Kadima Rehabilitation Harmony: Neglect Violation - PA
That was not the only time someone entered his room that evening and left without helping him. Staff came in with meal trays. Staff came in with water. Staff came in with snacks. By the time the night was over, R105 had spent hours in the same condition, wet and unattended, while the floor moved around him.
Federal inspectors cited Kadima Rehabilitation & Nursing at Harmony following a complaint investigation completed April 30, 2026. The citation was for neglect: specifically, failing to ensure that R105 received timely incontinence care during the evening shift on February 25, 2026. The facility's own Director of Nursing confirmed the failure during an interview the day before the inspection closed.
The nursing aide working the 2 p.m. to 10 p.m. shift on the northwest wing that night, identified in inspection records as Employee E19, provided a written witness statement dated February 26, 2026, the day after the incident. In it, she laid out exactly how the evening unfolded, and the picture that emerges is not of a callous worker but of a single aide caught between several emergencies at once, making assumptions that turned out to be wrong, and never stopping to verify them.
E19 wrote that she was responsible for the care of several residents that shift, including R105 and another resident, identified as R11, and a third resident who began vomiting and did not stop. The vomiting resident consumed the early part of her evening. She had to provide direct medical support while also mopping the entire room for infection control. That task alone, in the middle of a dinner service, would have stretched any aide working a full assignment.
After dinner trays were picked up, she helped an agency aide, a temporary worker not regularly assigned to the floor, with that aide's two residents. Then she went to R11's room for what she described as a full bed change, something she called routine for him. She was moving, she was working, she was not standing still.
At some point during that stretch, R105's call light came on. E19 wrote that she noticed it while she was taking another resident to the shower room. She was already committed to that task. Passing by the beauty shop, she asked the agency aide to cover her lights. The agency aide said okay. When E19 came out of the shower room, R105's light was off. She assumed the agency aide had answered it and taken care of whatever he needed.
"When I answer lights I do what they want," E19 wrote. "I don't turn off the bell and leave so I assume that's what she did since Resident R105 didn't ring again the rest of the night."
That assumption was the gap through which R105 fell.
E19 never followed up with the agency aide to find out what R105 had rung for. She wrote that she was "so wrapped up in the other resident's chaos" that she genuinely forgot to ask. She noted that multiple nurses had gone into R105's room during the shift and none of them told her he still needed to be changed. When she came out of the shower room and his light was dark, she took that as confirmation his needs had been met.
They had not been.
R105, for his part, told inspectors he had not used his call bell during that time. He said staff had come in and out of his room periodically, bringing trays, water, and snacks, but that incontinence care was not provided during any of those visits. He did not say how long he waited, or describe his condition in terms the inspection report captured in detail. What the record shows is that the facility's own director of nursing, interviewed on April 29, 2026, confirmed that the facility had failed to ensure he was free from neglect.
The director of nursing did not contest the finding.
What the inspection report describes is a failure that no single person entirely caused and that no single procedural fix would have entirely prevented. E19 was managing a vomiting resident, mopping a room, covering another aide's patients, completing a full bed change, and transporting a third resident to the shower, all within the span of a few hours on a single shift. The agency aide she asked to cover her lights was a temporary worker whose familiarity with the residents and their care needs the report does not address. The nurses who entered R105's room and said nothing to E19 about his condition are mentioned in her statement but not interviewed in the portion of the report made available.
The result was that an incontinent man sat through dinner and into the evening while a rotating cast of staff moved through his room and nobody stopped.
E19's statement captures the logic of how this happens without anyone deciding to let it happen. She wrote: "I may have forgotten to check on Resident R105 when his light was on when I was taking another resident to the shower room." She used the word "may." She was not certain. She was reconstructing a shift that had been chaotic enough that she could not account for every moment. The agency aide said okay, the light went off, and she moved on to the next emergency.
That is how neglect happens in understaffed facilities handling multiple crises simultaneously. Not through indifference, necessarily, but through a system where one aide is expected to manage a vomiting patient, a full bed change, a shower transfer, and an agency worker's coverage gap all at once, and where the communication between staff is informal enough that a resident's unmet need can disappear into the assumption that someone else handled it.
R105 told inspectors he had not rung his call bell. He had waited. Staff had come in. Staff had left. He had not rung again.
The inspection classified the harm level as minimal harm or potential for actual harm, and noted that few residents were affected. The regulatory citations attached to the finding cover the licensee's responsibility, facility management, resident care policies, and nursing services under Pennsylvania code.
None of that language captures what the evening of February 25th was like for R105, sitting in his room while the floor stayed busy around him, his light eventually going dark, and everyone assuming someone else had taken care of it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kadima Rehabilitation & Nursing At Harmony from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
KADIMA REHABILITATION & NURSING AT HARMONY in HARMONY, PA was cited for neglect violations during a health inspection on April 30, 2026.
That was not the only time someone entered his room that evening and left without helping him.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.