Misericordia Nursing & Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF656Oct 12, 2023

  Based on review of facility policy, observations, staff interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for five of 16 resident records reviewed (Residents 13, 24, 33, 102, and 202). Findings Include: Review of facility policy, titled Care Plans, Comprehensive Person-Center, not dated, read, in part, comprehensive person-centered care plans describe services to be furnished to attain or maintain resident highest practicable physical, mental, and psychosocial wellbeing. […]

• No harm, potential for more than minimal, patternF812Oct 12, 2023

  Based on observation, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the main kitchen and for one of one kitchenette. Findings include: Review of facility policy, titled Food Storage, revised August 2019, read, in part, ready-to-eat foods must be labeled with a use by date. Thickened liquids, once opened, user must add use by information; product to be used within five days after opening. Observation in the dry storeroom on October 10, 2023, at 9:35 AM, revealed one bag of spaghetti was open with contents partially removed and was not date marked with an open date. […]

• No harm, potential for more than minimal, patternF689Oct 14, 2021

  Based on observations, facility policy review, clinical record review and staff interview, it was determined that the facility failed to ensure the resident environment remains free of accident hazards for one of seventeen resident records reviewed (Resident 5) and failed to maintain an environment that was free of accident hazards during medication administration on one of two nursing units (Fayfield Place). Findings Include: Review of Resident 5's October 2021 physician orders revealed diagnoses including dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and a history of falling. […]

• No harm, potential for more than minimal, isolatedF636Sep 18, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF657Sep 18, 2025

  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… […]