MISERICORDIA NURSING & REHABILITATION CENTER

Nursing Home Inspector

998 SOUTH RUSSELL STREET
YORK, PA 17402
York County
Phone: 717-755-1964
Provider Number: 395998
Last Inspection: 01/05/2017

About the Nursing Home

Number of Beds: 50
Number of Residents: 37
Beds Available: 13
Percent Occupancy: 74%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

19

Facility
24

County
23

PA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

19

2017
12

2015
9

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

1/5/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Isolated : Minimal 3 2/20/2017
 
Failed To: Put firmly secured handrails on each side of hallways. Pattern : Minimal 4 2/20/2017
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 2/20/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 2/20/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 2/20/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 2/20/2017
 

12/16/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 2/12/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 2/12/2016
 
Failed To: 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day. Pattern : Minimal 4 2/12/2016
 

1/23/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 3/16/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 3/16/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 3/16/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

2/22/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 3/21/2017
 
Failed To: Employ staff that are licensed, certified, or registered in accordance with state laws. Isolated : Minimal 3 3/21/2017
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg PA State Avg
Number of Residents 37 129.87 110.03
Registered Nurses 0.96 0.68 0.94
Licensed Practical / Vocational Nurses 1.20 1.03 0.85
Certified Nursing Assistants 2.78 2.43 2.26
Total Staff Hours 4.93 4.15 4.05

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% PA State Avg%
of high risk long-stay residents with pressure ulcers 8 3 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 97 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100 98 95
of long-stay residents experiencing one or more falls with major injury 0 2 3
of long-stay residents who have depressive symptoms 4 3 2
of long-stay residents who lose too much weight 4 6 7
of long-stay residents who received an antianxiety or hypnotic medication 17 20 22
of long-stay residents who received an antipsychotic medication 12 15 15
of long-stay residents who self-report moderate to severe pain 3 7 6
of long-stay residents who were physically restrained 0 5 0
of long-stay residents whose ability to move independently worsened 12 18 20
of long-stay residents whose need for help with daily activities has increased 10 12 15
of long-stay residents with a catheter inserted and left in their bladder 2 2 1
of long-stay residents with a urinary tract infection 4 3 3
of low risk long-stay residents who lose control of their bowels or bladder 87 58 56
of short-stay residents assessed and appropriately given the pneumococcal vaccine 89 87 83
of short-stay residents who had an outpatient emergency department visit 2 8 10
of short-stay residents who made improvements in function 86 65 64
of short-stay residents who newly received an antipsychotic medication 3 1 1
of short-stay residents who self-report moderate to severe pain 12 15 15
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 85 84 82
of short-stay residents who were rehospitalized after a nursing home admission 22 18 20
of short-stay residents who were successfully discharged to the community 52 48 52
of short-stay residents with pressure ulcers that are new or worsened 3 0 0