Marywood Heights

F-F690

28 Pa. Code 211.10(a)(c)(d) Resident care policies

28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 22 395625

F-F880

28 Pa. Code 211.12 (d)(3)(5) Nursing services

28 Pa. Code 211.10 (a)(c)(d) Resident care policies

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 22 395625 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395625 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marywood Heights 2500 Adams Avenue Scranton, PA 18509

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)

F 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39929

Residents Affected - Few Based on review of clinical records and staff interview it was determined that the facility failed to consistently provide necessary services to meet the behavioral health needs of one of 19 sampled residents (Resident 27).

Findings include:

Review of the clinical record revealed that Resident 27 was admitted to the facility on [DATE REDACTED], and had diagnoses, which included major depressive disorder.

Resident 27's clinical record revealed documentation dated from the time of the resident's admission through

the survey ending July 25, 2024, that the resident had consistent behavioral symptoms of yelling out repeatedly. These episodes occurred almost daily and not easily redirectable.

Review of Resident 27's care plan in effect at time of survey ending July 25, 2024, revealed a focus area related to the resident's history of depression with an intervention for psyche follow ups as ordered/scheduled.

A review of Resident 27's clinical record revealed the resident had an appointment with a psychiatrist scheduled for May 28, 2024. This appointment was canceled due to the facility being unable to provide transportation for the resident to attend the appointment. Further review revealed that this appointment was not yet rescheduled as of end of survey July 25, 2024.

There was no documented evidence that Resident 27 was provided timely follow-up psych services treatment thru the time of the survey ending July 25, 2024.

During an interview with the Nursing Home Administrator (NHA), on July 24, 2024, at approximately 11:00 a. m., the NHA was unable to provide evidence that Resident 27 had received psychological/psychiatric services as recommended.

28 Pa. Code 211.2 (d)(8) Medical director

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 22 395625 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395625 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marywood Heights 2500 Adams Avenue Scranton, PA 18509

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)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39929

Residents Affected - Some Based on review clinical records and medication administration record, and staff interview, it was determined that the facility failed to ensure that the attending physician acted upon on the pharmacist's reports of irregularities in the drug regimen of one resident of 19 residents reviewed (Resident 41).

Findings include:

Review of Resident 41's clinical record revealed admission to the facility on [DATE REDACTED], with diagnoses that included major depressive disorder (major loss of interest in pleasurable activities), anxiety disorder, obsessive-compulsive disorder and 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).

Review of the consultant pharmacist's Note to Attending Physician/Prescriber dated January 24, 2024, addressed the physician's order for Ativan (an antianxiety medication) 0.5 mg three times a day for anxiety.

The pharmacist recommended a Gradual Dose Reduction (GDR), noting that per CMS guidelines for psychotropic drugs, a GDR must me attempted annually, unless clinically contraindicated. The pharmacist further noted that if the drug therapy is to continue, the physician must document why the risk of the adverse consequences presented by an attempted GDR exceed the benefit of the GDR due to potential negative impact on the resident's psychiatric instability, functional capacity and quality of life.

The facility failed to provide written documentation of the attending physician's response to the consultant pharmacist's recommendation and there was no documentation that the resident's physician acknowledged

this identified pharmacy report.

Review of the consultant pharmacist's Note to Attending Physician/Prescriber dated April 24, 2024, noted that Resident 41 was prescribed three medications for anxiety: Remeron, Ativan, and Buspar with recommendation to evaluate if any of the medications could be reduced or discharged to avoid duplication of effect.

The facility failed to provide written documentation of the attending physician's response to the consultant pharmacist's recommendation and there was no documentation that the resident's physician acknowledged

this identified pharmacy report.

Review of the consultant pharmacist's Note to Attending Physician/Prescriber dated June 26, 2024, indicated that this is the 2nd request regarding three medications for anxiety: Remeron, Ativan, and Buspar with recommendation to evaluate if any of the medications could be reduced or discharged to avoid duplication of effect.

