Inspection·June 12, 2025

F 0603 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review, observations and resident and staff interviews, it was revealed that the facility failed to prevent involuntary seclusion for one of six residents reviewed (Resident R5). Residents Affected - Few Findings include: Review of the facility policy Abuse Protection reviewed 4/25/25, indicated the resident has the right to be free from verbal, physical, mental abuse, neglect, corporal punishment, and involuntary seclusion. Abuse means the infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Involuntary seclusion is defined as separation of a resident from other residents from his/her room or confinement to his/her room against the resident's will. Review of the Resident Rights reviewed 4/25/25, indicated the resident has the right to a dignified existence and self-determination. The facility will protect and promote the rights of each residents. Residents are to be treated with dignity and respect. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE], with diagnoses that included anxiety, depression, and psychotic disorder. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 5/24/25, indicated the diagnoses were current. Further review of the MDS, Section C: Cognitive Patterns; Question C0500 BIMS Summary Score indicated 15. Section GG: Functional Abilities; Question GG0170 Mobility D: indicated the resident was dependent-helper does all of the effort. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395758 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 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)