York South Skilled Nursing and Rehabilitation Ctr

Inspectors wroteBased on facility policy review, record review, wound tracking form, and staff interview, it was determined the facility failed to maintain a method of accuracy for wound measurement assessments between facility staff and the wound provider specialist for one of 31 residents reviewed (Resident 5).

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 for two of four pantry refrigerators and the ceiling in the kitchen area.

Inspectors wroteBased on facility policy review, facility document review, and resident and staff interviews, it was determined that the facility failed to promote care for residents in a manner that enhances each resident's dignity for one of 31 residents reviewed (Resident 138).

Inspectors wroteBased on facility policy review, observations, and resident representative and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable and home-like environment in one of five resident areas observed (400 Hallway).

Inspectors wroteBased on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents receive treatments and care and services in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for two of 31 residents reviewed (Residents 9 and 109).

Inspectors wroteBased on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide restorative nursing services to improve or maintain upper extremity motion on a consistent basis for one of 31 residents reviewed (Resident 11).

Inspectors wroteBased on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, including ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments, received at a certified dialysis facility for one of two residents reviewed for dialysis treatments (Resident 108). Findings Include: Review of the facility's policy, titled Dialysis: Hemodialysis (HD) Provided by a Certified Dialysis Facility, effective October 1, 2018, read, Patients who require HD services receive care consistent with professional standards of practice. Professional standards of practice include- Ongoing assessment and oversight of the patient before and after HD treatments. [...]

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to store medications properly in one of three medication carts observed (400 Wing) and in one of three medication rooms observed (400 Wing).

Inspectors wroteBased on review of select food service committee meeting minutes, resident and staff interviews, observation, and completion of one meal test tray, it was determined that the facility failed to provide foods that are palatable and at appetizing temperatures.

Inspectors wroteBased on observations, policy review, and staff interview, it was determined that the facility failed to ensure that waste is properly contained in the dumpster, and that the area surrounding the dumpster is free from debris for one of two dumpsters.

Inspectors wroteBased on clinical record review, facility document review, and staff interview, it was determined that the facility failed to provide care and services consistent with the resident comprehensive plan of care, which resulted in harm as evidenced by a decline in health status for one of three residents reviewed (Resident 1).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 31 residents reviewed (Residents 48, 86, and 101).

Inspectors wroteBased on facility policy review, clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure that the comprehensive care plan was reviewed and revised for three of 31 reviewed (Residents 39, 51, and 55).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for three of seven residents reviewed for pressure ulcers (Resident 4, 122, and 238).

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, for three of four residents reviewed for respiratory care (Residents 17, 23, and 78).

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 and for one of three nourishment pantries.

Inspectors wroteBased on observations, record review, policy review, and staff interview, it was determined that the facility failed to ensure the environment meets the individual needs of each resident by ensuring the call bell was in reach for three of 31 residents reviewed (Residents 31, 59, and 67).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for one of six residents reviewed for hospitalization (Resident 86). Findings Include: Review of facility policy, titled Bed Holds last revised January 16, 2023, read, in part, Bed hold notification is required per Federal Regulation. The resident/resident representative may choose to pay to hold the bed privately if the bed hold is not covered by Medicaid, Medicare, insurance, etc. If the resident representative is not present to receive the written notice upon transfer, the notice is delivered via e-mail, fax, or hard copy via mail. Purpose: [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement a baseline care plan within 48 hours for one of six residents reviewed that were admitted during the prior 30 days (Resident 238).

Inspectors wroteBased on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that each resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one of 31 residents reviewed (Resident 95). Findings Include: Review of the facility's policy, titled Restorative Nursing, recently revised August 7, 2023, defined its purpose To promote the patient's ability to adapt and adjust to living as independently and safely as possible. Also, To help the patient attain and maintain optimal physical, mental, and psychosocial functioning. Restorative programs are coordinated by nursing or in collaboration with rehabilitation and are patient-specific based on individual patient needs. [...]

Inspectors wroteBased on facility policy reviews, clinical record review, observations, and staff interviews, it was determined that the facility failed to precisely and effectively monitor hydration for one of one resident reviewed for hydration status (Resident 78), and failed to ensure proper monitoring to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, for one of four residents reviewed for nutritional status (Resident 131).

Inspectors wroteBased on staff and resident interviews, observation, and completion of one meal test tray, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures at one of one meal observed (May 6, 2025, lunch meal).

Inspectors wroteBased on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure staff implemented infection control policies to prevent the spread of infection for two of 31 residents on transmission-based precautions reviewed (Residents 67 and 238) Findings Include: Review of facility policy, Transmission Based Precautions, revised May 1, 2025, revealed in a section: Initiating Transmission Based Precautions, Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the patient's room. Additionally, either the CDC category of Transmission Based Precautions (e.g., Contact, Droplet, or Airborne) or instructions to see the nurse before entering the room will be included in the signage. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections consistent with physician orders and the resident's person-centered care plan for one of three residents reviewed (Resident 1).

