Pennsylvania Department of Health
 KADIMA REHABILITATION & NURSING AT HARMONY
Patient Care Inspection Results

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KADIMA REHABILITATION & NURSING AT HARMONY
Inspection Results For:

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KADIMA REHABILITATION & NURSING AT HARMONY - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey in response to three complaints completed on February 24, 2026, it was determined that Kadima Rehabilitation &; Nursing at Harmony was not in compliance with the following requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.\~




 Plan of Correction:


483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on review of facility policy, clinical record review and resident and staff interviews it was determined that the facility failed to provide Activities of Daily Living (ADL) assistance for three of four residents reviewed (Resident R1, R2, and R3).

Findings include:

Based on review of facility policy "Activities of Daily Living", dated 1/19/26, indicated: "The facility will, based on resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following of activities of daily living: bathing, dressing, grooming, and oral care."

Review of the clinical record indicated Resident R1 was admitted to the facility on 4/14/25.

Review of Resident R1 Minimum Data Set (MDS- a periodic assessment of care needs) dated 12/17/25, indicated diagnosis of anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissue), hypertension (when the pressure in in your blood vessels is too high), and BPH (prostate to increase in size). Section GG - Functional Abilities, Question GG0130E indicted the resident was coded at a "02" for substantial/maximal assistance for shower and bath; the ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair).

Review of Resident R1 task card indicated Resident R1 is scheduled to receive a shower Wednesday and Saturday Day shift.

Review of Resident R1 December 2025 shower documentation indicated no shower, or bath was provided on 3rd,6th,17th, 20th, and 27th
January 2026: 14th,17th,20th, and 27th
February 2026:4th

During an interview on 2/ 23/26, at 12:57 p.m. Resident R1 indicated that he does not get showers consistently, he has to ask for them and does not always receive them, or they offered at night which is not his preference.

Review of the clinical record indicated Resident R2 was admitted to the facility on 2/14/25.

Review of Resident R2 MDS dated 1/3/26, indicate diagnosis of malnutrition (refers to deficiencies, excesses imbalances in a person's intake of energy and/or nutrients), paraplegia (paralysis that affects your legs, but not your arms) and chronic pain syndrome (pain that last for over three months). Section GG - Functional Abilities, Question GG0130E indicated the resident was coded at a "01" for dependent helper does all of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.

Review of Resident R2 task card indicated Resident R2 is scheduled to receive a shower Friday and Tuesday.

Review of Resident R2 December 2025 shower documentation indicated no shower or bath was given on 2nd,5th,9th,16th,19th, and 23rd.
January 2026: 2nd, 6th, 30th.
February 2026: 3rd.

During an interview on 2/23/26, at 1:31 p.m. Resident R2 indicated that he prefers showers, and does not receive them consistently, that he likes showers over bed baths.

Review of the clinical record indicated Resident R3 was admitted to the facility on 2/28/25.

Review of Resident R3 MDS dated 2/12/26, indicated diagnosis of Heart Failure (occurs when the heart muscle doesn't pump blood as well as it should), PVD (slow and progressive circulation disorder caused by narrowing blockage or spasms in a blood vessel), and thyroid disorder (thyroid gland does not make enough thyroid hormones). Section GG- Functional Abilities, Question GG0130E indicated the resident was coded at a "03" for partial/moderate assistance - helper does less than half the effort. Helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort.

Review of Resident R3 task card indicated Resident R3 is scheduled to receive a shower Wednesday and Saturday day shift.

Review of Resident R3 December 2025 shower documentation indicated no shower or bath was given on : 16th, 19th, and 23rd.
January 2026: 2nd, 13th, and 20th.

During an interview on 2/24/26, at 11:30 a.m. Director of Nursing was informed that the facility failed to offered baths and or showers on the dates listed above and that the facility failed to provide activities of daily living for Resident R1, R2 and R3.

28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services.





 Plan of Correction - To be completed: 04/06/2026

Resident R1, R2, and R3 have received showers and were interviewed to determine their preferred shower schedules to best meet their needs. Showers continue to be offered in accordance with their established schedules.

The facility will ensure that nursing staff follow shower schedules as per plan of care.

The Director of Nursing or designee will educate all nursing staff on proper shower schedules and appropriate documentation of care.

The Director of Nursing or designee will perform 10 shower audits weekly for 4 weeks then monthly for 3 months to ensure residents are receiving appropriate hygienic care per their plan of care.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.

§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Review of facility census data and nursing time schedules from 12/21/25 through 12/27/25, 1/11/26 through 1/17/26, and 2/17/26 through 2/23/26 revealed the following Nurse Aide (NA) staffing shortages.

Findings include:

Day Shift:
Date Census Full Time Equivalents (FTE)Present FTE Required
12/21/25 109 8.61 10.90
12/25/25 108 9.04 10.80
12/26/25 109 10.83 10.90
12/27/25 109 8.68 10.90


Evening Shift:
Date Census FTE Present FTE Required
12/21/25 1096.91 9.91
12/24/25 107 6.87 9.73
12/25/25 108 9.60 9.82
12/26/25 109 9.69 9.91


Night Shift:
Date Census FTE Present FTE Required
12/23/25 108 6.89 7.20
12/25/25 107 4.81 7.20
12/26/25 109 6.94 7.27
12/27/25 109 6.94 7.27

During an interview on 2/24/26, at 11:30 a.m. the Director of Nursing confirmed that the facility failed to provide a minimum of one nurse aide per 10 residents during the day shift, and one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on night shift.





