Yorktown Rehabilitation & Nursing Center

Inspectors wroteBased on interviews and record reviews during a survey, the facility failed to ensure residents were free from sexual abuse by a staff member for one (1) (Resident #1) of three (3) residents reviewed for abuse. Specifically, the facility incident report documented on 02/21/2026 at 6:53 AM., Certified Nurse Aide #1 observed Housekeeper #1 in bed with Resident #1 who had severe cognitive impairment, lying in prone position on top of Resident #1. Subsequently Resident #1 was transferred to the hospital on [DATE] for evaluation and treatment. It was determined that Resident #1's likelihood to experience actual psychosocial harm, using the reasonable person concept (referenced in the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity Guide), occurred because of the alleged assault.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00348017/806183), the facility did not ensure assessments accurately reflected the resident's status for 1 out of 3 residents (Resident #1) reviewed for assessments. Specifically, Resident #1 who was cognitively impaired, had chronic confusion and gait/balance disturbances was not identified as a high risk for falls on admission. Resident #1 had an unwitnessed fall on 06/08/2024 and sustained a laceration to their left eyebrow and a bruise to their left elbow. Review of Resident #1's fall risk assessment dated [DATE] revealed it was not completed, reflecting inaccurate scoring on the assessment tool.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00348017/806183), the facility did not ensure the resident environment remained as free of accident hazards as is possible; and that each resident received adequate supervision to prevent accidents for 1 out of 3 residents (Resident #1) reviewed for safety and supervision. Specifically, Resident #1 who had severe cognitive impairment with impaired thought process was assessed on admission as a low fall risk for fall. Resident #1 was left alone in their room on 6/8/2024. The resident had an unwitnessed fall and sustained a laceration to their left brow and bruising to their left elbow. Resident #1's room was located behind the nurse's station out of view from. Resident #1 had no specific measures in place for monitoring and oversight.

Inspectors wroteBased on observation, record review, and interview conducted during the abbreviated survey (NY00315980) the facility did not ensure that 1 of 3 residents (Resident #3) reviewed for quality of care, received treatment and care in accordance with professional standards of practice. Specifically, Resident #3 exited the building unnoticed and was found on the ground. There was no documented evidence the resident was assessed before being transferred to the wheelchair and taken back into the building. The resident was sent to the hospital over 12 hours later with a broken hip.

Inspectors wroteBased on observation, record review and interviews during the abbreviated survey ( NY00315980) the facility did not ensure residents were provided supervision to avoid accident hazards for 1 of 3 residents (Resident #3) reviewed for accidents. Specifically, Resident #3 exited the building on 5/4/23 at 5:28 AM, undetected by staff, and was found an hour and half later at the end of the driveway. Later it was determined the resident had a fractured (broken) left hip.

Inspectors wroteBased on observations, interview, and record review, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, 1) Food brought into the facility for use by staff was stored in a freezer unit, 2) Two (2) soiled cooling coil fans were in use in the dairy refrigerator, and this presented a risk for food contamination. 3) Open, perishable foods were not appropriately labeled. 4) a. For 4 of 4 microwaves in use on the resident units, there were no thermometers available to check food temperatures when reheating foods to ensure safe temperatures for food service, and b. for 3 of 4 microwaves there were no procedures or guidance posted for microwave use.

Inspectors wroteBased on observation and interview conducted during the Recertification Survey from 01/17/24 to 01/24/24, the facility failed to ensure that the residents were informed and educated about their rights for 7 of 7 residents (Residents #44, #33, #91, #43, #32, #12, and #17) attending the Resident Council meeting. Specifically, the Residents' [NAME] of Rights was not posted on two of three floors in the facility.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the recertification survey from 1/17/24-1/24/24, the facility did not ensure that the menus met the nutritional needs and preferences for 1 of 2 residents (Resident #4) reviewed for food. Specifically, Resident #4 did not receive double portions of food as planned.

Inspectors wroteBased on observations, record review and interviews conducted during the recertification survey from 1/17/24-1/24/24, the facility did not ensure that they were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 2 residents (Resident #72) reviewed. Specifically, the call system unit at the bedside for Resident #72 was not operational and the call system push button was broken and not accessible.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated (NY00309033) surveys from 1/17/24 to 1/24/24, the facility did not maintain a safe, clean, and comfortable environment in 2 (Rooms 137, and 138) resident rooms. Specifically, room [ROOM NUMBER] had a hole in the wall, and room [ROOM NUMBER] had a hole on the window soffit ceiling.

