Health inspection·December 17, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on a review of the facility's policies, clinical records review, and staff interviews, it was determined that the facility failed to ensure resident was free from neglect for one of the two residents reviewed. (Resident CL1).Findings include:A review of the facility's policy titled Abuse Reporting and Investigation, revealed ABUSE means the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse facilitated or enabled using technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Types of abuse include Verbal Abuse, Sexual Abuse, Physical Abuse, Involuntary Seclusion, Mental Abuse, Neglect, and Misappropriation of Resident Property.A review of the facility's policy titled Medication Administration, with a revision date of November 2024, revealed that medications are administered, as prescribed, in accordance with good nursing principles and practices and only by person legally authorized to do so to comply with Federal Laws governing Medication Administration and in order to ensure the safe, accurate and timely administration of medications.Clinical records revealed Resident CL1 had a diagnosis of as follows: Chronic Lymphocytic Leukemia (Cancer of the white blood cell), Congestive Heart Failure (CHF-A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), and generalized anxiety. Further review revealed the resident's medical condition continues to decline. The resident was placed on Hospice care (A compassionate, team-based care approach for terminally ill patients with a focus on comfort, dignity, and quality of life) in July 2025.Clinical records revealed Resident CL1 had a fall in the facility, which resulted in a left femur (The longest and strongest bone in your body, running from the hip to the knee) fracture on November 24, 2025. The resident was sent to the hospital for evaluation, but it was determined that the resident was not a candidate for surgery, Resident CL1 was returned to the facility on November 25, 2025.A review of Resident CL1's physician's order dated November 26, 2025, revealed an order for Morphine Sulfate (A powerful opioid analgesic used to manage moderate to severe pain) oral solution 100/5 ml. Give 0.5 ml every 2 hours for pain. An additional order was made on November 27, 2025, for lorazepam (to treat anxiety), give 1 tablet by mouth every 6 hours for terminal restlessness at 12:00 a.m., 6:00 a.m., 12 noon, and 6:00 a.m.A review of November 2025, Medication Administration Record (MAR) revealed Resident CL1 was not administered with Morphine Sulfate on November 27, 2025, at 8:00 p.m., 10:00 p.m., November 28, 2025, at 12:00 a.m., and 2:00 a.m. Additional MAR review revealed the resident was also not administered Ativan (lorazepam) on November 28, 2025, at 12:00 a.m.A review of the nursing progress notes dated November 28, 2025, at 8:16 a.m., revealed that the agency nurse, Employee E3, reported that the daughter was upset and was insisting on giving the residents' Ativan and Morphine medication. Further review of the same notes revealed Per [Employee E3's name], she/he stated she/he was uncomfortable with administering both doses together due to no signs of restlessness per assessment.A (continued on next page) 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: 395590 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 395590 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Lititz 125 South Broad Street Lititz, PA 17543 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)