York North Skilled Nursing and Rehabilitation Ctr

Inspectors wroteBased on resident and staff interviews, observations, and completion of a test tray for one meal, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures.

Inspectors wroteBased 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 kitchen and in four nourishment pantries (A, B, Medbridge, and C stations).

Inspectors wroteBased on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure each resident was informed in advance of the risks and benefits of psychotropic medications for one of five residents reviewed for unnecessary medications (Resident 3). Findings Include: Review of the facility's policy, titled Health Care Decision Making, reviewed June 12, 2025, read, It is the right of all patients/residents to participate in their own healthcare. The policy continued, Health care decision making refers to consent, refusal to consent, or withdrawal of consent of health care, treatment, service, or a procedure to maintain, diagnose, or treat a patient's physical or mental condition. [...]

Inspectors wroteBased on review of the RAI manual (Resident Assessment Instrument- A standardized guide used in nursing homes and long-term care facilities to assess residents health, functional status, and care needs), clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident's status for two of 32 residents reviewed (Residents 1 and 25).

Inspectors wroteBased on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 30 residents reviewed (Residents 6, 45, and 81). Findings Include: Review of facility policy, titled Person-Centered Care Plan, reviewed [DATE], revealed, The Center must develop and implement a person-centered care plan for each patient/resident consistent with patient rights, measurable objectives, and timeframes to meet a patient's medical, nursing and mental and psychosocial needs and all services that meet professional standards of quality. [...]

Inspectors wroteBased on clinical record review and resident and interviews, it was determined that the facility failed to ensure each resident receives proper treatment and assistive devices to maintain vision abilities for one of 30 residents reviewed (Resident 92).

Inspectors wroteBased on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of two residents reviewed for limited range of motion (Resident 7).

Inspectors wroteBased on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents who need respiratory care are provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents reviewed for respiratory care (Resident 9).

Inspectors wroteBased on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure that its residents who require dialysis receive such services consistent with professional standards of practice for one of two residents reviewed for dialysis services (Resident 45). Findings Include: Review of the facility's policy, titled Dialysis Guidelines, dated June 2017, read, Both the center and the dialysis facility are responsible for shared communication regarding patients receiving dialysis services. The Hemodialysis Communication Form is to be used. Collaborative communication includes . timely mediation administration, physician/treatment orders, laboratory values, and vital signs. [...]

Inspectors wroteBased on observations, policy review, and staff interviews, it was determined that the facility failed to ensure that its corridors were equipped with firmly secured handrails on both sides in two of the seven resident halls observed (400 and 500 Halls). Findings Include: Review of the facility's policy, titled Safe and Homelike Environment, revised November 14, 2025, read, The resident/patient has the right to a safe, clean, comfortable and homelike environment. An observation in the 500 hall on March 25, 2026, at approximately 12:00 PM, revealed that the handrail affixed on the left side of the hall was loose to touch. An observation in the 400 hall on March 25, 2026, at 1:25 PM, revealed that the handrail affixed on the right side of the hall, near the therapy gym, was loose to touch. [...]

Inspectors wroteBased on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure its residents receive treatment and care in accordance with professional standards of practice and the person-centered, comprehensive plan of care for one of four residents reviewed (Resident 3). Findings Include:Review of the facility's policy, titled Medication Administration, dated 2007, read, in part, Medications are administered in accordance with written orders of the prescriber. Review of Resident 3's physician orders revealed diagnoses that included Atrial Fibrillation (an irregular and very rapid heart rhythm that can lead to blood clots, stroke, and heart failure) and anxiety (characterized by intense worry, fear, or panic that interferes with daily life, often involving physical symptoms like a racing heart or sweating). [...]

Inspectors wroteBased in review of facility policy, documentation provided by the facility, clinical record review, and staff interviews, it was determined that the facility failed to protect the resident's right to be free from involuntary seclusion by a staff member (Resident 1).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to notify the resident/resident representative and the representative of the Office of the State Long-Term Care Ombudsman of resident transfers in writing to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman for three of four resident records reviewed regarding hospitalizations (Residents 37, 66, and 121).

Inspectors wroteBased on clinical record review, policy review, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for three of 37 residents reviewed (Residents 10, 14, and 57). Findings Include: Review of the facility's policy, titled Person-Centered Care Plan, revised October 24, 2022, read, A comprehensive person-centered care plan must be developed for each patient. Review of the clinical record for Resident 10, revealed clinical diagnoses that included neurogenic bladder (a condition that occurs when the nervous system's connection to the bladder is disrupted), diabetes mellitus (the body has trouble controlling blood sugar), pneumonia (lung infection), and three Stage 4 chronic pressure ulcers (wounds that extend deep in the tissue, exposing muscle, tendon, or bone and a high risk of infection). [...]

