Health inspection·April 17, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, it was determined that the facility failed to provide a safe, clean, and comfortable environment on one of one nursing units. Findings include: On April 17, 2025, from 10:00 a.m. to 3:25 p.m., the following was observed: The right-side swinging glass door of the facility front door is did not open. In the dining room, the interior entrance door handle and windows were dirty with a white substance. There was garbage on the floor under the dining room exterior windows. There was a reddish stain on the door frame of the linen closet across from the nurse station. In the hallway, there was damage on the wall's wallboard and wallpaper at rooms 1, 3, 8, 24, 27, and 30. In room [ROOM NUMBER], the floor was sticky with a black residue between the door and A bed. There was a urine smell. In room [ROOM NUMBER], the floor was sticky with a black residue between the door and the bed. In room [ROOM NUMBER], there was a damaged spot on the wall behind the A bed. In room [ROOM NUMBER], the floor was sticky around the resident's bed. There was dust in the room's corners. In room [ROOM NUMBER], there was garbage under the heater. In room [ROOM NUMBER], the floor was sticky with a black residue around both residents' beds and along the interior walls. CFR: 483.10(i) Safe, Clean, Comfortable, and Homelike Environment. Previously cited 7/18/24 and 8/28/24 Page 1 of 5 395846 395846 04/17/2025 Kadima Rehabilitation & Nursing at Campbelltown 2880 Horseshoe Pike Palmyra, PA 17078

F 0584 28 Pa. Code 201.18(b)(1)(e)(2.1) Management. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395846 Page 2 of 5 395846 04/17/2025 Kadima Rehabilitation & Nursing at Campbelltown 2880 Horseshoe Pike Palmyra, PA 17078

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 facility policy review, facility documentation, clinical record review, resident interview, and staff interview, it was determined that the facility failed to immediately report an allegation of abuse or injury of unknown origin to the Administrator/Abuse Prevention Coordinator of the facility and the State Survey Agency for one of six sampled residents. (Resident 6) Findings include: Review of the facility policy, Abuse Reporting and Investigation, last reviewed November 9, 2024, revealed that all suspected or alleged incidents of abuse, neglect, or exploitation would be reported to the Administrator immediately. The State Agency would be notified of the alleged or actual event of abuse within two hours. Clinical record review revealed that Resident 6 had diagnoses that included Parkinsonism. The Minimum Data Set assessment dated [DATE], indicated that the resident was not cognitively impaired and needed substantial/maximal staff assistance with showering or bathing. Resident 6 stated in an interview on April 17, 2025, at 11:10 a.m., that she had reported to nursing staff that on March 28, 2025, two nurse aides treated her in an abusive and humiliating manner during her shower by forcefully removing her clothing, shoving her under first cold, then hot water, and roughly scrubbing her while making derogatory remarks about her skin. Review of facility documentation revealed that Resident 6 reported the incident in writing on April 1, 2025. There was no documented evidence that facility staff reported the allegation to the Administrator as required. There was no evidence that the facility reported the incident to the State Survey Agency. In an interview on April 17, 2025, at 2:21 p.m., the Administrator confirmed that there was no evidence the incident alleged by Resident 6 was reported as required. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395846 Page 3 of 5 395846 04/17/2025 Kadima Rehabilitation & Nursing at Campbelltown 2880 Horseshoe Pike Palmyra, PA 17078

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, review of facility documentation, resident interview, and staff interview, it was determined that the facility failed to thoroughly investigate an allegation of abuse for one of six sampled residents. (Resident 6) Residents Affected - Few Findings include: Review of the facility policy, Abuse Reporting and Investigation, last reviewed November 9, 2024, revealed that all suspected or alleged incidents of abuse, neglect, or exploitation would be investigated. Clinical record review revealed that Resident 6 had diagnoses that included Parkinsonism. The Minimum Data Set assessment dated [DATE], indicated that the resident was not cognitively impaired and needed substantial/maximal staff assistance with showering or bathing. In an interview on April 17, 2025, at 11:10 a.m Resident 6 reported that on March 28, 2025, two aides treated her in an abusive and humiliating manner during her shower by forcefully removing her clothing, shoving her under first cold, then hot water, and roughly scrubbing her while making derogatory remarks about her skin. Resident 6 stated she reported the incident verbally on March 28th to facility staff. Review of facility documentation revealed that Resident 6 also reported the incident in writing on April 1, 2025. There was no documented evidence that the facility completed an investigation of Resident 6's allegation of abuse. In an interview on April 17, 2025, at 2:21 p.m., the Administrator confirmed that there was no evidence of an investigation. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395846 Page 4 of 5 395846 04/17/2025 Kadima Rehabilitation & Nursing at Campbelltown 2880 Horseshoe Pike Palmyra, PA 17078

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to provide behavioral health services for one of three sampled residents with mood and behavior concerns. (Resident 6) Findings include: Clinical record review revealed that Resident 6 had diagnoses that included schizoaffective disorder, borderline personality disorder, intermittent explosive disorder, and anxiety disorder. Review of the care plan dated January 21, 2025, revealed the resident had a history of mood problems and used anti-anxiety and anti-depressant medications. The interventions included notification of the resident's physician of mood changes and behavioral problems and referral to behavioral health services as needed. On March 25, 2025, the psychiatric nurse practitioner recommended referral to outpatient mental health therapy for increased anxiety. On April 3, 2025, notes indicated the resident had requested referral to outpatient therapy for increased anxiety. There was no evidence that staff notified the resident's physician of the alteration in the resident's mood or of the referral recommendation. In an interview on April 17, 2025 at 11:10 a.m., the resident stated that her anxiety had been increasing and she had requested a referral to outpatient therapy. In an interview on April 17, 2025, at 2:55 p.m., the Director of Nursing confirmed that there had been no referral to outpatient mental health therapy as requested by Resident 6 and the psychiatric nurse practitioner. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395846 Page 5 of 5