York Nursing and Rehabilitation Center

Inspectors wroteBased on observations, clinical record review, facility documentation, and staff interviews, it was determined that the facility failed to ensure residents were free from physical restraint that was not required to treat the resident's medical or behavioral symptoms for one of three residents reviewed (Resident R1). This deficiency was cited as past noncompliance.

Inspectors wroteBased on observations, resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for seven of thirty-four residents reviewed (Residents R1, R2, R3, R5 and R6).

Inspectors wroteBased on interview with resident and staff, review of clinical record and facility provided documentation, it was revealed that facility did not ensure to administer medications according to professional standards of practice for two of five residents reviewed (Residents R1, R12)

Inspectors wroteBased on review of clinical record, review of facility documents, review of policy and procedures, and interview with staff, it was determined that the facility failed to ensure that medications were administered according to physician's instructions and failed to provide treatments according to physician's instructions for one resident (Resident R1) Review of facility policy on Administering Medications reviewed: December 11, 2024, and revised on June 1, 2025, revealed that under section POLICY: Medications shall be administered in a safe and timely manner, and as prescribed. Under section PROTOCOL:2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions.3. Medications must be administered in accordance with orders, including any required time frame.6. [...]

Inspectors wroteBased on review of facility policy, facility documentation, resident clinical records, observations, and staff interviews, it was determined the facility failed to provide adequate supervision for one of three residents assessed as at risk for elopement (Resident R223). Resident R223 exited the second-floor nursing unit via elevator and walked out the back rear entrance of the facility. Resident R223 was located by local law enforcements approximately four hours after the resident exited the facility, approximately 1.5 miles away in a busy [NAME] area. This failure resulted in actual harm to Resident R223 who was admitted to the hospital with hypothermia and resulted in an Immediate Jeopardy situation. [...]

Inspectors wroteBased on review of facility documentation, observations, and staff interviews it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment on two of two nursing units (2-North and 1-North)

Inspectors wroteBased on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated transfers and discharges for two of six months reviewed (July and August). Findings Include: Review of documentation provided by the Nursing Home Administrator on December 16, 2025, at 10:35 a.m. revealed the Office of the State Long Term Care Ombudsman was not made aware of facility-initiated transfers during the months of June and July. The Nursing Home Administrator was able to provide documentation for the month of September, October, and November. Interview on December 17, 2025, at 10:15 a.m. with the Social Worker, Employee E7, confirmed the ombudsman was not made aware of the discharges. [...]

Inspectors wroteBased on policy review, observations, clinical record review, and interviews it was determined that the facility did not ensure the comprehensive care plan was implemented for three of thirty-six residents reviewed (Resident R87, R156, and R56). Findings Include: Review of the facility policy titled, Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates with a revision date on October 1, 2024 states, Policy Statement-the facility will follow a uniform process for initiating the baseline care plan upon admission, the Comprehensive care plan upon CAA completion, and ensuring care plans are updated to reflect the resident's status. Review of Resident R87's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnosis: [...]

Inspectors wroteBased on review of facility documents, review of facility records, review of facility policy and interview with staff, it was determined that the facility failed to ensure that controlled substances are accounted for in order to identify diversion and lost narcotics in a timely manner for one of thirty-six residents reviewed (Resident R89). Review of facility policy on Controlled Substance Log dated April 24, 2023Revised: November 2025 revealed that under section POLICY The facility shall comply with all laws, regulations, and other requirements related to receiving, handling, storage, disposal, and documentation of Schedule II and other controlled substances. Under section GUIDELINES: Storage and Maintenance of Controlled Drugs: 1. [...]

Inspectors wroteBased on observations, interviews with staff, and a review of facility documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety (Main Kitchen and 1-South Pantry).

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and interviews with staff, it was determined that the facility failed to promptly notify a residents representative of a change in condition related to an elopement for one of 36 residents reviewed (Resident R223). Findings Include:Review of undated facility policy Resident Elopement Protocol revealed the unit manager/supervisor would be responsible to notify the resident representative of the elopement. [...]