The facility failed to provide written documentation of the attending physician's response to the consultant pharmacist's 2nd request for recommendation and there was no documentation that the resident's physician acknowledged this identified pharmacy report.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 22 395625 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395625 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marywood Heights 2500 Adams Avenue Scranton, PA 18509

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)

F 0756 An interview with Director of Nursing on July 24, 2024, at approximately 2:00 PM confirmed that the facility was unable to provide documented evidence that the attending physician acted upon the pharmacy Level of Harm - Minimal harm or recommendations. potential for actual harm 28 Pa. Code 211.9 (k) Pharmacy services. Residents Affected - Some 28 Pa Code 211.5 (f) Medical records

28 Pa. Code 211.2 (d)(7) Medical director

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 22 395625 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395625 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marywood Heights 2500 Adams Avenue Scranton, PA 18509

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)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41460 potential for actual harm Based on a review of clinical records and staff interviews it was determined that the facility failed to ensure Residents Affected - Few that the resident's drug regimen was free of unnecessary antibiotic drugs for one out of 19 residents sampled (Resident 13).

Findings included:

Clinical record review revealed that Resident 13 was admitted to the facility on [DATE REDACTED], with diagnoses which included hemiplegia and hemiparesis following a stroke affecting left non-dominant side, bipolar disorder, and anxiety and was cognitively intact.

A review of documentation dated June 25, 2024, at 2:27 PM, revealed that the resident was sent to the emergency room for an evaluation due to complaints of dizziness and nausea after sustaining a fall in the bathroom and hitting her head earlier that day.

Documentation dated June 25, 2024, at 11:35 PM, indicated that the resident returned to the facility with no acute injuries and an order for Keflex 500mg twice a day for 10 days for diagnosis of possible urinary tract infection and will follow-up with hospital to obtain culture results when available.

Review of Medication Administration Record (MAR) dated June 2024, revealed that the antibiotic therapy for treatment of a possible UTI was initiated on June 26, 2024, at 8 AM.

Documentation dated June 28, 2024, at 2:16 PM, indicated that a call was placed to the hospital to request urinalysis results that were performed on June 25, 2024. The hospital did not complete a culture and sensitivity test on the urine during the evaluation. Urinalysis results were made available and given to nursing supervisor.

Nursing documentation dated from June 25, 2024, through July 5, 2024, revealed no documentation that the resident was displaying signs or symptoms of a UTI.

Review of Resident 13's clinical record revealed that antibiotic therapy continued to be administered two times per day from June 26, 2024, through July 5, 2024, despite the resident not having signs/symptoms of a UTI or the necessary diagnostic studies to clinically justify the administration of the antibiotic Keflex.

Interview with the Infection Preventionist on July 25, 2024, at approximately 12:45 PM, confirmed that the administration of Keflex was not clinically justified for treatment of Resident 13's possible UTI.

28 Pa. Code 211.2 (3) Medical Director

28 Pa. Code 211.9 (k) Pharmacy Services

28 Pa. Code 211.12 (d)(1)(3) Nursing Services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 22 395625 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395625 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marywood Heights 2500 Adams Avenue Scranton, PA 18509

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)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 41460 Residents Affected - Few Based on observation and staff interview, it was determined that the facility failed to ensure adherence to medication and pharmaceuticals expiration dates in one of 4 medication carts.

Findings include:

An observation of the second-floor Cart A medication cart on July 25, 2024, at 8:05 AM revealed two multidose insulin vials opened.

One multidose vial of Lantus 100units/ mL and one multidose vial of Admelog 100units/ mL were labeled with

an expiration date of July 17, 2024.

Employee 4, licensed practical nurse, confirmed the observations of the expired medications at the time of

observation.

Interview with the Director of Nursing on July 25, 2024, at 1:33 PM confirmed that the expired medications should have been removed from the medication cart and discarded.

28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services

28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 22 395625 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395625 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marywood Heights 2500 Adams Avenue Scranton, PA 18509

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)

F 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48277 potential for actual harm Based on review of clinical records and staff interview, it was determined that the facility failed to offer routine Residents Affected - Few annual dental services for one Medicaid payor source out of four residents sampled (Resident 23) for dental services.

