Inspection visit

InspectionMay 9, 2025

KADIMA REHABILITATION & NURSING AT HARMONYCMS #39575850 citations on this visit

50 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 50 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on review of observations and staff interview, it was determined that the facility failed to protect and value residents' private space (South Wing Resident R18, and R63) Residents Affected - Few Findings include: Review of the facility policy Confidentiality dated 4/25/25, indicated that to protect resident's privacy and dignity, the staff should not enter rooms without knocking except in an emergency. During an observation on South Wing on 5/5/25, at 12:03 p.m. Nurse Aide (NA) Employee E1 was seen entering Resident 18's room without knocking or requesting permission to enter. During an observation on South Wing on 5/5/25, at 12:05 p.m. Nurse Aide (NA) Employee E1 was seen entering Resident 63's room without knocking or requesting permission to enter. During an interview on 5/5/25, at 12:05 p.m. NA Employee E1 confirmed that she failed to knock prior to entering Resident R18, and R63's rooms which failed to protect and value the residents' private space. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 201.29(a)Resident Rights. 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 38 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 05/09/2025 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)

F 0575 Level of Harm - Potential for minimal harm Residents Affected - Many Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Based on observations and staff interview it was determined that the facility failed to have required postings for the facility in areas that are accessible to all residents throughout the facility for State Agency information, how to file a complaint with State Agency, Adult Protective Service information, and complete contact information for State Long-Term Care Ombudsman program posted at the facility. Findings include: During an observation on 5/8/25, at 12:42 p.m. in the [NAME] Hallway there was a poster with Ombudsman contact information, which only consisted of the phone number, and did not have name, address, or email address listed. During an observation on 5/8/25, at 12:44 p.m. at the nursing station between the South Hallway and North Hallway, failed to include information on State Agency, how to file a complaint with State Agency, and Adult Protective Services. During an observation on 5/9/25, at 9:47 a.m. in the Northwest Hallway, failed to include information on State Agency, how to file a complaint with State Agency, and Adult Protective Services. During an interview on 5/9/25, at 11:12 a.m. the Nursing Home Administrator confirmed that the facility failed to have required postings in areas that are accessible to all residents throughout the facility for State Agency information, how to file a complaint with State Agency, Adult Protective Services information, and complete contact information for State Long-Term Care Ombudsman program. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(b)(3) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 2 of 38 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 05/09/2025 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)

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of five medication carts (North Medication Cart). Residents Affected - Few Findings include: Review of facility policy Confidentiality dated 4/25/25, indicated the resident has the right to personal privacy and confidentiality of his or her personal and clinical records. Access to resident medical records will be limited to the staff and consultants providing services to the resident. During an observation on 5/6/25, at 11:20 a.m. the North Medication Cart at the nurses station was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. During an interview on 5/6/25, at 11:20 a.m. Registered Nurse Employee E4 confirmed the above observation and that the facility failed to maintain the confidentiality of residents' medical information as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.29(c.3) Resident Rights. 28 Pa. code: 211.5(b) Medical records. 28 Pa. Code: 211.12(d)(1)(3) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 3 of 38 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 05/09/2025 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and staff interview, it was determined that the facility failed to maintain a clean, safe, and homelike environment for three of ten residents (Resident R106, R102, and R64). Findings Include: Review of the facility policy Resident Environment dated 4/25/25, indicated the facility will provide a safe, clean, comfortable, and homelike environment. During observations of the North nursing unit on 5/5/25, at 9:45 a.m. the following was observed: -Resident R106 in room [ROOM NUMBER]-D, indicated the perimeter of the wall to the left of the entrance door was dirty with built up grime, the floor mat beside the bed was dirty with white and gray markings and smudges, the perimeter of the wall under the heating element was corroded with built up grime, the bathroom had five visibly cracked floor tiles. -Resident R102 in room [ROOM NUMBER]-D, indicated a bathroom with three visibly cracked floor tiles around the base of the commode. -Resident R64 in room [ROOM NUMBER]-B, indicated gnats flying around the bedside table that had an old meal tray from breakfast still there. The perimeter of the wall under the heating element was corroded with built up grime, and there was an air condition unit sitting on the floor in the corner of the room. Tour and interview with the Nursing Home Administrator (NHA), on 5/5/25, at 10:05 a.m. the NHA confirmed the facility failed to maintain a clean, safe, and homelike environment for three of ten residents (Resident R106, R102, and R64). 28 Pa. code: 201.14 (b) Responsibility of licensee. 28 Pa Code: 201.18 (e)(1)(2) Management. 28 Pa Code: 201.29 (a)(c) Resident Rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 4 of 38 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 05/09/2025 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, facility provided documents, clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from mental abuse and threats of punishment or deprivation for one of three residents reviewed (Resident R64). Findings include: The facility's policy Abuse Protection dated 4/25/25, indicated each resident has the right to be free from abuse. Abuse means the infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation, denial of food or privileges. Review of admission record indicated Resident R64's was admitted to the facility on [DATE]. Review of Resident R64's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/18/25, indicated the diagnoses of chronic atrial fibrillation (irregular heart rhythm), mechanical complications of an internal fixation device of bones, and chronic pain. Section C indicated a BIMS score of 15 (Brief Interview for Mental Status - a screening test that aides in detecting cognitive impairment). A total score of 13 -15, indicated cognitively intact. Review of Resident R64's care plan on 5/9/25, at 12:30 p.m. indicated resident has pain related to osteoarthritis (flexible protective tissue at the ends of bones, cartilage, wears down and worsens over time), lymphedema (swelling in arm or leg caused by a lymphatic system blockage), chronic osteomyelitis (inflammation of bone caused by infection), and mechanical complication of internal fixator device of bone. Goal indicated the pain will be resolved within one hour of intervention. Administer pain medications per physician order and note the effectiveness. Acknowledge presence of pains and discomfort. Listen to resident's concerns. Review of Resident R64's physician orders indicated the following medications for pain; -Order dated 2/12/25, indicated gabapentin (medication for chronic nerve pain) 300 milligrams (mg) three times daily. -Order dated 4/16/25, indicated acetaminophen (medication that treats mild aches and pain) 650mg every eight hours. -Order dated 4/17/25, indicated oxycodone (a potent narcotic for pain)/acetaminophen 7.5mg/325mg every six hours. Review of Resident R64's medication administration record indicated resident was receiving medications as prescribed. Observation of Resident R64 on 5/5/25, at 10:00 a.m. indicated resident lying in bed with a visibly enlarged and disfigured left ankle wrapped heavily in an ACE wrap (elastic bandages). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 5 of 38 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 05/09/2025 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 5/5/25, at 10:00 a.m. Resident R64 indicated he injured his left ankle over four years ago and has had terrible pain and complications ever since. Resident indicated the doctors here won't give me my medicines every four hours and that he really needed them every four hours as the terrible pain returns too soon with the medications being every six hours. Review of Certified Registered Nurse Practitioner (CRNP) Employee E17's palliative care consultation dated 5/7/25, at 1:41 p.m. indicated Reason for Palliative Consultation chronic pain from osteomyelitis of left foot/ankle, debility and behavioral disturbance. Further review of CRNP Employee E17's consultation indicated Resident R64's mood was stable that morning, although he did have a verbal outburst with aggression/chair throwing over the weekend. Resident was upset with staff that his pain medication was not given 30 minutes early as staff had competing priorities. CRNP Employee E17 indicated I discussed at length with resident that it is never ok to treat staff that way, we do not tolerate verbal abuse and will reduce pain medications in future if this behavior persists. Interview on 5/9/25, at 10:48 a.m. the Assistant Director of Nursing (ADON) Employee E10 and the Nursing Home Administrator were notified by survey agency of the CRNP Employee E17's palliative consultation and the intimidation, threatening to decrease pain medications as mental abuse and threats of punishment or deprivation of services. Interview on 5/9/25, at 10:49 a.m. the NHA confirmed that the consultation note indicated a form of intimidation and threatening to deprive Resident R64 of pain medications was not appropriate. Interview on 5/9/25, at 1:30 p.m. the NHA confirmed the facility failed to make certain a resident was free from mental abuse and threats of punishment or deprivation for one of three residents reviewed (Resident R64). 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(2)(3) Management. 28 Pa. Code 211.10(a)(c.)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 6 of 38 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 05/09/2025 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident records, facility documentation, incidents submitted to the local State field office, resident council interview, resident and staff interviews it was determined that the facility failed to submit a report of an allegation of emotional abuse in a timely manner to the local State field office for one of five sampled residents (Resident R96). Findings include: The facility Abuse reporting and investigation policy dated 11/1/24 and last reviewed 4/25/25, indicated that the facility will thoroughly investigate all reports of suspected or alleged abuse. Abuse includes the deprivation by an individual of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Mental abuse includes humiliation, harrassment, threats of punishment, or deprivation. Department of Health will be notified of an alleged event by the Administrator. Review of Resident R96's admission record indicated that he was originally admitted on [DATE]. Review of Resident R96's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 2/2/25, indicated that he had diagnoses that included hypertension (a condition impacting blood circulation through the heart related to poor pressure), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning). Review of Resident R96's care plans dated 5/6/25, indicated to gently redirect activities when Resident R96 makes inappropriate actions. Review of Resident R96's Nurse practitioner note dated 4/25/25, indicated that Resident 96 stated his mood is ok and he began complaining about some issues such as bathroom had poop all over it and sometimes they are mean to me referring to staff. Review of Resident R96's clinical nurse progress note dated 4/25/25 , indicated that at 8:28 p.m. Resident R96 was screaming profanities and racial slurs at staff. Staff approached resident in hallway by his room asked him to stop yelling and he continued to yell about the staff. Staff escorted him to his room and offered emotional support he was not accepting of support and told staff to get the f out of his room. Staff left his room and he then slammed the door. Review of Resident R96's clinical nurse progress note dated 4/25/25 , indicated that at 9:33 p.m. Resident R96 continued to come out of his room and verbally attack staff. He was witnessed on the floor in the hallway and he was screaming profanities and racial slurs; he stated that he is going to call the police on staff. He then began to throw the battery to the hoyer lift at staff. Emotional support was offered but he replied with f- you. He then went to the end of west hall in his wheelchair and was trying to pull the fire alarm. Staff called EMS and the police for assistance. Police arrived and Resident R96 calmed down and voluntarily went with EMS to hospital for a psychological evaluation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 7 of 38 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 05/09/2025 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R96's Nurse practitioner note dated 4/29/25, indicated that Resident R96 was observed in his wheelchair. He sated they still don't treat me right referring to staff. He further stated they pick on me. I ask them for things and they taunt me. Resident R96 had significant behaviors on Saturday which required a 911 call and transfer to the hospital for evaluation. During a resident council group interview on 5/7/25, at 1:02 p.m. Resident R53 voiced a concern with staff to resident intimidation. During an interview on 5/8/25, at 9:43 a.m. Resident R53 stated the following: yes, there was an incident. It occurred next to us. There was a bathroom problem. Older gentleman had issues; it was Resident R96. It does not take much to trigger him. The bathroom was cleaned around 5:00 p.m. to 6:00 p.m. The bathroom was a mess again and an African-American female agency aide was asked to clean it and she refused. Resident R96 got mad and threw food. Then they (Resident R96 and the unidentified staff person) started swearing back and forth at one another. Resident R96 was later sent to the hospital to evaluate for mental illness. The toilet was not cleaned until the next day. The people here know about it. During an interview on 5/8/25, at 9:52 a.m. information relayed to Nursing Home Administrator (NHA) and the NHA stated that it sounded familiar and he will provide documentation. Review of reports and facility documents submitted to the local State field office from 2/1/25 to 5/7/25 did not include a report related to Resident R96's allegation of emotional abuse. During an interview on 5/8/25, at 1:09 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to submit a report of an allegation of emotional abuse in a timely manner to the local State field office involving Resident R96 as required. 28 Pa Code: 201.18 (e)(1)(2) Management 28 Pa Code: 201.29 (a )(c)(d) Resident Rights 28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 8 of 38 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 05/09/2025 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)