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents' dependent on staff for assistance with these activities of daily living for two of two residents reviewed for activities of daily living (Residents 112 and 117).

Inspectors wroteBased on observations, review of the clinical record, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for three of 33 residents reviewed (Residents 14, 90, and 252).

Inspectors wroteBased on clinical record review, policy review, and staff interviews, it was determined that the facility failed to monitor the resident's nutritional status for four of seven residents reviewed for nutrition (Residents 90, 117, 131, and 252).

Inspectors wroteBased on observation, policy review, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to provide sufficient dining services staff to ensure that resident meals and nourishments were served timely during two of three meals observed (February 11 and 12, 2025).

Inspectors wroteBased on review of facility policy, observations, 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 kitchen.

Inspectors wroteBased on observation, policy review, and staff interviews, it was determined that the facility failed to maintain a safe environment that supports infection prevention and control for five of 33 residents reviewed (Residents 10, 37, 108, 113, and 119).

Inspectors wroteBased on resident and staff interviews, policy review, clinical record record review, and facility document review, it was determined that the facility failed to ensure the resident right to receive mail, including packages, in a timely manner for one of one resident reviewed for personal property (Resident 19).

Inspectors wroteBased on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure each resident and/or representative the right to formulate an Advance Directive for one of two residents reviewed for Advance Directives (Resident 57). Findings Include: An Advance Directive is defined as a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. A review of the facility's policy, titled Health Care Decision Making, revised January 8, 2024, read, It is the right of all patients/residents to participate in their own health care decision making .including the right to formulate or not formulate an advance directive. [...]

Inspectors wroteBased on clinical record review, facility document and policy reivew, and staff interviews, it was determined that the facility failed to ensure residents were free from chemical restraints for one of five residents reviewed for unnecessary medication (Resident 143).

Inspectors wroteBased on review of the Resident Assessment Instrument (RAI- a standardized approach for applying a problem identification process in nursing homes, adopted to examine nursing home quality and to improve nursing home regulation), clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that each resident received an accurate assessment, reflective of the resident's status at the time of the assessment, by staff who are qualified to assess relevant care areas for two of 37 residents reviewed (Residents 10 and 118).

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to develop and implement a baseline care plan for one of one resident reviewed for baseline care plans (Resident 252).

Inspectors wroteBased on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for two of 37 residents reviewed (Residents 59 and 118). Findings Include: Review of Resident 59's clinical record revealed diagnoses that included malignant neoplasm of colon (a cancerous tumor in the colon) and congestive heart failure (a serious condition that occurs when the heart can't pump blood efficiently enough to meet the body's needs). Review of Resident 59's care plan revealed a focus area of, Resident 59 requires indwelling catheter due to terminal illness/comfort measures, with a revision date of December 15, 2024. Observation of Resident 59 on February 10, 2025, at 10:30 AM, revealed Resident 59 lying in bed and no catheter was present. [...]

Inspectors wroteBased on review of facility policy, observations, record reviews, and resident and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for two of 37 residents reviewed (Residents 48 and 77).

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of two residents reviewed for dialysis (Resident 88).

Inspectors wroteBased on clinical record review, facility document review, pharmacy statement review, and staff interviews, it was determined that the facility failed to ensure pharmaceutical services that assured the accurate acquiring and administration of medications were provided that met the needs of each resident for one of 33 resident records reviewed (Resident 252).

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed provide therapy services to ensure residents receive specialized rehabilitative services to assist them to attain, maintain, or restore their highest practical level of physical, mental, functional, and psycho-social well-being for one of 37 residents reviewed (Resident 23).

Inspectors wroteBased on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure all residents receive treatment and care in accordance with professional standards of practice for one of three residents reviewed (Resident 2). Findings Include: A review of the facility's policy, titled Medication Regimen Review, recently reviewed June 1, 2024, read, in part, The consultant pharmacist will conduct MRR's [Medication Regimen Reviews] .and will make recommendations based on the information made available in the resident's health record. The policy continued, Facility should independently review each resident's medication regimen directly from the resident's medical chart and with interdisciplinary care team member, resident, or responsible party, as needed. [...]

Inspectors wroteBased on observation, facility-provided documentation, and resident and staff interviews, it was determined that the facility failed to provide meals at regular times and in accordance with resident needs, preferences, and requests for five of 10 resident areas reviewed for mealtimes and one of three residents reviewed (Resident 1). Findings Include: A review of the facility's document, titled Time Sheet for Cart Services to Stations, dated June 4, 2024, revealed the posted arrival time for the dinner meal on Medbridge #2 at 5:20 PM. A review of the document also revealed the cart left the kitchen at 6:05 PM. The document also revealed the posted arrival time on the C-1 Station at 5:30 PM, and the cart arrival at 6:15 PM; the posted arrival time on the C-2 Station at 5:40 PM, and the cart arrival time at 6:22 PM; [...]

