Health inspection·November 20, 2025

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. Based upon clinical record review, it was determined that the facility failed to obtain a physician's discharge summary for a resident discharged home (Resident 41)Findings include:Review of Resident 41's Closed Record revealed Resident 41 was discharged to home from the facility.Further clinical record review failed to reveal evidence that a Physician's Discharge Summary was completed prior to Resident 41's discharge.Interview with Director of Nursing on November 20, 2025, at 10:39 a.m. confirmed that no Physician's Discharge Summary was completed prior to Resident 41's discharge home. 28 Pa. Code 211.5(d)(f) Clinical Records Previously cited 2/27/2025 Page 1 of 6 395827 395827 11/20/2025 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

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 Based on clinical record review and staff interviews, it was determined that the facility failed to follow physician-ordered parameters for pain medication administration for one of 16 residents reviewed (Resident R24).Findings include:Review of Resident R24's clinical record revealed an active order for oxycodone-acetaminophen 5-325 mg, administer one tablet by mouth every eight hours as needed for moderate to severe pain. With a start date of August 28, 2025.Review of the facility's Pain Assessment, Step Five, indicated: Determine the appropriate type of pain medication as ordered by the physician using the following pain scale (may be individualized per physician order): 1-3 = mild pain; 4-7 = moderate pain; 8-10 = severe pain.Review of Resident R24's Medication Administration Records (MARs) for August, September, October, and November 2025 revealed the resident received the medication outside of the prescribed parameters on six occasions.An interview conducted on November 20, 2025, at 1:10 p.m. with the Regional Clinical Director confirmed that staff administered Resident R24's pain medication outside the physician-ordered parameters. Pa Code 211.12(d)(5) Nursing Services Pa Code 201.14(a) Responsibility of licensee.Pa Code 201.18(b)(3) Management. Residents Affected - Few 395827 Page 2 of 6 395827 11/20/2025 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based upon observation, it was determined that the facility failed to ensure residents were free from accidents and hazards for one of two medication carts (Cart 1).Findings include:Observation of Medication Cart 1 on November 18, 2025, at 9:10 a.m. revealed the medication cart to be unlocked and unattended. Further observation of the medication cart revealed medications in a medication cup on the top of the cart with multiple residents in the hallway and room doorways. Further observation failed to reveal evidence of any nursing staff member in the vicinity of the medication cart at the time of the observation.Interview with the Director of Nursing on November 20, 2025, at 10:00 a.m. confirmed that nursing staff should not have left medications on the top of the cart unattended. 28 Pa. Code 211.12(d)(1)(5) Nursing ServicesPreviously cited 11/27/2024, 12/30/2024 395827 Page 3 of 6 395827 11/20/2025 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, staff interviews, and policy review, it was determined that the facility failed to implement non-pharmacological interventions prior to administering PRN pain medication for one of 16 residents reviewed (Resident R24).Findings include:Review of Resident R24's clinical record revealed an active order for oxycodone-acetaminophen 5-325 mg, administer one tablet by mouth every eight hours as needed for moderate to severe pain. With a start date of August 28, 2025.Review of the facility's Pain Assessment documentation indicated: Record all assessment data obtained during the procedure, including location of pain, level of pain using the pain scale, type of pain relief used, and any non-pharmacological interventions applied prior to the administration of PRN pain medication.Review of Resident R24's clinical record failed to reveal documentation of any non-pharmacological interventions attempted prior to administering PRN pain medication.An interview conducted on November 20, 2025, at 1:10 p.m. with the Regional Clinical Director confirmed that staff were not implementing non-pharmacological interventions prior to administering PRN pain medication. Pa Code 211.12(d)(5) Nursing Services Pa Code 201.14(a) Responsibility of licensee.Pa Code 201.18(b)(3) Management. Residents Affected - Few 395827 Page 4 of 6 395827 11/20/2025 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, date, and monitor food products in the Main Kitchen.Findings include:During an observation on November 18, 2025, at 9:45 a.m. in the dry storage room, the following items were observed without labels or dates:Six plastic bags of dried pastaOne bag of brown powderOne bag of toasted oatsDuring an observation on November 18, 2025, at 9:45 a.m. in the freezer located in dry storage, the following item was observed without a label or date:One bag of frozen English muffinsDuring an observation on November 18, 2025, at 9:45 a.m. in the freezer located in the Main Kitchen, the following item was observed without a label or date:One bag of frozen fishDuring an observation on November 18, 2025, at 9:45 a.m. in the refrigerator located in the Main Kitchen, the following item was observed to be expired:One container of sweet tea with a use by date of November 17, 2025An interview conducted on November 20, 2025, at 1:52 p.m. with the Dietary Manager confirmed that the facility failed to ensure food items were properly labeled, dated, and used within their designated timeframes. Pa Code 201.14(a) Responsibility of licensee.Pa Code 201.18(b)(3) Management. 395827 Page 5 of 6 395827 11/20/2025 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based upon observation, it was determined that the facility failed to ensure infection control practices were monitored on two of two nursing units and two of two medication carts.Findings include:Observation of the hand sanitizer units on November 19, 2025 at 9:15 a.m. revealed the following - hand sanitizer unit near the nurses' station had an expiration date of January, 2024; hand sanitizer unit in the short hallway near the nurses' station had an expiration date of January 2024; hand sanitizer unit outside the dining room had an expiration date of February 2023; hand sanitizer unit In the dining room had an expiration date of January 2024; hand sanitizer unit located inside the front door had an expiration date of January 2024; hand sanitizer unit in the activity room had an expiration date of December 2023 and the hand sanitizer unit outside the Nursing Home Administrator's office had an expiration date of January 2024.Observation on November 19, 2025, of two medication carts revealed pudding used for medication administration with a date of November 14, 2025, located on the top of the container. The above information was conveyed to administration on November 20, 2025, at 11:00 a.m. 28 Pa. Code 201.18(a) ManagementPreviously cited 11/27/2024, 2/27/2025 Residents Affected - Some 395827 Page 6 of 6