Health inspection·August 31, 2023

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm Based on review of facility documentation and staff interview, it was determined that the facility failed to provide the required Notice of Medicare Provider Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) to the resident or resident's representative for three of three records reviewed (Residents 100, 101, and 102). Residents Affected - Many Findings include: Review of form titled Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (notice that informs the recipient when care receive from skilled nursing facility is ending and how you can contact a Quality Improvement Organization (QIO) to appeal) instructs that a Medicare provider must be delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. Review of the form title Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) states that this notice is given to make residents aware of care that no longer meets Medicare coverage requirements and they may have to pay out of pocket for the care listed. The provider must ensure that the beneficiary or their representative signs and dates the SNFABN to demonstrate that the beneficiary or their representative received the notice of possible out of pocket costs. Review of facility documentation revealed that Resident 100 was discontinued from Medicare Part A on April 3, 2023, with benefit days remaining. There was no documentable evidence that the resident or resident's representative was provided the required NOMNC or SNF-ABN form. Review of facility documentation revealed that Resident 101 was discontinued from Medicare Part A on June 5, 2023, with benefit days remaining. There was no documented evidence that the resident or resident's representative was provided the required NOMNC or SNF-ABN form. Review of facility documentation revealed that Resident 102 was discontinued from Medicare Part A on April 10, 2023, with benefit days remaining. There was no documentated evidence that the resident or resident's representative was provided the required NOMNC or SNF-ABN form. Interview with the Employee E3 on August 31, 2023, at 12:40 p.m. confirmed that there was no evidence that the NOMNC and SNF-ABN notices were provided to the above residents or their representative. 483.10(g)(18)(i) Medicaid/Medicare Coverage/liability notice Page 1 of 5 395590 395590 08/31/2023 Kadima Rehabilitation & Nursing at Lititz 125 South Broad Street Lititz, PA 17543

F 0582 Previously cited 9/30/22 Level of Harm - Potential for minimal harm 28 Pa. Code 201.18(b)(2) Management Previously cited 9/30/22 Residents Affected - Many 28 Pa. Code 201.18(e)(1) Management Previously cited 9/30/22 28 Pa. Code 201.29(a) Resident rights Previously cited 9/30/22 395590 Page 2 of 5 395590 08/31/2023 Kadima Rehabilitation & Nursing at Lititz 125 South Broad Street Lititz, PA 17543

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure MDS assessments accurately reflected the resident's status for three of 16 residents reviewed (Residents 28, 33, and 39). Residents Affected - Some Findings include: Review of Resident 28's quarterly MDS assessment (Minimum Data Set - periodic assessment of resident needs) dated July 13, 2023, Section H0100 - Appliances, indicated that the resident had an indwelling catheter (tube maintained within the bladder for continuous drainage of urine). Review of the clinical record revealed Resident 28 did not have an indwelling catheter at the time of the assessment. Review of Resident 33's quarterly MDS dated [DATE], Section O0100 - Special Treatments, Procedures, and Programs indicated that the resident was not receiving hospice services. Review of Resident 33's physician orders included an order for hospice dated November 17, 2022. Review of Resident 39's quarterly MDS assessment (Minimum Data Set - periodic assessment of resident needs) dated June 28, 2023, Section H0100 - Appliances, indicated that the resident had an indwelling catheter (tube maintained within the bladder for continuous drainage of urine). Review of Resident 39's clinical record revealed the resident did not have an indwelling catheter at the time of the assessment. Interview with the Director of Nursing, on August 31, 2023, at 1:20 p.m. confirmed that the assessments did not accurately reflect the resident's status. 28 Pa. Code 211.5(f) Clinical records Previously cited 11/21/22, 9/30/22 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 9/30/22 395590 Page 3 of 5 395590 08/31/2023 Kadima Rehabilitation & Nursing at Lititz 125 South Broad Street Lititz, PA 17543

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on clinical record review and staff interview, it was determined that the facility failed to ensure a discharge summary contained a reconciliation of all medications for one of three closed records (Resident 48). Findings include: Review of progress note of May 31, 2023, revealed that discharged was planned for June 5, 2023, with resident's son providing transportation to resident's home. Further review of Resident 48's closed clinical record revealed no documented evidence of the reconciliation of the medications or the disposition at the time of discharge from the facility. Interview with the Director of Nursing on August 31, 2023, at 12:08 p.m. confirmed that there was no documentation of the reconciliation of the medications. 28 Pa. Code 201.14 (a) Responsibility of licensee Previouslu cited 9/30/22 28 Pa. Code 201.18 (b)(2) Management Previouslu cited 9/30/22 28 Pa. Code 201.18 (b)(3) Management Previously cited 2/17/23 28 Pa. Code 211.5 (f) Clinical records Previously cited 11/21/22, 9/30/22 28 Pa. Code 211.9 (j) Pharmacy services 28 Pa. Code 211.12 (d)(3) Nursing services 395590 Page 4 of 5 395590 08/31/2023 Kadima Rehabilitation & Nursing at Lititz 125 South Broad Street Lititz, PA 17543

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on review of facility policy and clinical records, it was determined that facility failed to respond to recommendations made by the consultant pharmacist for four of five residents reviewed for unnecessary medications (Residents 4, 23, 28, and 44). Findings include: Review of facility policy Documentation and Communication of Consultant Pharmacist Recommendations, undated, revealed that comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medicationm regimen review. Recommendations are acted upon and documented by the facility staff and/or the prescriber. Review of Resident 4's Note to Attending Physician/Prescriber revealed monthly medication regimen reviews (MRRs) from November 6, 2022, December 11, 2022, February 9, 2023, March 6, 2023, and April 7, 2023, where the physician failed to respond to recommendations made by the pharmacist. Review of Resident 23's Note to Attending Physician/Prescriber revealed MRRs from November 6, 2022, December 11, 2022, May 7, 2023, and June 8, 2023, where the physician failed to respond to recommendations made by the pharmacist. Review of Resident 28's Note to Attending Physician/Prescriber revealed a MRR from March 6, 2023, was not addressed until July 18, 2023. Review of Resident 44's Note to Attending Physician/Prescriber revealed MRRs from May 7, 2023, and June 8, 2023, where the physician failed to respond to recommendations made by the pharmacist. Interview with the Director of Nursing on August 31, 2023, at approximately 2:00 p.m. confirmed the facility failed to ensure a physician's timely response to the above mentioned MRRs. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.5(f)(h) Clinical records 28 Pa. Code 211.12(c)(d)(3)(d)(5) Nursing services 395590 Page 5 of 5