Health inspection·February 14, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, and observation, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for three of four sampled residents. (Residents 2, 3, and 4) Residents Affected - Some Findings include: Review of the facility policy entitled, Covid-19 Policy and Procedure, last reviewed February 5, 2025, revealed personal protective equipment (PPE) was to be worn when caring for residents who tested positive or had potentially been exposed to Coronavirus Disease 2019 (COVID-19). PPE was to include gloves, a gown, a face mask, and a face shield. Precautions were to remain in place for at least 14 days and up to 20 days, depending on severity of the residents' symptoms. Observations on February 14, 2025, at 10:00 a.m., revealed one cart containing PPE supplies was centrally located in each of the three resident occupied hallways. Two signs hung on the room doors of Residents 2, 3, and 4, indicating droplet and contact precautions were to be followed when entering the room. The signs instructed staff to clean hands before entering and when leaving, cover eyes, nose, and mouth fully before entering, remove face protection before exiting, and put gown, gloves on before entering and take off before exiting. Clinical record review revealed that Resident 2 tested positive for COVID-19 on February 11, 2025, according to a nursing note. On February 14, 2025, from 10:28 a.m. to 10:48 a.m., nurse aide (S4) and nurse aide (S5) entered the resident's room and provided care without wearing gowns. Clinical record review revealed that Resident 3 tested positive for COVID-19 on February 13, 2025, according to a physician's note. On February 14, 2025, from 10:35 a.m. to 10:50 a.m., occupational therapist (S6) was observed entering and exiting the room and providing care without wearing a gown. Clinical record review revealed that Resident 4 had a diagnosis of COVID-19 on February 8, 2025. On February 14, 2025, from 9:55 a.m. to 10:10 a.m., S6 was observed providing care in Resident 4's room while wearing a gown, gloves, and face mask. S6 exited the room and walked through the residents areas before removing the gown at the front door. In an interview on February 14, 2025, at 11:50 a.m., the Nursing Home Administrator, Director of Nursing, and Infection Preventionist confirmed that S4, S5, and S6 were providing care to Resident 2 and Resident 3 without wearing the required PPE, and that S6 was observed walking from Resident 4's room to the front door of the facility wearing a gown that was worn while providing care. 28 Pa. Code 211.10(d) Resident care policies. Page 1 of 2 395506 395506 02/14/2025 Kadima Rehabilitation & Nursing at Palmyra 341 North Railroad St Palmyra, PA 17078

F 0880 28 Pa. Code 211.12(d)(1)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395506 Page 2 of 2