Inspection·December 12, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, shower schedule documents, resident clinical records, resident and staff interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of seven sampled residents (Resident R1). Residents Affected - Few Findings include: The facility Flow of care policy dated 2/1/24, indicated that care will be provided to residents, as needed 24-hour a day to attain and maintain the highest level of functioning. The flow of care is to be implemented on a continuous basis to promote quality of life with the resident. The provision of targeted care needs shall be documented on Care Tracker (electronic record), Point of Care (electronic record), or ADL (Activity of Daily Living) Flow Records. The 7 a.m. -3 p.m. shift may provide the following: oral hygiene, toileting, breakfast, and showers/baths. The 3 p.m.- 11 p.m. shift may provide the following: Evening meal, repositioning, hydration, and bath/showers. Review of facility shower schedule documentation indicated that Resident R1 showers are scheduled for Tuesdays and Fridays during the 3 p.m. to 11 p.m. shift. Review of Resident R1's admission record indicated he was admitted [DATE]. Review of Resident R1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 11/22/24, indicated he had diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), hyperlipidemia (elevated lipid levels within the blood), and hypertension (a condition impacting blood circulation through the heart related to poor pressure). The diagnoses were found current upon review. Review of Resident R1's care plan indicated that he was risk for functional decline in ADL's and to monitor skin integrity during baths/showers as Review of Resident R1's shower documentation indicated there was no shower provided the week of 12/1/24 to 12/7/24. Review of Resident R1's clinical nurse progress notes did not indicate he was provided a shower or refused a shower the week of 12/1/24. During an interview on 12/12/24, at 11:04 a.m. Resident R1 stated: They are a little short on staff in the evenings. I get an aide to help me in the shower. I did miss one shower. (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 12/12/2024 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)