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **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 make certain that the necessary resident information was communicated to the receiving health care provider for two of three residents sampled with facility-initiated transfers (Residents R3, and R110). Findings include: Review of the admission record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/28/25, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and hyperlipidemia (high levels of fat in the blood). Review of the clinical record indicated Resident R3 was transferred to the hospital on 4/28/25. Review of Resident R3's clinical record 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 facility. Interview with the Director of Nursing on 5/9/25, at 10:00 a.m. confirmed Resident R3's clinical record did not contain the required information prior to transferring to the hospital. Review of the clinical record indicated Resident R110 was admitted to the facility on [DATE]. Review of Resident R110's MDS dated [DATE], indicated diagnoses of high blood pressure, delirium due to known physiological condition, and altered mental status. Review of the clinical record indicated Resident R110 was transferred to the hospital on 4/12/25. Review of Resident R110's clinical record 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 facility. During an interview on 5/9/25, at 11:55 a.m. the Assistant Director of Nursing (ADON) Employee E10 confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of three residents as required. 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 9 of 38 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 05/09/2025 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)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for four of ten residents (Residents R2, R55, R74, and R89). Residents Affected - Some Findings include: Review of facility policy MDS/RAI/Care Planning dated 4/25/25, indicated the Resident Assessment Instrument (RAI) and Care Planning Process provide a tool for interdisciplinary approach to plan the care of the resident. The purpose of the RAI is to incorporate the identified medical, nursing, nutritional, rehabilitative, and psychosocial needs of each resident into interventions and goals to meet those needs. The RAI is a process that defines an interdisciplinary approach to resident assessment and plan of care to help the resident attain the highest practicable functional level. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated the following instructions: - Section A1500: Preadmission Screening and Resident Review (PASRR): code 1, yes if: PASSR Level II screening determined that the resident has a serious mental illness and/or ID/DD (Intellectual Disability/Developmental Disability) or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. - Section J1300: Current Tobacco Use: code 1, yes if: the resident or any other source indicates that the resident used tobacco in some form during the 7-day look-back period. - Section N0415: High-Risk Drug Classes: Use and Indication, Question N0415E1 - Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 day). Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's quarterly MDS dated [DATE], indicated diagnoses of high blood pressure, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), and muscle weakness. Review of Resident R1's Preadmission Screening Resident Review Identification (PASRR-ID) Level 1 form, dated 1/5/17, indicated the resident has a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition; requires further evaluation (Level II). Review of a letter from The Department of Human Services, dated 1/4/17, indicated Resident R2 had evidence of a Mental Health condition that meets criteria for review by the Office of Mental Health and Substance Abuse Services. Review of Resident R2's annual comprehensive MDS dated [DATE], Question A1500 Preadmission (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 10 of 38 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 05/09/2025 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)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Screening and Resident Review (PASRR) indicated no the resident is not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. During an interview on 5/8/25, at 10:58 a.m. Social Service Director Employee E20 confirmed Resident R2 is considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Review of the clinical record indicated Resident R55 was admitted to the facility on [DATE]. Review of Resident R55's admission MDS dated [DATE], indicated diagnoses of high blood pressure, schizophrenia, and depression. Question A1500 Preadmission Screening and Resident Review (PASRR) indicated no the resident is not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Question J1300 indicated the resident was coded 0 No for Current Tobacco Use. Review of Resident R55's Preadmission Screening Resident Review Identification (PASRR-ID) Level 1 form, dated 1/31/25, indicated the resident has a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition; requires further evaluation (Level II). Review of a letter from The Department of Human Services, dated 2/14/25, indicated Resident R55 had evidence of a Mental Health condition that meets criteria for review by the Office of Mental Health and Substance Abuse Services. During an interview on 5/8/25, at 10:58 a.m. Social Service Director Employee E20 confirmed Resident R55 is considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Review of a physician order dated 4/15/25, indicated OK to smoke per facility protocol. Review of Resident R55's Smoking Safety Screening assessment dated [DATE], indicated the resident smokes 5-10 cigarettes a day and was safe to smoke with direct supervision. Review of a nursing progress note dated 4/15/25, stated, While out smoking this evening, the resident was arguing with another resident about the Vietnam War, insisting that he was fighting against Americans. This caused quite a disruption in the smoking time for residents as there are veterans in the group. The CNA (Certified Nurse Aide) that took them out reported that this resident kept getting louder and more aggressive with his argument. Review of the clinical record indicated Resident R74 was admitted to the facility on [DATE]. Review of Resident R74's quarterly MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and muscle weakness. Question N0415E1 indicated the resident received an anticoagulant during the 7-day look-back period. Review of Resident R74's clinical record failed to include a physician order for an anticoagulant medication. Review of the clinical record indicated Resident R89 was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 11 of 38 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 05/09/2025 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)

