Health inspection·September 18, 2025

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the comprehensive resident assessments were completed in the required timeframe for two of 15 resident records reviewed (Residents 16 and 20). Findings Include:Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1, revised October 2024, revealed Discharge Assessment-return not anticipated are to be completed no later than the discharge date + 14 calendar days. Further review revealed admission (comprehensive) assessment should be completed no later than the 14th calendar day of the resident's admission (admission date + 13 calendar days).Review of Resident 16's census information, provided by the facility, revealed that Resident 16 was discharged from the facility on May 8, 2025.Review of Resident 16's Minimum Data Set (MDS- an assessment tool utilized to identify a residents' physical, mental, and psychosocial needs) information on September 15, 2025, at 1:30 PM, revealed that a discharge MDS had not yet been completed.During an interview with the Nursing Home Administrator (NHA) on September 16, 2025, at 9:45 AM, it was revealed that Resident 16's discharge MDS was not completed in the required 14-day window because of a dating error in their system, and now that the problem was identified it would be corrected.Review of Resident 20's census information, provided by the facility, revealed that Resident 20 was admitted to the facility on [DATE].Review of Resident 20's MDS information on September 17, 2025, at 1:00 PM, revealed that a comprehensive admission assessment had not yet been completed for Resident 20. Interview with the NHA on September 18, 2025, at 9:30 AM, revealed that Resident 20's comprehensive admission assessment should have been completed within 14 days of the Resident's admission28 Pa. Code 211.5(f) Clinical records. Page 1 of 2 395998 395998 09/18/2025 Misericordia Nursing & Rehabilitation Center 998 South Russell Street York, PA 17402

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to review and revise the resident plan of care for two of 14 residents reviewed (Residents 1 and 24). Findings include: Review of Resident 1's clinical record revealed diagnoses that included anxiety (an emotion characterized by fear, tension, and worry about real or perceived threats) and dementia (mental decline severe enough to interfere with daily life, caused by various brain diseases and injuries).Review of Resident 1's plan of care revealed a care plan under the problem category: Psychotropic Drug Use, Resident receives PRN (as needed) antianxiety medication related to anxiety and hospice care.Review of current physician orders for Resident 1 failed to reveal any current orders for any antianxiety medications.An interview with the Director of Nursing (DON) on September 18, 2025, at 12:15 PM, revealed that Resident 1 had previously used antianxiety medication and it was discontinued in June 2025.Review of resident 24's clinical record documented she was admitted to the facility on [DATE]. Diagnoses included: dementia with behavioral disturbances, Alzheimer's disease (a progressive neurodegenerative disorder that primarily destroys memory and other important mental functions), and depression (feelings of severe despondency and dejection). Review of Resident 24's physician orders included: Lexapro (medication used to treat depression and anxiety) 20 mg in AM, started March 12, 2025; mirtazapine (medication use to treat depression) 7.5 mg at nighttime, started August 14, 2025; and olanzapine (antipsychotic medication used bipolar disorder) 5 mg once daily for dementia with behavioral disturbances, started April 14, 20205. Review of Resident 24's care plan prior to September 17th, 2025, failed to document the use of an antidepressant or antipsychotic medication. Review of Resident 24's quarterly Minimum Data Set (MDS - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated June 12, 2025, documented use of routine antipsychotic and antidepressant medications. During an interview with the DON on September 18, 2025, at 11:00 AM, it was revealed that Resident 24 should have a care plan for the antidepressant and antipsychotic medications. 28 Pa. Code 211.12(d)(5) Nursing services 395998 Page 2 of 2