Inspection·July 31, 2024

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **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 obtain a physician's order for a discharge and make certain that the necessary resident information was communicated to the receiving health care provider for one out of five residents sampled with facility-initiated transfers (Resident R1). Findings include: Review of facility policy Documentation of Resident Discharge dated 2/1/24, indicated that documentation will be completed when a resident is discharged form this facility. The following items are to be documented when a resident is discharged from the facility to home or another facility: - Resident current condition, including mental status - Physician's discharge order has been obtained - Transfer form, facesheet, history, and physical - Physician current orders and completed testing Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/5/24, indicated diagnoses of high blood pressure, muscle spasms, and multiple sclerosis (a disease that affects central nervous system). During a review of the clinical record indicated Resident R1 was transferred to an Inpatient Rehabilitation Center on 7/25/24. During a review of Resident R1's clinical record on 7/31/24, at 12:05 p.m. failed to reveal a physician order for discharge to an inpatient rehabilitation center on 7/25/24. During a review of Resident R1's clinical record on 7/31/24, at 12:10 p.m. revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving (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 2 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 07/31/2024 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)