F 0641 Level of Harm - Minimal harm or potential for actual harm Review of Resident R89's quarterly MDS dated [DATE], indicated diagnoses of hyperkalemia (high levels of potassium in the body), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and depression. Question N0415E1 indicated the resident received an anticoagulant during the 7-day look-back period. Residents Affected - Some Review of Resident R89's clinical record failed to include a physician order for an anticoagulant medication. During an interview on 5/9/25, at 10:56 a.m. Licensed Practical Nurse Assessment Coordinator Employee E9 confirmed that the facility failed to ensure that Minimum Data Se assessments accurately reflected the resident's status for four of ten residents as required. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.5(f) Medical records. 28 Pa. Code 211.12(c)(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 12 of 38 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 05/09/2025 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)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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, observation and interviews it was determined that the facility failed to provide care and services to meet the accepted standards of clinical practice two of four residents (Resident R14 and R16). Residents Affected - Few Findings include: A review of the facility policy Controlled Medications dated 4/25/25, indicated when a controlled drug is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record: date and time of administration, amount administered, signature of the nurse administering the dose, completed after the dose is actually administered. Observation of medication storage on 5/7/25, at 12:42 p.m. of the North Medication Cart, it was discovered that the random narcotic count for accurate record keeping was inaccurate. Interview on 5/7/25, at 12:43 p.m. Licensed Practical Nurse (LPN) Employee E6 indicated, the count is not going to be correct, because I gave the medications this morning. I signed them on the medication administration record (MAR), but not yet on the narcotic accountability record. Review of admission Record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/16/25, indicated diagnoses of high blood pressure, anxiety and depression. Review of Resident R14's physician order dated 4/8/25, indicated to give clonazepam (a controlled substance that treats anxiety) 0.5 milligrams (mg) three times daily. Review of Resident R14's MAR for 5/7/25, indicated the clonazepam was signed off by LPN Employee E6 as administered per orders. Observation and interview with LPN Employee E6 on 5/7/25, at 12:44 p.m. Resident R14's card of clonazepam had 47 pills in it and the narcotic accountability log indicated there should have been 48 pills, due to LPN Employee E6 not immediately documenting it after it was given. Review of admission Record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's MDS dated [DATE], indicated the diagnoses of heart failure (heart does not pump blood as well as it should), high blood pressure, and anxiety. Review of Resident R16's physician order dated 12/31/24, indicated lorazepam (a controlled substance that treats anxiety) 0.5mg three times daily. Review of Resident R16 MAR for 5/7/25, indicated the lorazepam was signed off by LPN Employee E6 as administered per orders. Observation and interview with LPN Employee E6 on 5/7/25, at 12:46 p.m. Resident R16's card of lorazepam had 20 pills in it and the narcotic accountability log indicated there should have been 21 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 13 of 38 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 05/09/2025 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)

F 0658 pills, due to LPN Employee E6 not immediately documenting it after it was given. Level of Harm - Minimal harm or potential for actual harm During an interview 5/7/25, at 2:00 p.m. the Director of Nursing confirmed that the facility failed to provide care and services to meet the accepted standards of clinical practice two of four residents (Resident R14 and R16). Residents Affected - Few 28 Pa. Code 211.10(a)(c.)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 14 of 38 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 05/09/2025 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)

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 review of facility policy, clinical records, and staff interview it was determined that the facility failed to follow a physician order for an edema (swelling) glove for one out of three residents (Resident R35). Residents Affected - Few Findings include: Review of the facility policy Quality of Care: Attain and Maintain dated 4/25/25, indicated each resident must receive and the facility will provide the necessary services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Review of the admission record indicated Resident R35 was admitted on [DATE]. Review of Resident R35's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/29/25, indicated the diagnoses of high blood pressure, stroke (damage to the brain from an interruption of blood supply), and seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness). Review of Resident R35's physician order dated 2/21/25, indicated resident to wear right edema glove on with morning care off with evening care. Review of Resident R35's care plan dated 4/3/25, indicated resident to wear right edema glove on with morning care off with evening care. Observation on 5/7/25, at 1:00 p.m. Resident R35 was out of bed in the wheelchair, dressed and ready for the day without the edema glove to his right hand as ordered. Observation on 5/9/25, at 10:00 a.m. Resident R35 was out of bed in the wheelchair, dressed and ready for the day without the edema glove to his right hand as ordered. Interview on 5/9/25, at 10:05 a.m. Nurse Aide (NA) Employee E18 indicated it was her normal assignment and nobody on that hall (North Hall) had a glove for edema or swelling. Interview on 5/9/25, at 10:09 a.m. NA Employee E19 indicated it was her normal assignment and nobody on that hall (North Hall) had a glove for edema or swelling. Interview on 5/9/25, at 10:30 a.m. Licensed Practical Nurse (LPN) Employee E6 confirmed on the computer that Resident R35 was ordered to have a right-hand edema glove on and confirmed he did not have it on as ordered. Interview on 5/9/25, at 1:30 p.m. the Director of Nursing confirmed the facility failed to follow a physician order for an edema glove for one out of three residents (Resident R35). 28 Pa. Code 201.18(b)(1)(2)(3) Management. 28 Pa. Code 211.10(a)(c.)(d) Resident care policies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 15 of 38 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 05/09/2025 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)

F 0684 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 16 of 38 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 05/09/2025 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)