Inspectors wroteBased on observations, policy review, and resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one out of five nursing units (Medbridge). Findings Include: Review of the facility's policy, titled NSG101 Call Lights, last review date February 1, 2023, revealed the following: Staff will respond to call lights and communication devices promptly. During an observation on April 23, 2024, at 10:47 AM, Resident 1's call light was noted to be on. The call light remained on until a staff member entered the room at 11:33 AM. [...]

Inspectors wroteBased on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for six of 33 residents reviewed (Resident 3, 10, 67, 111, 118, and 127). Findings Include: Review of the Resident Assessment Instrument, Version 3.0, dated October 2023, Chapter 3, Section L, read, in part, if resident has dentures examine for loose fit. Ask resident to remove denture to examine and complete exam of lips and oral cavity. Review of Resident 3's clinical record revealed diagnoses that included low back pain, depression, and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). [...]

Inspectors wroteBased on clinical record review, observations, facility policy reivew, and staff interviews, it was determined that the facility failed to revise and/or update the resident comprehensive plan of care for six of 30 residents reviewed (Residents 10, 11, 73, 93, 118, and 129). The facility also failed to ensure that care plan meetings included representation from the interdisciplinary team for four of 33 residents reviewed (Residents 10, 11, 93, and 129).

Inspectors wroteBased on staff and resident interviews, facility policy review, and review of facility documents, it was determined that the facility failed to provide an ongoing program of activities designed to meet the needs, interests, and functional abilities for seven of seven months reviewed (September 2023-March 2024) and for five of five residents interviewed (Residents 39, 54, 77, 109, and 132).

Inspectors wroteBased on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure physician orders were followed for catheter care for one of four residents reviewed for catheters (Resident 127).

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to ensure residents requiring urostomy services receive care consistent with professional standards of practice and based on the comprehensive person-centered plan of care for one of one resident reviewed needing nephrostomy care (Resident 53). Findings Include: A urostomy is defined as an opening in the belly (abdominal wall) that's made during surgery. It re-directs urine away from a bladder that's diseased, has been injured, or isn't working as it should. [...]

Inspectors wroteBased on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice for one of one residents reviewed for dialysis (Resident 127).

Inspectors wroteBased on observation, review of facility policy, and resident and staff interviews, it was determined that the facility failed to provide food and beverage that were at a safe and appetizing temperature for one of one meals observed on the Heritage Nursing Unit.

Inspectors wroteBased on observations, 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 kitchen area.

Inspectors wroteBased on document review and staff interview, it was determined that the facility failed to ensure nurse-aides are sufficient with in-service training, continuing education competencies to include dementia and resident abuse prevention training, and the training be no less than 12 hours per year for five of five nurse aide training documents reviewed (Employees 16-20). Findings Include: Review of Employee 16's employment documentation revealed a hire date of December 10, 2022. Continued review of the documentation revealed Employee 16 to have no annual dementia or abuse prevention training and annual training hours to total 4.5 hours. Review of Employee 17's employment documentation revealed a hire date of December 10, 2022. Continued review of the documentation revealed Employee 16's annual training hours to total 10:44. [...]

Inspectors wroteBased on observations, clinical record review, and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming, transfers, and meal assistance for residents dependent on staff for assistance with these activities of daily living (ADL) for two of 33 residents reviewed (Residents 33 and 241).

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 33 residents reviewed (Residents 11 and 241).

Inspectors wroteBased on facility policy review, clinical record review, facility incident report review, and staff interviews, it was determined that the facility failed to ensure that a thorough investigation was conducted following resident falls, and failed to ensure that residents received adequate assistance to prevent accidents for one of four residents reviewed for falls (Resident 3).

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to monitor the resident's clinical condition after a significant weight loss was identified for two of five residents reviewed for nutrition (Residents 93 and 129).

Inspectors wroteBased on review of facility policy, observations, record review, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice of one of 33 residents reviewed (Resident 73).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the physician addressed a significant weight loss in a timely manner for two of four residents reviewed for nutritional concerns related to weight loss (Residents 93 and 129).

Inspectors wroteBased on observation, staff and resident interviews, and record review, it was determined that the facility failed to provide routine and/or emergency dental services for one of 33 residents reviewed (Resident 67).

Inspectors wroteBased on observations, and resident and staff interviews, it was determined that the facility failed to provide sufficient maintenance services necessary to maintain a safe, sanitary, comfortable, and home-like interior on three of five nursing units (Heritage, A, and Mebridge units).

Inspectors wroteBased on clinical record review, staff interview, and policy review, it was determined that the facility failed to ensure accurate clinical record documentation for one of eight residents reviewed (Resident 1).