Health inspection·March 28, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records and the Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that the MDS assessment accurately reflected the status of one of 16 residents reviewed (Resident R2). Residents Affected - Few Findings include: Review of MDS instructions for Section H Bladder and Bowel subsection H0300 Urinary Continence indicated that urinary continence is to be coded as not rated if during the seven-day look-back period the resident had an indwelling bladder catheter (tubing from the bladder to drain urine into the bag), condom catheter, ostomy, or no urine output for the entire seven days. Resident R2's clinical record revealed an admission date of 3/4/24, with diagnoses that included Benign Prostatic Hyperplasia (BPH - a noncancerous enlargement of the prostate gland, which can result in frequent urination, difficulty starting or stopping urination and a weak urine stream), depression (condition characterized by persistent feeling of sadness loss of interest in activities once enjoyed), gastro-esophageal reflux disease (a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]), and high blood pressure. Resident R2's clinical record revealed a physician's order dated 3/4/24, for an Indwelling Catheter. Resident R2's discharge MDS with Assessment Reference Date (ARD) of 5/30/24, admission MDS with ARD of 6/10/24, and quarterly MDS's with the ARD's of 9/10/24, 12/10/24, and 3/12/25, Subsection H0100 Appliances was coded as Indwelling Catheter and Subsection H0300 Urinary Continence was coded as Always Continent, although Resident R2 had an indwelling catheter for the entire seven-day look-back period. During an interview on 3/28/25, at 8:53 a.m. Registered Nurse Assessment Coordinator Employee E1 confirmed that the 5/30/24, 6/10/24, 9/10/24, 12/10/24 and 3/12/25, MDS's were coded inaccurately and urinary continence should have been coded as not rated for Resident R2. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(ix) Medical records Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 395794 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saint John XXIII Home 2250 Shenango Freeway Hermitage, PA 16148 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)