F 0685 Assist a resident in gaining access to vision and hearing services. 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 policies and clinical records and resident and staff interviews, it was determined that the facility failed to make certain that residents receive proper treatment and assistive devices to maintain visual ability for one of four residents (Resident R41). Residents Affected - Few Findings include: Review of the facility policy Vision and Hearing dated 4/25/25, indicated the facility will ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities. Interview on 5/6/25, at 9:40 a.m. Resident R41 asked survey agency to read the menu for lunch as he could not read it. Resident indicated he used to have glasses but has not had a pair in a long time. Review of the admission record indicated Resident R41 was admitted to the facility on [DATE]. Review of Resident R41's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/12/25, indicated the diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), stroke (damage to the brain from an interruption of blood supply), and depression. Section B1200 corrective lenses indicated Yes. Review of Resident R41's eye care chart note dated 11/30/23, indicated resident presents for evaluation of cataracts (clouding of the normally clear lens of the eye) in the right and left eye. It affects both eyes and the symptom is constant. The condition is moderate. No treatment at this time, monitor for progression. New glasses will be ordered pending insurance/payer approval. Review of Resident R41's eye care chart note dated 8/15/24, indicated the assessment showed age-related nuclear cataract of both eyes. Plan - after education and discussion, the patient would like to be referred out for cataract surgery. Return to clinic in two to four months for follow up. Review of Resident R41's progress note dated 10/8/24, indicated resident returned back from ophthalmology appointment in stable condition but unable to be seen due to insurance issues as per physician's office. Review of Resident R41's optometry note dated 3/10/25, indicated cancelled visit. Resident did not have cataract surgery and does not need to be seen. Interview on 5/8/25, at 1:00 p.m. Assistant Director of Nursing (ADON) Employee E10 verified that resident had not had cataract surgery and did not have glasses. Interview on 5/9/25, at 1:30 p.m. the Director of Nursing confirmed the facility failed to make certain that residents receive proper treatment and assistive devices to maintain visual ability for one of four residents (Resident R41). 28 Pa. Code: 211.10(a)(c)(d) Resident care policies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 17 of 38 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 05/09/2025 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)

F 0685 28 Pa. Code: 211.12(d)(3)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 18 of 38 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 05/09/2025 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one of five residents (Resident R2). Findings include: Review of facility policy Splint/Brace Management dated 4/25/25, indicated residents will be assessed to determine a splint/brace device program to attain, maintain, and prevent decline in joint mobility. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/30/25, indicated diagnoses of high blood pressure, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), and muscle weakness. Review of a physician order dated 1/31/25, indicated resident to wear bilateral (both sides) palm roll splints (a brace used to prevent finger contractures and skin break down in the palm) at all times, remove for hygiene and perform skin checks every shift. During an observation on 5/6/25, at 10:47 a.m. Resident R2 was observed without her bilateral palm roll splints applied. During an observation on 5/7/25, at 10:50 a.m. Resident R2 was observed without her bilateral palm roll splints applied. During an observation on 5/7/25, at 1:20 p.m. Resident R2 was observed without her bilateral palm roll splints applied. During an interview on 5/7/25, at 1:25 p.m. Licensed Practical Nurse Employee E6 confirmed Resident R2 did not have her palm roll splints applied and that the facility failed to ensure Resident R2 received appropriate services, equipment, and assistance to maintain or improve mobility. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10(a)(c)(d) Resident care policies. 28 Pa. Code: 211.12(c)(d)(1)(2)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 19 of 38 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 05/09/2025 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility documents, resident interview, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident (Resident R110), and failed to properly identify a resident's risk for elopement (Resident R54). This failure created an immediate jeopardy situation for two of 108 residents. Findings include: Review of facility policy Resident Elopement dated 4/25/25, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leaves of absence) and/or any necessary supervision to do so. Upon admission, residents will be assessed for elopement risk. Cognitively impaired residents with the physical ability to leave the facility without assistance, and who have demonstrated or vocalized a desire to leave the facility will be placed on a unit with an electronic monitoring system or similarly secured unit. Residents at risk for elopements shall have their pictures maintained for identification purposes. Residents at high risk for elopement shall not be admitted to the facility unless appropriate interventions are identified prior to admission and the facility has the ability to appropriately supervise and monitor the resident. Review of the clinical record indicated Resident R110 was admitted to the facility on [DATE]. Review of Resident R110's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/16/25, indicated diagnoses of high blood pressure, delirium due to known physiological condition, and altered mental status. Review of Resident R110's clinical record revealed an Elopement Risk Assessment completed on 3/10/25, which consisted of the following information: Risk Assessment: 1) Is the resident cognitively impaired? Yes 2) Is the resident independently mobile (ambulatory or wheelchair)? Yes 3) Does the resident have poor decision-making skills? Yes 4) Has the resident demonstrated exit seeking behavior? Yes 5) Does the resident wander oblivious to safety needs? Yes 6) Does the resident have a history of elopement? No Determination: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 20 of 38 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 05/09/2025 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)

F 0689 1) Resident is determined AT RISK for elopement. Yes Level of Harm - Immediate jeopardy to resident health or safety 2) Plan has been implemented to ensure resident safety. Yes Residents Affected - Few Review of Resident R110's care plan dated 3/11/25, indicated the resident will not wander out of facility through next review. Interventions included assist in reorientation to room and facility using verbal cues and reminders, check resident's whereabouts frequently, door alarms on at all times and answer alarms promptly, encourage group activity and attempt to keep occupied, make receptionist and other staff aware of elopement risk, notify social services for persistent attempts to leave building and not responding to redirection, photo identification on file in front lobby, put familiar items in resident's room to assist in identifying room, redirect from exits as needed based on behavior, and Wanderguard device (electronic monitoring safety bracelet) check placement and function each shift. Score: 1.0 Category: At Risk for Elopement Review of a physician order dated 3/11/25, indicated Wanderguard every evening shift check for proper function. Review of a physician order dated 3/11/25, indicated Wanderguard every shift check for proper placement. Review of an event submitted by the facility dated 3/24/25, stated, On 3/24/25 at approximately 1930 (7:30 p.m.) the Supervisor was made aware that Resident R110 was unintentionally let out by a CNA (Certified Nurse Aide). While the CNA was attending to another resident and helping them through the doorway, Resident R110 walked outside and away from CNA to another location of facility grounds. CNA was alerted that the resident walked away and immediately alerted the Supervisor. The Supervisor immediately alerted other staff to search facility grounds. Within two minutes, staff from the facility Personal Care (PC) side called the Supervisor to make her aware that Resident R110 was found knocking on their front door. Addendum - when code is entered, and the door is opened the wanderguard system does not alarm. In this instance when the staff member entered the code and opened the door to allow residents outside, Resident R110 was not close enough to the door to allow the system to alarm prior to the staff opening the door. Review of a nursing progress note dated 3/24/25, stated, Resident was let out with smokers and walked around building to door. PC called to make staff aware of situation. Floor staff went to PC to bring resident back to unit. CNA educated on the importance of knowing who can't go out at smoke times. Resident willingly returned to unit and had no injuries or distress noted. Review of a witness statement completed by Registered Nurse (RN) Employee E14 dated 3/25/25, stated, Last night on 3-11 shift, this RN was notified by staff that Resident R110 had followed the smoking residents out the door with staff for their smoke break. In less than two minutes, PC staff notified this staff that he was outside, and he was immediately accompanied into the building. He was pleasant and courteous with staff, fully assessed, VSS (vital signs stable), and Resident R110 was in good spirits. His wander guard was checked along with all doors, and he was supervised at all times, as one of the residents also noticed his walking out with the smokers and alerted the group. Physician and family notified. Review of a witness statement dated 3/25/25, completed by Nurse Aide (NA) Employee E5 stated, I was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 21 of 38 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 05/09/2025 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety taking the residents out for smoking break and another resident, Resident R110, walk passed while I was tending to another resident while getting her out the door way. In the midst of assisting that resident over to the rest of the residents another resident informed me that Resident R110 had taken off walking away from the facility building. I instantly started running to see where he was, I didn't see him so I ran inside the building asking the nurses for help because Resident R110 had walked off. At that moment everyone set out to find out where Resident R110 had gone to. Residents Affected - Few Review of a Current Smokers list provided by the facility on 5/5/25, indicated the facility has 12 residents who smoke. Resident R110 was not identified by the facility as a current smoker. During an observation on 5/6/25, at 10:37 a.m. seven residents were observed in the designated smoking area with one staff member. During this observation, while staff had the door open to allow residents outside, the wanderguard system continuously alarmed while the door was held open. During an interview on 5/6/25, at 10:44 a.m. RN Employee E13 stated, We don't have any documentation that we bring with us during smoking, we just know who smokes. They're never all out at once. During an observation on 5/6/25, at 11:18 a.m. of an Elopement Binder located at the nurse's station revealed Residents R104, R106, and R110 were identified as elopement risks. During an interview on 5/6/25, at 11:23 a.m. NA Employee E2 stated, I just started in March. The facility gave me education about their elopement policy. I know residents are an elopement risk because they have one of those bracelets. I'm not sure about a binder with elopement risks. Resident R106 tries to get out, she's the only one I know for sure. During an interview on 5/6/25, at 11:25 a.m. NA Employee E1 stated, Therapy approves smokers for safety. There is no list used for smokers, we basically know who smokes. There are too many smokers to go outside with just one person watching. When asked who elopement risks are, NA Employee E1 stated, Her and pointed to Resident R54. NA Employee E1 stated, She got outside one time with visitors about a week ago. We couldn't find her in the building another time, we all had to look for her. Review of the clinical record revealed that Resident R54 was admitted to the facility on [DATE]. Review of Resident 54's MDS dated [DATE], indicated diagnoses of high blood pressure, chest pain, and dementia (a progressive decline in mental ability, impacting memory, thinking, language, and behavior, to the point where it affects daily life). Review of Resident R54's clinical record revealed an Elopement Risk Assessment completed on 4/8/25, which consisted of the following information: Risk Assessment: 1) Is the resident cognitively impaired? Yes 2) Is the resident independently mobile (ambulatory or wheelchair)? Yes 3) Does the resident have poor decision-making skills? Yes 4) Has the resident demonstrated exit seeking behavior? Yes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 22 of 38 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 05/09/2025 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)