 Plan of Correction - To be completed: 04/06/2026

The facility cannot correct that nurse aide staffing ratios were not met on 12/21/25 through 12/27/25, 1/11/26 through 1/17/26, and 2/17/26 through 2/23/26.

The facility has added an additional staffing agency to ensure adequate coverage. The facility also has additional incentives for current employees and recruitment efforts including referral bonus, weekend shift differential, pick up shift bonuses and a same day pay option. The facility will ensure that nurse aide staffing ratios are met every shift.

The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5520 and ensuring nurse aide staffing ratios are met each shift.

Daily staffing ratios will be reviewed at daily staffing meeting. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel and/or call extra support staff to assist.

The nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure nurse aide staffing ratios are being met.

The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on review of nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one Licensed Practical Nurse (LPN) per 25 during the day shift (2/17/26 through 2/23/26), and one LPN per 40 residents during the night shift (12/21/25 through 12/27/25, 1/11/26 through 1/17/26, and 2/17/26 through 2/23/26).

Findings include:

Review of the facility census data nursing time schedules from the day shift 2/17/26 through 2/23/26, night shift 12/21/25 through 12/27/25, 1/11/26 through 1/17/26, and 2/17/26 through 2/23/26 revealed the following LPN shortage:

Day Shift:
Date Census Full Time Equivalents (FTE)Present FTE Required
2/19/25 111 4.03 4.44

Night Shift:
Date Census FTE Present FTE Required
12/23/25 108 2.62 2.70
12/24/25 107 1.97 2.68
12/25/25 108 1.90 2.70
1/13/26 110 2.05 2.75
1/14/26 111 2.09 2.78
2/20/26 110 1.95 2.75

During an interview on 2/24/26, at 11:30 a.m. the Director of Nursing confirmed that the facility failed to provide a minimum of one Licensed Practical Nurse (LPN) per 25 during the day shift, and one LPN per 40 residents during the night shift.





 Plan of Correction - To be completed: 04/06/2026

The facility cannot correct that LPN staffing ratios were not met on 12/21/25 through 12/27/25, 1/11/26 through 1/17/26, and 2/17/26 through 2/23/26.

The facility has added an additional staffing agency to ensure adequate coverage. The facility also has additional incentives for current employees and recruitment efforts including referral bonus, weekend shift differential, pick up shift bonuses and a same day pay option. The facility will ensure that LPN staffing ratios are met every shift.

The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift.

Daily staffing ratios will be reviewed at daily staffing meeting. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist.

The nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure LPN staffing ratios are being met.

The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.

§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of nursing time schedules and staff interview it was determined that the facility failed to provide the minimum of general nursing hours to each resident in a 24 hour period on 18 of 21 days (12/21/25, 12/23/25, 12/24/25, 12/26/25, 12/27/25, 1/11/26, 1/12/26, 1/13/26, 1/14/26, 1/15/26, 1/16/26, 1/17/26, 2/17/26, 2/19/26, 2/20/26, 2/21/26, and 2/22/26).

Findings include:

Review of facility census data and nursing time schedules from 12/21/25 through 12/27/25, 1/11/26 through 1/17/26, and 2/17/26 through 2/23/26, revealed that the facility failed to maintain 3.20 hours of general nursing care (PPD) to each resident in a 24-hour period on the following dates:

Date Census PPD
12/21/25 109 2.75
12/23/25 108 3.16
12/24/25 107 2.92
12/25/25 108 2.64
12/26/25 109 3.05
12/27/25 109 2.91
01/11/26 109 2.85
01/12/26 108 2.98
01/13/26 110 2.98
01/14/26 111 2.99
01/15/26 112 3.01
01/16/26 115 2.86
01/17/26 115 2.80
02/17/26 109 3.10
02/19/26 111 2.88
02/20/26 110 3.03
02/21/26 110 3.09
02/22/26 108 3.11

During an interview on 2/24/26, at 11:30 a.m. Director of Nursing confirmed that the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on 18 of 21 days.






 Plan of Correction - To be completed: 04/06/2026

The facility cannot correct that the PPD was below a 3.20 staffing level on 12/21/25 through 12/27/25, 1/11/26 through 1/17/26, and 2/17/26 through 2/23/26.

The facility has added an additional staffing agency to ensure adequate coverage. The facility also has additional incentives for current employees and recruitment efforts including referral bonus, weekend shift differential, pick up shift bonuses and a same day pay option. The facility will ensure that PPD is met every day.

The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5640 and make sure that PPDs are met. Daily schedules will be reviewed to monitor the projected PPD and the IDT will adjust if needed to ensure PPDs are met. The Nursing Supervisors will review staffing sheets on the weekends. If the facility projects to not meet PPD on any given day, the scheduler/designee will be responsible for calling off duty personnel and/or call extra support staff to assist.

The nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure PPDs are being met.

The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.


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