Inspectors wroteBased on review of facility policy, review of clinical records and staff interviews, it was determined that the facility failed to ensure pre-admission screening and resident review, (PASRR Level I screenings(a program that ensures Individuals with a serious mental illness or intellectual development developmental disabilities aren't unnecessary place in nursing homes and if they are they receive specialized services.) were accurately completed for two (2) residents. Specifically, the facility did not correctly identify or document indicators of serious mental illness and/or intellectual disability on the PASRR Level I screens, resulting in inaccurate PASRR determinations for these residents. [...]

Inspectors wroteBased on review of clinical record, observations, and staff interviews it was determined that the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for one of 36 residents reviewed (Resident R135). Findings Include:Review of Resident R135's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated October 3, 2025, revealed the resident had diagnoses of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), muscle weakness, and muscle wasting. Further review of Resident R135's comprehensive MDS dated [DATE], revealed the resident had severe cognitive impairments. [...]

Inspectors wroteBased on review of facility documentation, review of clinical records, observations, and staff and resident interviews it was determined that the facility failed to ensure residents received proper treatment and care to maintain good foot health for one of 36 residents reviewed (Resident R44). Findings Include:Review of Resident R44's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 29, 2025, revealed the resident was cognitively intact and had diagnoses of cerebral palsy (neurological condition that affects movement and posture) and muscle wasting. Review of Resident R44's comprehensive care plan revised July 3, 2025, revealed the resident had an activity of daily living self-care performance deficit related to weakness and impaired mobility. Interview on December 15, 2025, at 11:30 a.m. [...]

Inspectors wroteBased on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility to ensure that residents were properly supervised. This resulted in an Immediate Jeopardy situation for a resident, who had had a diagnosis of dementia and history of exit seeking behaviors, to exit and elope from the building. Findings Include:Review of the job description of the Nursing Home Administrator (NHA) revealed that, the employee assumes full-time administrative authority, responsibility and accountability for the operations of the nursing facility. The employee manages facility employees in the provision of care and services rendered in accordance with professional standards, and in compliance with state and federal laws and regulations. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to maintain and implement infection control program related to handwashing for one of thirty-six residents observed (Resident R47). Observation on Resident R47 conducted on December 2, 2025, during mediation administration revealed that Employee E32 administered Artificial Tears to the resident's right and left eye. Further observation revealed that Employee E32 did not perform hand hygiene between administering eye drops to the right and left eyeFurther observation revealed that Employee E32 administered Oxymetazoline HCl 0.05% Nasal Spray to Resident R47 left and right nostrils. Further observation revealed that Employee E32 did not perform hand hygiene prior to administering the nasal spray and between administration to left and right nostrils. [...]

Inspectors wroteBased on observation, employee interviews and a review of facility policies, it was determined that the facility failed to maintain the dish machine in a safe operating condition.

Inspectors wroteBased on interviews, review of facility policy and the review of facility documentation, it was determined that the facility failed to ensure one resident was free from misappropriation of resident funds and exploitation for one out of two residents reviewed (Resident R1).

Inspectors wroteBased on interviews with staff, review of clinical records, facility policies and facility documentation, it was determined the facility failed to implement interventions to assure one resident (Resident R3) was free from physical abuse resulting in actual harm to Resident R3 who was struck by Resident R4 in the face with a leg rest, and sustained a chipped tooth for one of 10 resident records reviewed. (Resident R3 and Resident R4)

Inspectors wroteBased on observations, resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for three of 10 residents reviewed. (Resident R3, Resident R6, Resident R7)

Inspectors wroteBased on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for five of ten residents reviewed (Residents R112, R121, R60, R56 and R32).

Inspectors wroteBased on observations of the physical environment, interviews with staff and reviews of the pest control operators reports, it was determined that the facility was not maintaining an effective pest control program.

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that a resident's right to request or refuse medical treatments were accurately reflected in the resident's record for one of 35 residents reviewed (Resident R96).

