Kadima Rehabilitation & Nursing at Harmony

In the surveyor’s words

From the most serious findings on record at Kadima Rehabilitation & Nursing at Harmony, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 9, 2025

  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. […]

• Immediate jeopardy, isolatedF689Jan 26, 2024

  Based on review of facility policy, clinical records, facility investigation, resident and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent injuries for two of four residents (Resident R3 and R1). This failure caused Resident R3 to have an unsupervised fall causing head trauma, abrasion of nose and fracture of nasal bone and Resident R3 was unsupervised smoking and suffered a burn. Resident R1suffered a fall during care and sustained blunt force injuries of the head and cervical spine from the fall which resulted in the death of Resident R1. […]

• No harm, potential for more than minimal, widespreadF806May 9, 2025

  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). 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. […]

• No harm, potential for more than minimal, widespreadF812May 9, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF835May 9, 2025

  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. 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. […]