F 0689 5) Does the resident wander oblivious to safety needs? Yes Level of Harm - Immediate jeopardy to resident health or safety 6) Does the resident have a history of elopement? No Residents Affected - Few 1) Resident is determined AT RISK for elopement. Yes Determination: 2) Plan has been implemented to ensure resident safety. Left Blank Score: 1.0 Category: At Risk for Elopement Review of Resident R54's clinical record revealed a physician's order dated 4/8/25, for a Wanderguard, which was discontinued on 4/15/25. During an observation on 5/6/25, at 11:26 a.m. Resident R54 was observed pushing on an external door and asked State Agency how to get out of the door. During an interview on 5/6/25, at 11:45 a.m. NA Employee E3 stated, Resident R54 has exit seeking behaviors. Coworkers informed me she got out the front door with visitors about a week ago. I have to redirect her often. She does not have a Wanderguard. An additional review of Elopement Binder on 5/6/25, at 11:50 a.m. confirmed that Resident R54 was not identified as an elopement risk. During an interview on 5/6/25, at 11:55 a.m. the Nursing Home Administrator (NHA) stated he was not aware that Resident R54 had gotten out of the building or if she was an elopement risk. During an interview on 5/6/25, at 12:11 p.m. the Director of Nursing (DON) stated, When Resident R54 was admitted we were told by a nurse who had Resident R54 at a prior facility that she was an elopement risk. When she was admitted , we put her as an elopement risk and put a Wanderguard on her. We watched her for a week, and she did not communicate any wants to leave, so we discontinued her Wanderguard. Elopement assessments are done at admission and quarterly. Staff are to notify the supervisor if there is a change in a resident's behavior. The Activity Director updates the elopement binder anytime there is a change. Elopement risks are reviewed daily, it's part of our clinical stand-up meeting. On 5/6/25, at 1:45 p.m., the NHA and DON were made aware that Immediate Jeopardy (IJ) existed, NHA was provided the IJ Template, for two of 108 residents, which resulted in an elopement from the facility, and a corrective action plan was requested. During a telephonic interview on 5/6/25, at 2:43 p.m. NA Employee E5 stated, I was letting the smokers out and he [Resident R110] must have gotten by me and I really didn't notice. One of the other residents was like, the guy left and the resident told me who it was. I immediately went to the front of the building, couldn't find him, went back in and told nurses. We never found him; he went to personal care. He got out in the midst of letting the smokers out, I was helping a resident over the little hump of the door, she couldn't push herself over in her wheelchair. He must have went around me and I didn't notice. The facility had previously given me education about elopements. At the time of the incident, I didn't know he was a wanderer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 23 of 38 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 05/09/2025 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety During an observation on 5/6/25, at 3:53 p.m. Resident R54 was observed attempting to get out of the facility through an external door. The Wanderguard system alarmed when Resident R54 approached the door, alerting staff of her attempt to exit the building. On 5/6/25, at 4:02 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Residents Affected - Few Immediate Action: - The facility immediately reviewed and revised the elopement policy on 5/6/25, at 2:00 p.m. Residents: - The Director of Nursing or designee will complete assessments on all residents to identify their risk for elopement on 5/6/25, and care plans will be updated to reflect the residents' current condition, risk for elopement and resident centered interventions on 5/6/25. A list of residents at risk for elopement will be placed at each nursing station to inform staff of residents at risk. System Correction: - The root cause of the elopement has been determined to be lack of staff education and supervision. - The Nursing Home Administrator or Designee will educate all staff, including agency staff, on elopement policies and procedures, documenting residents with exit seeking behaviors, reporting exit seeking behaviors to administration and implementing proper interventions for these residents prior to staff's next scheduled shift. - The facility immediately will allocate additional staff members to supervise smokers to ensure appropriate supervision is available to meet residents. The facility will immediately have one staff member for every eight residents who smoke. Monitoring: - The Facility will complete a head count of all residents each shift for four weeks to ensure residents are safe and provided adequate supervision. - The Director of Nursing of Designee will review progress notes daily for four weeks to identify any residents with new exit seeking behaviors to ensure appropriate interventions are in place. - The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for frequency of audits. The facility's policy and procedures for elopements were reviewed on 5/6/25, no revisions were made. The facility's policy and procedures for smoking were reviewed and revised on 5/7/25, to reflect supervision of one staff member for every eight residents during supervised smoking. During an observation on 5/7/25, at 10:38 a.m. six residents were observed outside smoking with three staff members present. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 24 of 38 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 05/09/2025 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety On 5/7/25, at 11:20 a.m. it was confirmed 108/108 residents were reassessed for an elopement risk. 4/108 residents were identified as at risk, and 4/4 care plans were updated to include interventions to prevent elopement. 4/4 residents were included in the elopement binders. Elopement books with 4/4 identified residents were observed at two of two nursing stations and the front desk. The residents' photos and names were listed. Residents Affected - Few Review of facility documents on 5/7/25, revealed that the facility has 126 employees and that 100% had received elopement education. 59 of these employees received formal education on the policy Resident Elopement which included reporting residents with exit seeking behaviors to the supervisor and documenting all exit seeking behaviors in the clinical record. 67 of these employees had received education via telephone as they had not been working in the building. Staff are to sign when they are in the building before the start of their next shift. During employee interviews on 5/7/25, from 9:58 a.m. through 11:55 a.m. 36 employees confirmed they had received education on the facility's elopement policy and procedures, as stated above. The Immediate Jeopardy was lifted on 5/7/25, at 12:07 p.m. when the action plan implementation was verified. During an interview on 5/7/25, at 12:08 p.m. the NHA confirmed that the facility failed to make certain each resident received adequate supervision that resulted in an elopement for one resident (Resident R110) and failed to properly identify a resident's risk for elopement (Resident R54). This failure created an immediate jeopardy situation for two of 108 residents who may not have been identified properly as an elopement risk. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 25 of 38 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 05/09/2025 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)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for two of two residents (Residents R11 and R89). Findings include: Review of facility policy Side Rails Proper Use dated 4/25/25, indicated an assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's bed mobility and ability to transfer between positions, to and from bed or chair, to stand and toilet. The use of quarter or half-side rails, as an assistive device will be addressed in the resident care plan. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE]. Review of Resident R11's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/24/25, indicated diagnoses of high blood pressure, hyponatremia (low levels of sodium in the blood), and depression. During an observation on 5/5/25, at 11:32 a.m. two top enabler bars were present on Resident R11's bed. Review of Resident R11's clinical record on 5/7/25, failed to include an ongoing assessment for the resident's enabler bar usage, and failed to include the development of goals and interventions related to the resident's enable bar usage in the care plan. Review of the clinical record indicated Resident R89 was admitted to the facility on [DATE]. Review of Resident R89's MDS dated [DATE], indicated diagnoses of hyperkalemia (high levels of potassium in the body), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and depression. During an observation on 5/5/25, at 10:30 a.m. two top enabler bars were present on Resident R89's bed. Review of Resident R89's clinical record on 5/7/25, failed to include an ongoing assessment for the resident's enabler bar usage, and failed to include the development of goals and interventions related to the resident's enable bar usage in the care plan. During an interview on 5/8/25, at 2:21 p.m. the Assistant Director of Nursing Employee E10 confirmed that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for two of two residents as required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 26 of 38 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 05/09/2025 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)

