Health inspection·June 27, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Review of Resident R2's admission record indicated she was originally admitted on [DATE], with diagnoses that included anxiety, osteoarthritis and difficulty walking. Review of Resident R2's quarterly Minimum Data Set(MDS-a periodic assessment of care) dated 5?10/24 indicated diagnosis remain current. Interview for Mental Status (BIMS a screening test that aides in detecting cognitive function. The BIMS total score suggests the following distributions: 13-15 cognitively intact 8-12 moderately impaired 0-7 severe impairment Resident R1's score was 15- cognitively intact Review of facility documentation indicated Resident R2's had a grievance on 5/31/24. She stated she did not get care. The facility resolution was to put a white board in Resident R2's room with who her nurse and nurse aide for the day. Interview on 6/27/24 at 12:35 p.m. Resident R2 stated the concern above were not resolved. The white board was dated 6/25/24 and had no staff listed. Resident R2 stated why have the board, there is nothing on it. Review of Resident R1's admission record indicated he was admitted on [DATE], with diagnoses that included neuromuscular dysfunction of bladder, major depressive disorder and muscle weakness. Review of Resident R1's quarterly Minimum Data Set(MDS-a periodic assessment of care)dated 6/15/24 indicated diagnosis remain current. Interview for Mental Status (BIMS a screening test that aides in detecting (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: 395758 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 395758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Harmony 191 Evergreen Mill Road Harmony, PA 16037 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)