Findings include:

Review of the clinical record of Resident 23 revealed admission to the facility on [DATE REDACTED], and the resident's payor source was Medicaid. There was no documented evidence at the time of the survey ending July 25, 2024, that the resident had been offered dental services in the past year.

Review of Resident 23's care plan initially dated April 13, 2020, and revised December 9, 2023, indicated that the resident declined dental visits. However, the facility was unable to provide documented evidence that

the resident was offered and declined dental services for the past year.

Interview with the Director of Nursing on July 25, 2024, at 1:27 PM confirmed that the facility had not offered Resident 23 routine dental services in the past year.

28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 22 395625 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395625 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marywood Heights 2500 Adams Avenue Scranton, PA 18509

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)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41460

Residents Affected - Some Based on review of clinical records and resident and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice, reflecting

the medial care for three residents out of 19 sampled (Residents 13, 37 and 60).

Findings included:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in

a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care:

Assessments

Clinical problems

Communications with other health care professionals regarding the patient

Communication with and education of the patient, family, and the patient ' s designated support person and other third parties.

Clinical record review revealed that Resident 13 was admitted to the facility on [DATE REDACTED], with diagnoses which included hemiplegia and hemiparesis following a stroke affecting left non-dominant side, bipolar disorder, and anxiety.

Review of documentation dated June 25, 2024, at 2:27 PM revealed that Resident 13 was sent to the emergency room for an evaluation due to complaints of dizziness and nausea after sustaining a fall.

Documentation dated June 25, 2024, at 9:53 PM indicated that Resident 13 returned to the facility at 8 PM. Verbal report was received from the hospital with instruction for the facility to administer Keflex 500mg twice

a day for 10 days for a possible urinary tract infection.

A review of the resident's clinical record conducted during the survey ending July 25, 2024, revealed no documented evidence from Resident 13's evaluation in the emergency roiagnom on [DATE REDACTED], which resulted

in treatment for a possible UTI.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 22 395625 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395625 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marywood Heights 2500 Adams Avenue Scranton, PA 18509

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)

F 0842 During an interview with the Infection Preventionist on July 25, 2024, at 11:00 AM confirmed there was no evidence of any documentation from the emergency room evaluation of Resident 13. The Infection Level of Harm - Minimal harm or Preventionist produced the information at approximately 1 PM on July 25, 2024. potential for actual harm

Review of Resident 37's clinical record revealed admission to the facility on [DATE REDACTED], with diagnoses which Residents Affected - Some included Alzheimer's disease, venous insufficiency, and hypertension.

Review of resident's immunization record failed to provide evidence that Resident 37 was screened for Tuberculosis prior to admission to the facility or annually per facility policy.

Interview with the facility's Infection Preventionist (IP) on July 24, 2024, at approximately 10:30 AM, confirmed that the resident's clinical record did not include evidence of screening for Tuberculosis since admission to the facility.

Review of resident screenings for Tuberculosis provided by the IP on July 24, 2024, revealed that Resident 37 had been screened according to policy, and last screening was performed in October 2023, yet the screenings were not provided in the resident's clinical record.

Interview with the DON and Nursing Home Administrator (NHA) on July 25, 2024, at approximately 1:45 PM confirmed that the resident clinical records were not completed and or maintained accordingly.

A review of the clinical record revealed Resident 60 was admitted to the facility on [DATE REDACTED], with diagnoses to include polyneuropathies (damage/disease affecting the peripheral nerves featuring weakness, numbness and burning pain), autonomic neuropathy (damage to the nerves that control the automatic body functions such as blood pressure, temperature control, digestion, and bladder function), and anxiety.

An Admission Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated April 29, 2024, indicated that the resident was cognitively intact with a BIMS (brief interview to assess cognitive status) score of 14 (13-15 represents cognitively intact responses).