Inspectors wroteBased on policy review, clinical record review, document 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 comprehensive person-centered plan of care for two of eight residents reviewed (Residents 1 and 3). Findings Include: A review of Resident 1's clinical record revealed diagnoses that included Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform daily tasks) and acute pancreatitis (a sudden inflammation of the pancreas). A review of Resident 1's physician's orders revealed an order dated September 28, 2024, that read Daily Weight: Notify cardiology or PCP [primary care physician] if increased by 3 lbs.[pounds] in one day or greater than 5 lbs. in one week. [...]

Inspectors wroteBased on policy review, clinical record review, and staff interview, it was determined that the facility failed to provide routine drugs for its residents and provide pharmaceutical services, including procedures that assure the accurate acquiring and administration of drugs to meet the needs of each resident, for one of eight residents reviewed (Resident 2). Findings Include: A review of the facility's policy, titled Provider Pharmacy Requirements, dated 2007, read, Regular and reliable pharmaceutical service is available to provide residents with prescription and non-prescription medications . The policy continued, The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to accurately dispensing prescriptions based on authorized prescriber orders. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for four of five residents reviewed with wound care orders (Residents 15, 17, 18, and 19). Findings Include: Review of Resident 15's clinical record revealed diagnoses that included severe protein-calorie malnutrition (insufficient protein intake or protein deficiency) and congestive heart failure (CHF-weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues). Review of Resident 15's July 2024 TAR (Treatment Administration Record - form used to document physician orders as well as when and how treatments are administered to a resident) revealed the following orders: [...]

Inspectors wroteBased on review of facility investigation documentation and job descriptions, review of online nurse aide registry information, as well as staff interview, it was determined that the facility failed to ensure that services provided to residents were provided by staff with the appropriate skills, experience, and qualifications to provide such services for two of two residents reviewed (Residents 20 and 21).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior in three of four resident shower rooms (first and second floor nursing units).

Inspectors wroteBased on policy review, document review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that all allegations of abuse, neglect, or mistreatment are reported no later than 24 hours to other officials, including Adult Protective Services, for two of three resident abuse investigations reviewed (Residents 40 and 61). Findings Include: A review of the facility's policy, titled Abuse Prohibition, revised October 24, 2022, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury or mental anguish. Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients . [...]

Inspectors wroteBased on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for four of 31 residents reviewed (Residents 38, 67, 68, and 82).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to appropriately monitor the pH of the sanitizer sink for manual ware-washing, and failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen area and two of three nourishment pantries (second floor and Arcadia units).

Inspectors wroteBased on clinical record review, policy review, observations, and staff interviews, it was determined that the facility failed to maintain infection control practices to prevent the spread of infection for two of 31 residents reviewed (Resident 78 and 82).

Inspectors wroteBased on document review and staff interview, it was determined that the facility failed to ensure each resident is periodically informed of charges for services not covered under Medicare or Medicaid for one of three residents reviewed at the termination of Medicare A services (Resident 239). Findings Include: A review of Resident 239's clinical record revealed an admission date of November 29, 2023, with diagnoses that included hypertension (elevated blood pressure) and heart failure (A lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). According to the clinical record, Resident 239 was admitted for short-term rehabilitation with a planned discharge to return to the community. [...]

Inspectors wroteBased on observations, 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 31 residents reviewed (residents 32, 62, and 70).

Inspectors wroteBased on clinical record review, facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to provide care and services regarding shaving facial hair for one of 31 residents reviewed (Resident 72).

Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure treatment and services were provided to promote healing and prevent infection for one of four resident's reviewed for pressure injury (Resident 78).

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of 31 residents reviewed (Resident 56).

Inspectors wroteBased on observations, facility policy review, clinical record review, 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 one of three residents reviewed for respiratory care (Resident 62). Findings Include: Review of facility policy, titled Bi-level Positive Airway Pressure (Bi-PAP- non-invasive ventilation is the use of breathing support administered through a face mask) /Continuous Positive Airway Pressure (CPAP- a machine that uses mild air pressure to keep breathing airways open while you sleep) including Trilogy (an all-in-one ventilation device capable of delivering both invasive and non-invasive ventilation modes) , revised April 1, 2022, failed to include information pertaining to cleaning and storage of equipment. [...]

Inspectors wroteBased on facility policy review, facility document review, and staff interview, it was determined that the facility failed to complete a performance review for one of five nurse aides reviewed at least once every 12 months (Employee 2).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure residents were educated on influenza vaccination for one of five residents reviewed (Resident 82).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for five of seven newly admitted residents reviewed (Residents 1, 4, 5, 7, 8). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included cellulitis of left lower limb (bacterial infection involving the inner layers of the skin) and diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel resulting in too much sugar circulating in the bloodstream). [...]