Yorktown Nursing and Rehabilitation Center

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected the resident's status for 3 of 16 residents (Residents #6, #28 and #34) reviewed for resident assessments. 1. The Facility failed to ensure Resident #6's active diagnosis of depression and her number of falls between assessments was accurately reflected on her quarterly MDS assessment, dated 01/12/2026. 2. The facility failed to ensure Resident #28's oxygen use was accurately reflected on her Significant Change MDS assessment, dated 01/16/2026. 3. The facility failed to ensure Resident #34's active diagnosis of dysphagia was accurately reflected on his quarterly MDS assessment, dated 12/29/2025 These deficient practices could place residents at risk of missed or inaccurate care.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 2 of 7 residents (Residents #6 and#10) reviewed for infection control. 1. The facility failed to ensure CNA B took off her soiled gloves, sanitized her hands, and put on clean gloves prior to placing a clean brief on Resident #6 during catheter care. 2. The facility failed to ensure the ADON took off and replaced her gown after leaving the room to get more gloves when she performed wound care for Resident #6 who was on EBP. 3. The facility to ensure Resident #10 was on EBP by not having PPE outside his door and a sign on his door when he had a diabetic ulcer which required a dressing. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. for 1 resident (Resident #10) of 2 residents observed for wound care. The facility failed to ensure the ADON followed physician orders when she performed Resident #10's diabetic ulcer (slow-healing open sore or wound, most commonly on the feet, that occurs as a complication of diabetes due to nerve damage and poor blood circulation) treatment. This deficient practice could result in a lack or delay in wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible; for 1 (room [ROOM NUMBER]) of 1 room on hallway with 6 residents residing on hallway reviewed for environment, in that:The facility failed to secure room [ROOM NUMBER] that was being used as storage with 2 unlocked housekeeping carts were not locked that contained potentially unsafe cleaning chemicals. This deficient practice could result in residents coming in contact with potentially unsafe cleaning chemicals.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for 2 (Residents #28 and #36) of 4 residents reviewed for oxygen therapy. The facility failed to ensure oxygen therapy was delivered at the prescribed rate for Resident #28. 2. The facility failed to ensure the oxygen concentrator that delivered oxygen to Resident #36 had a clean filter. These deficient practices could place residents at risk of respiratory distress.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 medication cart (Station II Medication Cart) reviewed. The facility failed to remove an expired tube of Medi-honey (wound gel, offers protection against invading bacteria, is effective against a wide variety of bacteria, cleans the wound, rapidly lifting dead tissue, reduces wound odor and provides a moist environment for healing) with an expiration date, of 07/01/2025 from Station II's II's medication cart. This deficient practice could result in decreased effectiveness of medications.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurate, readily accessible and systematically organized for 2 (Residents #28 and #36) of 19 residents reviewed for clinical records. The facility failed to ensure Resident #28's MAR/TAR reflected her order for receiving oxygen at 2 LPM via nasal cannula for nurses to monitor for proper setting. 2. The facility failed to ensure LVN A accurately documented in Resident #36's TAR that his oxygen concentrator filter was not cleaned when she initialed that it was. These deficient practices could result in inaccurate clinical records and decreased continuity of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility ice machine that provided ice for resident beverages at meals had visible rust on the outside and inside of the machine and contained large sections of yellow and brown ice. This failure could place residents who drink beverages with ice from the kitchen at risk for becoming sick from contaminated ice.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the kitchen. The facility failed to ensure dietary staff used proper hand hygiene during meal preparation. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on interviews and record review the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) level 1 residents with mental illness were provided with a PASRR level 2 evaluation for 1 of 4 residents (Resident #5), reviewed for resident assessment. Resident #5's PASRR level 1 screening form did not indicate mental illness and the resident did not have a PASRR level II evaluation. This could place residents at risk of not receiving necessary specialized services to meet their individual needs.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #23) reviewed for quality of care. Resident #23's tube feeding was not labeled with the required information. This failure could place residents at risk of decreased continuity of care, errors in tube feeding, and nutritional deficits.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 residents (Resident #18) reviewed for pharmacy services. Resident #18's Tramadol (narcotic) medication was left unsupervised in the top drawer of the medication cart in a paper pill cup after it was popped out of the medication card. This could put residents at risk of pain, medication errors, and drug diversion.

Inspectors wroteBased on interviews, observation, and record reviews the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents. The facility failed to ensure Resident #1 received 2-person assistance when CNA A transferred the resident from the wheelchair to the bed independently with a mechanical lift with the wrong sized sling. This failure could place residents at risk of injuries, falls, and a decline in quality of life. The noncompliance was identified as PNC. The noncompliance began on 08/25/2024 and ended on 08/27/2024. The facility had corrected the noncompliance before the survey began.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 dining rooms reviewed, in that: A supply cabinet located in the facility dining room was unlocked and contained potentially dangerous materials. This deficient practice could place residents, staff, and the public at risk of exposure to potentially dangerous materials.