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 Page 1 of 3 395758 395758 06/27/2024 Kadima Rehabilitation & Nursing at Harmony 191 Evergreen Mill Road Harmony, PA 16037

F 0585 The BIMS total score suggests the following distributions: Level of Harm - Minimal harm or potential for actual harm 13-15 cognitively intact 8-12 moderately impaired Residents Affected - Few 0-7 severe impairment Resident R1's score was 15- cognitively intact Review of facility documentation indicated Resident R1 on 5/1/24 needed help eating and was told no and was asked NA to go to bed, was told she was unavailable. 5/19/24 submitted a concern that no one was in to change him during the night. Interview on 6/27/24 at 1:15 p.m. Resident R1 stated the concerns above were not resolved. Resident R1 stated he doesn't get assistance to eat and proper incontinence care at night. Resident R1 stated If there is a hell, this place is it During an interview on 6/27/24, at 1:45 p.m. the Nursing Home Administrator confirmed that the facility failed to resolve grievances for 2 of 2 Resident R1 & R2. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 395758 Page 2 of 3 395758 06/27/2024 Kadima Rehabilitation & Nursing at Harmony 191 Evergreen Mill Road Harmony, PA 16037

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual 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 follow a physician order for one of seven residents (Resident R1). Residents Affected - Few Findings include: Review of Resident R1's admission record indicated he was originally admitted on [DATE], with diagnoses that included neuromuscular dysfunction of bladder, major depressive disorder and muscle weakness. Review of Resident R1's quarterly MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 6/15/24, indicated that the diagnoses were current upon review. Review of Resident R1's physician order's dated 5/17/24 indicated to administer Ferrous Gluconate Oral Tablet 324 (38 Fe) MG (Ferrous Gluconate) give 324 mg by mouth one time a day for anemia. Review of Resident R1's physician order's dated 5/17/24 indicated to administer Protonix Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium)give 1 tablet by mouth one time a day for GERD. Review of Resident R1's physician order's dated 5/17/24 indicated to administer LiquaCel Oral Liquid (Amino Acids) give 30 ml by mouth three times a day for wound healing. Review of Resident R1's MAR (medical administration record), the following was not administered: Ferrous Gluconate 6/15/24, 6/18/24, 6/22/24 Protonix 6/6/24, 6/9/24, 6/17/24 LiquaCel 6/22/24, 6/25/24 Review of Resident R1's clinical nurse notes indicated medications need reordered or not on cart and resident R1 did not receive on 6/6/24, 6/9/24, 6/15/24, 6/17/24, 6/18/24, 6/22/24 and 6/25/24. During an interview on 6/27/24, at 2:00 p.m. the Director of Nursing (DON) confirmed that Resident R1's above medications were not available and were not administered per physician's order. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 395758 Page 3 of 3