Inspectors wroteBased on observations and resident and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for two of four nursing units. (First floor South and North Nursing Units).

Inspectors wroteBased on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to perform criminal history background checks prior to hire for one of five personnel files reviewed (Employees 2). Findings Include: The facility policy titled Employment Screenings for Potential Hires: Pennsylvania dated, April 2, 2022, revealed under Procedure B. section Criminal records check: i. in accordance with Act 13 and the Older adults Protective Services Act, the Facility will conduct a Criminal History Check as a condition of employment within the first 30 days of hire. This includes clearance through the Pennsylvania State Police. Review of the personnel file for Director of Nursing, Employee 2 revealed hiring date on November 11, 2024. Further review indicated that a Pennsylvania State Police background check was completed on January 29, 2025. [...]

Inspectors wroteBased on review of facility policies and clinical records, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of two residents reviewed regarding a smoking (Resident R192)

Inspectors wroteBased on clinical record review, observations, 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 35 residents reviewed (Resident R114, and R60).

Inspectors wroteBased on facility policy review, clinical records review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the resident environment was free of accident hazards for one of 35 residents reviewed (Resident 35).

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to identify, implement, monitor, and modify interventions consistent with the residents needs and current professional standards of practice, to maintain acceptable parameters of nutritional status for one of eight residents reviewed. (Resident R67)

Inspectors wroteBased on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for three of 35 residents reviewed (R31, R88, R163).

Inspectors wroteBased on a review of facility's job descriptions and personnel files, as well as staff interviews, it was determined that the facility failed to check the annotation list which becomes available on quarterly bases to verify the nurse aide certification to be valid to allow individuals to work as a nurse aide for one of three nurse aides reviewed (Employee E8).

Inspectors wroteBased on review of facility policy, review of resident clinical records, interview with staff, it was determined that the facility failed to develop a comprehensive person-centered care plan relating to post traumatic stress disorder (PTSD) for two of two residents reviewed with this diagnosis of PTSD. (resident R 139, and R157)

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety.

Inspectors wroteBased on review of clinical records , interview with staff and facility policy, it was determined that the facility failed to maintain complete and accurate records for one of 35 resident records reviewed (Resident R603).

Inspectors wroteBased on review of facility policy and procedures, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices related to the use of appropriate protective equipment for wound care of two of two residents observed. (resident R4 and R 171).

Inspectors wroteBased on the staff interviews, reviews of facility documents and observation, it was determined that the facility failed to ensure that air temperatures were maintained in two of two resident rooms observed (room [ROOM NUMBER] and room [ROOM NUMBER]

Inspectors wroteBased on observation, review of clinical records and staff interviews, it was determined that the facility failed to ensure that one of 12 residents reviewed was able to received visitors. (Resident R1)

Inspectors wroteBased on interviews with staff, reviews of clinical records, policies and procedures and review of the office of Long-Term Living Bulletin, it was determined that the facility failed to conduct an accurate Pennsylvania Preadmission Screening Review for one of four residents. (Resident R94)

Inspectors wroteBased on review of facility policy, review clinical records and interview with staff, it was determined that the facility failed to ensure that resident received medication in accordance with physician orders for one of 35 residents reviewed. (Resident R49)

Inspectors wroteBased on observation, clinical record review, and reviews of policies and procedures, it was determined that the failed to ensure that devices to promote healing of pressure ulcers were implemented for one of two residents reviewed. (Resident R93)

Inspectors wroteBased on clinical record reviews, interviews with residents and staff and policy and procedure review, it was determined that the facility failed to ensure that each resident maintained acceptable parameters of nutritional status for usual body weight, laboratory values and nutritional assessment for one of five residents reviewed. (Resident R5)

Inspectors wroteBased upon observation, interviews with staff, review of clinical records and facility policy, it was determined that the facility did not ensure residents who needed respiratory care related to supplemental oxygen was provided care by failing to follow physician orders for two of 35 resident records reviewed (Resident R21 and R107).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure timely delivery of medications for one of 35 residents reviewed. (Resident R49)

Inspectors wroteBased on observation, staff interview and review facility policy, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for one of two medication rooms observed.