F 0700 28 Pa. Code: 201.14 (a) Responsibility of licensee. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code 211.10 (c)(d) Resident care policies. Residents Affected - Few 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 27 of 38 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 05/09/2025 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)

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical records and staff interviews, it was determined that the facility failed to provide sufficient and timely social services related to assistance in obtaining guardians for two of four residents (Resident R41 and R102). Residents Affected - Some Findings include: Review of the facility's Social Service Job Description indicated the social worker will develop a community resource file and establishes contact with new providers. Refer resident/family member to appropriate social service agencies when facility does not provide services or needs of resident. Review of the admission record indicated Resident R41 was admitted to the facility on [DATE]. Review of Resident R41's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/12/25, indicated the diagnoses of Alzheimer ' s Disease (a progressive disease that destroys memory and other important mental functions), stroke (damage to the brain from an interruption of blood supply), and depression. Section C- Brief Interview for Mental Status (BIMS - is a screening test that aides in detecting cognitive impairment) indicated a score of two: severe cognitive impairment. Interview on 5/8/25, at 1:00 p.m. Assistant Director of Nursing (ADON) Employee E10 verified that resident had not had cataract surgery and did not have glasses because he had problems with the grandson, and he needed a guardian. Interview on 5/8/25, at 1:10 p.m. the Nursing Home Administrator indicated the previous company quit paying the attorneys and they were in the process of establishing a new contract with another and verified there was a delay in getting Resident R41 a guardian. Review of the admission record indicated Resident R102 was admitted to the facility on [DATE]. Review of Resident R102's MDS dated [DATE], indicated the diagnoses of manic depression (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), psychotic disorder (a mental disorder characterized by a disconnection from reality), and borderline intellectual functioning. Section C - Brief Interview for Mental Status indicated a score of three: severe cognitive impairment. Upon admission agreement sign in review process on 5/9/25, it was discovered that Resident 102's admission sign in agreement was not completed from 7/19/24. Interview on 5/9/25, at 11:00 a.m. the Nursing Home Administrator indicated Resident R102 is also on the list for needing a guardian and did not currently have one and confirmed the admission agreement sign in was never completed, and provided a General Notes Report on Resident R102 that indicated the following: -7/22/24, Medical Assistance 103 admission sent (MA 103 must be completed by the facility or the resident's attending physician when a medical assistance applicant is admitted to the facility or converts to medical assistance, and when services are no longer required). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 28 of 38 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 05/09/2025 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)

F 0745 -8/9/24, Received CAO (County Assistance Office) request for more information. Level of Harm - Minimal harm or potential for actual harm -8/15/24, application sent without documents. -9/4/24, denial received need resources and a complete application. Needs appealed by 9/25/24. Residents Affected - Some -9/20/24, Appeal sent to CAO 10/9/24, Rep payee (a representative payee is someone appointed by the Social Security Administration (SSA) to manage Social Security benefits for individuals who are unable to manage their own money) sent 10/22/24, Resident needs a guardian. Need all resources. Resident cannot sign. Was at a personal care home that closed. 11/26/24, received approval 11/21/24. 5/8/25, spoke to private vendor about guardianship. Private vendor will reach out to law firm to file a petition for guardianship. Interview on 5/9/25, at 1:30 p.m. the Nursing Home Administrator confirmed the facility failed to provide sufficient and timely social services related to assistance in obtaining guardians for two of four residents (Resident R41 and R102) 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1)(3)(e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.16 (a)(1) Social services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 29 of 38 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 05/09/2025 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to properly secure a medication cart while not in use for one of five medication carts (North Medication Cart), and failed to properly store medications on three of three medication carts (North Medication Cart, North [NAME] Medication Cart, and Split Hall Medication Cart). Findings include: Review of facility policy Storage of Medications dated [DATE], indicated medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. Compartments containing medications are locked when not in use. During an observation on [DATE], at 12:42 p.m. of the North Hall Medication Cart indicated the following medications not dated upon opening or expired: -Resident R112's albuterol nebulizer (a medication used to prevent and treat narrowing of the airways in the lungs) -Resident R72's timolol eye drops (used for glaucoma) were dated [DATE], and should have been expired by 28 days and discarded. -Resident R12's albuterol nebulizer -Resident R7's albuterol nebulizer Interview on [DATE], at 12:43 p.m. Licensed Practical Nurse (LPN) Employee E6 confirmed the medications were not dated upon opening or expired. During an observation on [DATE], at 8:49 a.m. the North Medication Cart was observed outside of resident room [ROOM NUMBER] with the cart unlocked and unattended. During an interview on [DATE], at 8:52 a.m. Registered Nurse (RN) Employee E7 confirmed the North Medication Cart was unlocked and unattended and that the facility failed to properly secure a medication cart while not in use. During an observation on [DATE], at 9:13 a.m. of the North [NAME] Hall Medication Cart indicated the following medication not dated upon opening or expired: -Resident R29's albuterol nebulizer Interview on [DATE], at 9:13 a.m. LPN Employee E21 confirmed the medication was not dated upon opening as required. During an observation on [DATE], at 11:14 a.m. of the Split Hall Medication Cart indicated the following medications not dated upon opening: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 30 of 38 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 05/09/2025 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)

