Health 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 Page 1 of 2 395758 395758 07/31/2024 Kadima Rehabilitation & Nursing at Harmony 191 Evergreen Mill Road Harmony, PA 16037

F 0622 facility. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/31/24, at 1:05 p.m. Social Worker Employee E1 stated I faxed all the information but did not document anything. Residents Affected - Few During an interview on 7/31/24, at 2:10 p.m. Director of Nursing confirmed 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). 28 Pa. Code 201.29 (a) (c.3) (2) Resident rights. 395758 Page 2 of 2