Inspection·November 22, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify the physician of missed medication and increased behaviors for one of four residents (Resident CRR2) and failed to notify a resident's responsible party for an increase in medication dosage for one of three residents (Resident R1). Review of the facility's policy Notification Change in Condition Responsible Party dated 2/1/24, indicated the responsible party or guardian is to be notified of changes in condition or occurrences to ensure that the resident ' s responsible party or guardian is notified of changes and /or occurrences and action and pertinent information are documented. When any one of the following instances occurs, the resident's responsible party or guardian will be notified including but not inclusive to: There is a significant change in the resident's physical, mental or psychosocial status. An incident has occurred, (including falls, altercations, injuries, elopements, medication errors, etc.). Refusal of medications, treatments, labs. The nurse must document the name of the person notified, the date and time in the nurse's notes. Review of the facility's policyNotification of Condition Change Physician Notification dated 2/1/24, indicated licensed professional nurses are responsible to provide timely and complete communication to physicians when there is a change in a resident's condition. Document assessment data the attempted or actual correspondence with physician, and physician's response in the medical record. Review of Resident CRR2 indicated an admission date of 10/19/24. Review of Resident CRR2's Minimum Data Set (MDS) dated [DATE], indicated the diagnosis of hypertension (high blood pressure), hyperlipidemia (high fat in the blood), and dementia (impairment of memory and thinking). Section C0200 indicated Brief Interview for Mental Status (BIMS- is a screening test that aides in detecting cognitive impairment) The BIMS total score suggests the following distributions: 13-15: cognitively intact; 8-12: moderately impaired; 0-7: severe impairment. Resident CRR2 received a score of three indicating severe impairment. Review of Resident CRR2's admission elopement indicated resident was at risk for elopement. Review of Resident CRR2's progress note dated 11/5/2024, at 07:48 indicated resident approached this nurse stating, I don't want your food, I don't want any of your pills. I want that doctor here right now. You people are keeping me from Altoona. I want my sister. If I don't get to Altoona, I am going to hurt somebody. Resident was pacing the hallway, very agitated. He went back into his room and (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 5 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 11/22/2024 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)