F 0761 - Resident R33's Albuterol inhaler Level of Harm - Minimal harm or potential for actual harm - Resident R73's Albuterol inhaler Residents Affected - Some During an interview on [DATE], at 11:14 a.m. LPN Employee E8 confirmed the above observations and that the facility failed to properly store medications in the Split Hall Medication Cart. Interview on [DATE], at 1:30 p.m. the Director of Nursing confirmed the facility failed to properly secure a medication cart while not in use for one of five medication carts (North Medication Cart), and failed to properly store medications on three of three medication carts (North Medication Cart, North [NAME] Medication Cart, and Split Hall Medication Cart). 28 Pa. Code: 201(a) Responsibility of licensee. 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 31 of 38 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 05/09/2025 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)

F 0806 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observations, and staff interviews it was determined the facility failed to ensure that daily nutritional and special dietary needs for residents were met for one of four weeks (April/May 2025). Residents Affected - Many Findings include: During an observation in the South Wing on 5/5/25, at 12:08 p.m. lunch trays were observed to not have any tray tickets on the trays to identify the resident, diet, or food items. During an interview on 5/5/25, at 12:08 p.m. Nurse Aide (NA) Employee E1 stated that there have not been any tray tickets on trays for about a week, and that Dietary Staff have hand-written the residents' last name, room number, and diet order on the corner of the placemat on the trays. During an interview on 5/5/25, at 12:15 p.m. Dietary Manager (DM) Employee E15 confirmed that the facility had a broken printer for approximately one week, and that the facility had not been utilizing tray tickets during that time frame, and that dietary staff was writing the residents' name, diet order, and room number on the placement. When DM Manager Employee E15 was asked how dietary staff was made aware of the information to write on the placemat, DM Employee E15 produced a printout that contained each residents' name, room number, and diet order. It did not contain food allergies, or preferences. DM Employee E15 confirmed that the facility failed to ensure that proper information regarding resident preferences and food allergies were communicated and provided. During an interview on 5/5/25, at 12:20 p.m. DM Employee E15 informed that the printer is now working and that tray tickets would now be utilized. During an interview on 5/5/25, at 1:32 p.m. Nursing Home administrator confirmed that the facility failed to ensure that daily nutritional and special dietary needs for residents were met. 28 Pa. Code: 201.12(d)(5) Nursing services 28 Pa. Code: 201.18(b)(1)(e)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 32 of 38 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 05/09/2025 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and staff interviews, it was determined that the facility failed to properly label and date food products, monitor and maintain records of refrigeration/freezer temperature logs to make certain refrigeration/freezers function properly, and failed to maintain the cleanliness and sanitation of equipment in the Main Kitchen. (Main Kitchen). Findings include: During an observation in the Main Kitchen on 5/5/25, at 9:44 a.m. refrigeration/freezer temperature log on tray line refrigerator, revealed that the facility failed to monitor and record temperatures on 5/2/25, 5/3/25, 5/4/25, and 5/5/25. Observation also revealed that refrigeration/freezer temperature log on walk-in refrigerator, and walk-in freezer revealed that the facility failed to monitor and record temperatures on 5/3/25, and 5/4/25. During an observation on 5/5/25, at 9:45 a.m. in the walk-in refrigerator the following items were observed to have no label or date: · Plastic container of cooked beef patties · Plastic container of pickles · Plastic container of diced potatoes · Plastic container of sauerkraut · Plastic container of Jello · Bag of coleslaw mix During an observation on 5/5/25, at 9:46 a.m. in the cook's area a plastic container of Cheerios was observed with no label or date. During an observation in the Main Kitchen on 5/5/25, at 9:49 a.m. the meat slicer was observed to not have a cover in place to protect from contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 33 of 38 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 05/09/2025 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an observation in the Main Kitchen on 5/5/25, at 9:50 a.m. the stand mixer was observed to not have a cover in place to protect from contamination, and contained a thick layer of dried food particles. During an interview on 5/5/25, at 9:51 am the Dietary Manager Employee E15 confirmed that the facility failed to properly label and date food products, monitor and maintain records of refrigeration/freezer temperature logs, and failed to maintain the cleanliness and sanitation of equipment in the Main Kitchen. Pa Code 201.14(a) Responsibility of licensee. Pa Code 201.18(b)(3) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 34 of 38 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 05/09/2025 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)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to prevent the elopement of a resident (Resident R110), and failed to properly identify a resident's risk for elopement (Resident R54), which created an Immediate Jeopardy situation for two of 108 residents. Residents Affected - Many Findings include: The job description for the Nursing Home Administrator specified the primary purpose of the job position is to manage the Facility with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities To follow all facility policies and apply them uniformly to all employees. The ensure the highest degree of quality care is provided to our residents at all times. The job description for the Director of Nursing specified the purpose of the job is to plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. Based on findings identified in this report, the facility failed to prevent the elopement of a resident (Resident R110), and failed to properly identify a resident's risk for elopement (Resident R54), which placed the residents in Immediate Jeopardy. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 5/7/25, at 12:08 p.m. the NHA and DON confirmed that they failed to effectively manage the facility to prevent the elopement of a resident and failed to properly identify a resident's risk for elopement, which created an Immediate Jeopardy situation. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 35 of 38 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 05/09/2025 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)

F 0880 Provide and implement an infection prevention and control program. 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, resident records, a facility tour, and staff interview it was determined that the facility failed to follow transmission based precautions and utilize enhanced barrier precautions (EBP) creating the potential for cross contamination for two out of five sampled residents (Residents R79 and R92). Residents Affected - Few Findings include: The facility Infection control policies and procedure: enhanced barrier precautions policy dated 4/1/24 and last reviewed 4/25/25, indicated that enhanced barrier precautions are an infection control intervention designed to reduce transmission of multi-drug resistance organisms (MDRO) in nursing homes. Enhanced barrier precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those with increased risk such as residents with wounds or indwelling medical devices. Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheostomies. Review of Resident R79's admission record indicated she was originally admitted on [DATE]. Review of Resident R79's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 3/20/25, indicated she had diagnoses that included breast and lung cancer, chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and hyperlipidemia (elevated lipid levels within the blood). Review of Resident R79's physician orders dated 3/14/25, indicated to use 16-French foley catheter, change foley catheter bag, and to utilized enhanced barrier precautions. Review of Resident R79's care plans dated 3/17/25, indicated to utilize enhanced barrier precautions as ordered. During observations on 5/5/25, at 11:00 a.m. Resident R79 was observed in her room. She was observed with a catheter in place. Observations of her room and door did not include a Enhanced barrier precautions (EBP) signage or infection control gown and gloves. During observations on 5/5/25, at 11:31 a.m. Resident R79 was observed in her room. She was observed with a catheter in place. Observations of her room and door did not include a Enhanced barrier precautions (EBP) signage or infection control gown and gloves. During observations on 5/8/25, at 9:54 a.m. Resident R79 was observed in her room. She was observed with a catheter in place. Observations of her room and door did not include a Enhanced barrier precautions (EBP) signage or infection control gown and gloves. Resident R79 catheter bag was observed on the floor. During observations with Registered Nurse (RN) Employee E16 on 5/8/25, at 10:18 a.m. Resident R79 was observed in her room. She was observed with a catheter in place. Observations of her room and door did not include a Enhanced barrier precautions (EBP) signage or infection control gown and gloves. Resident R79 catheter bag was observed on the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 36 of 38 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 05/09/2025 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/8/25, at 10:19 a.m. Registered Nurse (RN) Employee E16 stated there is no sign on the door and yes, the bag is on the floor. Review of the admission record indicated Resident R92 admitted to the facility on [DATE]. Review of Resident R92's MDS dated [DATE], indicated the diagnoses of high blood pressure, obstructive uropathy (a urinary tract disorder that occurs when urine flow is obstructed, either structurally or functionally), and pyelonephritis (kidney infection). Review of Resident R92's physician order dated 3/17/25, indicated cleanse nephrostomy tube (a thin catheter inserted into the kidney to drain urine when normal flow is blocked or obstructed) drain site with normal sterile saline and apply drain sponge every day and to utilize enhanced barrier precautions. Review of Resident R92's care plan dated 3/19/25, indicated resident has a nephrostomy tube, use enhanced barrier precautions. Observation of Resident R92 on 5/8/25, at 1:37 p.m. indicated resident in his wheelchair, with catheter drainage bag, covered under the chair. The doorway did not include signage indicating enhanced barrier precautions. Interview on 5/8/25, at 2:00 p.m. Infection Preventionist Employee E22 confirmed Resident R92's doorway was not adorned with appropriate signage for enhanced barrier precautions as required. During an interview on 5/8/25, at 11:20 a.m. Assistant Director of Nursing (ADON) Employee Employee E10 was asked how is EBP is communicated and stated: we have signs on doors for precautions and there is an overhead with isolation garb, masks, gloves and equipment. We discuss who is on isolation during standup in the morning. During an exit interview on 5/9/25, at 1:30 p.m. information was disseminated to the Director of Nursing (DON) and Nursing Home Administrator (NHA) that the facility failed to follow transmission based precautions and utilize enhanced barrier precautions (EBP) creating the potential for cross contamination for Residents R79 and R92. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.28 (b)(1)(e )(1) Management. 28 Pa Code: 211.10 (d ) Resident care policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 37 of 38 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 05/09/2025 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)