Inspectors wroteBased on the review of facility documents and resident clinical record and staff interviews, it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement for two of three residents reviewed (Resident R153 and R148). Findings Include: Review of Resident R153's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated October 5, 2023, revealed the resident was admitted to the facility on [DATE], and had a diagnosis of schizophrenia, major depressive disorder, unspecified dementia, without behavioral disturbance psychotic disturbance, and mood disturbance and anxiety. [...]

Inspectors wroteBased on observation, clinical record review and interviews with staff, it was determined that the facility failed to administer oxygen therapy in accordance with professional standards of practice and failed to obtain physician orders for oxygen therapy for one of one resident reviewed. (Resident R1) Findings Include: Review of Resident R1's care plan dated December 6, 2023, revealed that the resident had a diagnosis of pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred. This thickened, stiff tissue makes it harder for the lungs to work properly), sarcoidosis (disease characterized by the growth of tiny collections of inflammatory cells) and respiratory illness which required the resident to need oxygen therapy. Observation on March 8, 2024 at 9:40 a.m. [...]

Inspectors wroteBased on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food was distributed at appropiate temperatures on one of four nursing units. (1st Floor South unit)

Inspectors wroteBased on the review of clinical records, facility policies, interviews with resident and staff, it was determined that the facility failed to ensure that the residents were free from verbal and mental abuse, which resulted in a staff member verbally and mentally abusing a resident (Resident R178) with documented history of mental health disorders. This failure caused the resident to experience fear and intimidation for one of 39 residents reviewed (Resident R178). This failure also put the resident at risk for potential physical abuse and bodily injury and resulted in an immediate jeopardy situation. This deficiency was identified as past non-compliance. (Resident R178) Findings Include: Review of an undated facility policy, titled, Abuse, revealed Abuse and neglect exist in many forms and to varying degrees. [...]

Inspectors wroteBased on observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior on two of two nursing units (First and Second floor nursing units).

Inspectors wroteBased on observations, review of clinical records, review of facility policies and staff interviews, determine the facility failed to prevent misappropriation of resident's medications for two of 38 resident records reviewed (Resident R259 and R260.

Inspectors wroteBased on interviews with staff, review of the clinical record and review of facility documents, it was determined that the facility failed to ensure a complete and through investigation to rule out abuse/neglect for an injury of an unknown origin for 1 out of 38 residents reviewed (Resident R108).

Inspectors wroteBased on observation, review of clinical records and facility policy and interviews with staff determined the facility failed to ensure a resident received necessary treatment and services consistent with professional standards of practice to prevent the development of a pressure ulcers for one of 38 resident records reviewed, (Resident R257).

Inspectors wroteBased on clinical record reviews, observations, review of facility policy and staff interviews, it was determined that the facility failed to properly supervise a resident to ensure a safe environment for one of 38 residents reviewed. (Resident R118).

Inspectors wroteBased on review of facility policy, review of clinical documentation, and interviews with staff and residents, determined the facility failed to ensure residents who require dialysis receive such services, consistent with professional standards of practice, and the comprehensive person-centered care plan, by failing to maintain ongoing documented communication with the dialysis center for continuity of care, failing to provide dialysis treatment and medication as ordered and failing to notify the physician when these orders were not followed, for four of six hemodialysis resident reviewed, (Residents R80, R24, R119 and R148).

Inspectors wroteBased on interviews with residents and staff, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that medications were reordered and stocked in a timely manner for 1 out of 38 residents reviewed (Resident R24).

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility failed to follow physician orders related to blood sugar monitoring and weights for two of four residents reviewed (Residents R2 and R4).

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to adequately monitor the nutritional and hydration status for two of four residents reviewed (Residents R2 and R4).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined that the facility failed to ensure communication with the dialysis provider for two of two residents on renal dialysis. (Resident R2 and Resident R4)