the resident to use through April 22, 2024, when the resident was transferred to the hospital. In an interview on April 27, 2024, at 2:00 p.m., the Nursing Home Administrator, confirmed that the facility did not have the needed equipment to support Resident CL1 and that the Pre-admission Process Policy had not been followed. 28 Pa Code 201.24 (c) admission policy. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 395506 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395506 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Palmyra 341 North Railroad St Palmyra, PA 17078 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)