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility policy and resident and staff interviews, it was determined that the facility failed to follow the policies established to assess one of twelve residents for safe smoking practices (Resident R64). Residents Affected - Few Findings include: Review of the facility Smoking Policy dated 4/25/25, stated (1) upon admission, residents who smoke will be reviewed for safety with independence in smoking (2) licensed staff or department managers will be responsible for completion of the resident smoking review upon admission(3) All smoking will be . (5) All smokers who are capable of understanding the rules and regulations will be asked to sign a smoking agreement to demonstrate their understanding of the rules concerning smoking. (7) smokers will be reviewed on admission, quarterly and as necessary depending on individual circumstances and changes in the resident's condition. Review of the admission record indicated Resident R64 admitted to the facility on [DATE]. Review of Resident R64's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/18/25, indicated the diagnoses of chronic atrial fibrillation (irregular heart rhythm), mechanical complications of an internal fixation device of bones, and chronic pain. Section J1300 indicated current tobacco use as No. Review of Resident R64's physician orders on 5/9/25, at 9:02 a.m. failed to include orders relating to smoking. Review of Resident R64's smoking evaluation dated 2/18/25, indicated resident was not a smoker. Review of Resident R64's care plan indicated resident is at risk for side effects from smoking and should wear a smoking apron when actively smoking. Interview on 5/5/25, at 10:00 a.m., Resident R64 indicated that he smoked, and the smoking times were at 8:30 a.m., 10:30 a.m., 1:30 p.m., 4:00 p.m., 7:00 p.m., and 9:00 p.m. Interview on 5/9/25, at 10:56 a.m. Assistant Director of Nursing Employee E10 confirmed that there was not a physician order for Resident R64 to smoke and the smoking evaluation on 2/18/25, was not completed correctly to reflect resident's smoking status. Interview on 5/9/25, at 1:30 p.m. the Director of Nursing confirmed the facility failed to follow the policies established to assess one of twelve residents for safe smoking practices (Resident R64). 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(2)(3) Management. 28 Pa. Code 211.10(a)(c.)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395758 If continuation sheet Page 38 of 38

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Citations

50 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0575GeneralS&S Cno actual harm
F575 - The facility must post, in a form and manner accessible and understandable
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
0583GeneralS&S Dpotential for harm
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
0584GeneralS&S Dpotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0806GeneralS&S Fpotential for harm
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0835GeneralS&S Fpotential for harm
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0006GeneralS&S Cno actual harm
Conduct risk assessment and an All-Hazards approach.
0293GeneralS&S Bno actual harm
Have properly located and lighted "Exit" signs.
0311GeneralS&S Epotential for harm
Have an enclosure around a vertical opening shaft.
0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
0600GeneralS&S Dpotential for harm
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
0609GeneralS&S Dpotential for harm
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
0628GeneralS&S Dpotential for harm
F628 - Documentation
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
0641GeneralS&S Epotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0658GeneralS&S Dpotential for harm
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0685GeneralS&S Dpotential for harm
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
0688GeneralS&S Dpotential for harm
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
0689SeriousS&S Jimmediate jeopardy
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0700GeneralS&S Dpotential for harm
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
0745GeneralS&S Epotential for harm
F745 - The facility must provide medically-related social services to attain or
Provide medically-related social services to help each resident achieve the highest possible quality of life.
0761GeneralS&S Epotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0926GeneralS&S Dpotential for harm
F926 - Establish policies, in accordance with applicable Federal, State, and
Have policies on smoking.
0041GeneralS&S Cno actual harm
Implement emergency and standby power systems.
0015GeneralS&S Cno actual harm
Address subsistence needs for staff and patients.
0020GeneralS&S Cno actual harm
Establish policies and procedures including evacuation.
0023GeneralS&S Cno actual harm
Establish policies and procedures for medical documentation.
0032GeneralS&S Cno actual harm
Provide primary/alternate means for communication.
0035GeneralS&S Cno actual harm
Provide family notifications of emergency plan.
0036GeneralS&S Cno actual harm
Establish emergency prep training and testing.
0100GeneralS&S Fpotential for harm
Meet other general requirements.
0111GeneralS&S Cno actual harm
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
0133GeneralS&S Fpotential for harm
Install a two-hour-resistant firewall separation.
0223GeneralS&S Epotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
0225GeneralS&S Epotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
0271GeneralS&S Fpotential for harm
Have exits that are accessible at all times.
0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0355GeneralS&S Cno actual harm
Properly select, install, inspect, or maintain portable fire extinguishes.
0363GeneralS&S Bno actual harm
Install corridor and hallway doors that block smoke.
0372GeneralS&S Fpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
0712GeneralS&S Bno actual harm
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
0741GeneralS&S Fpotential for harm
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
0911GeneralS&S Epotential for harm
F911 - Accommodate no more than four residents
Meet requirements for the installation and maintenance of electrical systems.
0912GeneralS&S Dpotential for harm
F912 - Measure at least 80 square feet per resident in multiple resident
Have power receptacles that are properly grounded.
0918GeneralS&S Fpotential for harm
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
0923GeneralS&S Cno actual harm
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.

FAQ · About this visit

Common questions about this visit

What happened during the May 9, 2025 survey of KADIMA REHABILITATION & NURSING AT HARMONY?

This was a inspection survey of KADIMA REHABILITATION & NURSING AT HARMONY on May 9, 2025. The surveyor cited 50 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at KADIMA REHABILITATION & NURSING AT HARMONY on May 9, 2025?

Yes, 50 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·May 9, 2025