Review of a nurses note dated May 31, 2024, at 11:29 AM revealed the facility received a call from the resident's wife stating that she received a call regarding a referral that was made while the resident was in

the hospital. The resident had a scheduled appointment with Psychology at [NAME] in Danville on July 1, 2024, at 12:25 PM. MD aware.

A nurses note dated June 12, 2024, at 7:54 AM revealed a call was placed to the resident's wife to communicate that the facility was unable to accommodate transporting the resident to the [NAME] Psychology appointment on July 1, 2024, due to distance as per Administrator and DON (Director of Nursing). Message left.

A nurses note dated June 12, 2024, at 12:00 PM revealed a call was received from the resident's wife acknowledging that the facility was unable to transport the resident. Wife stated she will call [NAME] Psychology to see if they will do a telehealth appointment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 22 395625 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395625 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marywood Heights 2500 Adams Avenue Scranton, PA 18509

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)

F 0842 A nurses note dated July 12, 2024, at 1:18 PM revealed the facility spoke with the Psychology department at [NAME] and the receptionist stated the resident will login (for his appointment) through his MyChart login. Level of Harm - Minimal harm or potential for actual harm During an interview with Resident 60 on July 23, 2024, at 11:50 AM, the resident stated that the facility was unable to transport him to the July 1, 2024, appointment so his wife and daughter drove him to his [NAME] Residents Affected - Some Psychology appointment in Danville.

A review of the resident's clinical record revealed no documented evidence that the resident had left the facility to attend the appointment on July 1, 2024, or the results of that appointment upon the resident's return to the facility.

Continued interview with Resident 60 revealed that the resident had a telehealth visit on July 12, 2024. The resident expressed frustration that the facility did not provide an electronic device to conduct the visit and his daughter had to scramble to get my son to bring in a device.

Further review of the resident's clinical record revealed no documented evidence that the resident had a scheduled telehealth visit and no documented evidence of the results of that visit.

Interview with the Director of Nursing on July 25, 2024, at approximately 12:15 PM, confirmed there was no documented evidence the resident left and returned to the facility for an appointment on July 1, 2024, no documented evidence that the resident attended a telehealth visit on July 12, 2024, and no documented evidence of the outcome of those visits.

28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

28 Pa. Code 211.5(f) Medical records

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 22 395625 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395625 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marywood Heights 2500 Adams Avenue Scranton, PA 18509

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)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41460 potential for actual harm Based on clinical record review, observations, and staff interview, it was determined that the facility failed to Residents Affected - Few maintain infection control practices to prevent potential spread of infection on one resident care unit out of two. (Second Floor).

Findings include:

Clinical record review revealed Resident 1 was admitted on [DATE REDACTED], with diagnoses which included retention of urine, acute cystitis (sudden bacterial infection of the bladder or lower urinary tract) without hematuria (blood in urine), urinary tract infection ([UTI] an infection of the urinary system which includes the kidney, bladder, or urethra), and required the use of an indwelling catheter( a thin hollow tube inserted through the urethra into the urinary bladder to collect and drain urine) for urination.

Review of clinical record revealed that on May 17, 2024, the resident had an appointment with Urology. Orders received from urology included to irrigate foley daily to prevent sediment buildup, irrigate as needed for decreased urinary output, maintain foley with changes every 4 weeks.

Observation on July 23, 2024, at 11:30 AM, revealed an undated bulb piston syringe, and an undated, unlabeled, opened 1000mL bottle of sterile water with approximately 600mL remaining in the bottle setting

on top of a 3-drawer cart in Resident 1's bathroom.

Interview with Employee 1, licensed practical nurse (LPN), confirmed the observation on July 23, 2024, at approximately 11:45 AM. Employee 1 further confirmed that there was no evidence of how old the items were, that the items should have been labeled and dated, and that the items were not in a manner to prevent

the potential spread of infection.

During an interview with the Director of Nursing (DON), and in the presence of the Nursing Home Administrator (NHA) on July 25, 2024, at 1:30 p.m., confirmed that the facility failed to maintain resident care equipment in a manner to prevent the potential spread of infection.

Refer