Inspectors wroteBased on interview and record review conducted during the recertification survey, it cannot be ensured that the facility did developed a person-centered comprehensive care plan with measurable goals, time frames and appropriate interventions based on the resident's comprehensive assessment or ensured that interventions were implemented as per the plan of care for 1 of 4 residents (Resident #99) reviewed for positioning/range of motion and 1 of 6 residents (Resident #69) reviewed for unnecessary medications. [...]

Inspectors wroteBased on record review and interview conducted during a recertification survey, it cannot be ensured that the facility reviewed and revised the residents' Comprehensive Care Plans (CCPs) with measurable objectives, time frames and appropriate interventions to address unplanned significant weight loss for 1 of 7 residents (Resident #88) reviewed for Nutrition, and to address the risk for Urinary Tract Infections for 1 of 4 residents (Resident #58) reviewed for hospitalization.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey, it cannot be ensured that the facility applied assistive devices appropriately and/or applied per physician's order to improve and/or prevent a further decline in range of motion (ROM). Specifically, a physician ordered left hand roll was not applied and a right-hand resting hand splint was not applied appropriately for 1 of 4 residents (# 99) reviewed for positioning and limited mobility.

Inspectors wroteBased on observations, record reviews and interviews conducted during a recertification survey, it could not be ensured that the facility stored foods in accordance with professional standards for food service safety to ensure prevention of foodborne illness. Specifically, 1) two kitchen refrigeration units contained expired or undated foods, 2) one kitchen refrigeration unit was found to have a) an internal thermometer reading greater than 41-degrees Fahrenheit (F), b) contain time and temperature controlled for safety (TCS) foods which were not maintained at 41 degrees (F) or less, and c) contain contaminated food and 3) inspection of 4 nourishment refrigerators identified: a) 2 of 4 contained unlabeled, undated or expired foods; b) 2 of 4 did not have internal thermometers. [...]

Inspectors wroteBased upon observations, interviews and record reviews conducted during a recertification survey it could not be ensured that the facility maintained all mechanical, electrical, and patient care equipment in safe operating condition. Specifically, a kitchen refrigeration unit (Unit #2) was not maintained in good working condition to keep foods at or below 41 degrees. Review of an invoice dated 9/30/2020 for work done on the walk-in refrigerator (Refrigeration Unit #2) showed that on 9/30/20 the technician found the unit at a high temperature due to low charge. The invoice also noted that the unit is, probably not worth fixing. Need new equipment. The Director of Maintenance was interviewed on 10/21/2020 at approximately 10:10AM and reported that he was aware that 2 weeks ago, Refrigeration Unit #2's compressor was not working properly. [...]

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, it cannot be ensured that the facility provided the appropriate care to promote healing of an existing pressure ulcer for 1 of 3 residents (Resident #12) reviewed for pressure ulcers. Specifically, Resident #12 was observed several times to be positioned on his back without prescribed adaptive equipment as ordered. Review of the Minimum Data Set (MDS; an assessment tool) dated 4/13/2020 showed that Resident #12 was admitted on [DATE] with a Stage 3 pressure ulcer (PU). The MDS notes that Resident #12 is to utilize a pressure reducing device while in a chair and in a bed. Resident #12 also receives pressure ulcer/injury care, has a Turning and Repositioning program and has nutrition and hydration interventions to manage skin problems. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey it could not be ensured that the facility did not ensure that each resident received adequate transfer assistance and assistance devices to prevent accidents for 1 (Resident #65) of 3 residents reviewed for accidents. Specifically, 1) a chair alarm was not being utilized as per the plan of care and, 2) transfer assistance was not consistently provided as per physician order and per plan of care. Findings Include: The facility Policy and Procedure titled, Certified Nursing Assistant (CNA) Care/Documentation effective date 4/2018, indicated that the level of care should be followed as detailed on the [NAME] and the care plan. The CNAs are to review the [NAME] to know the level of assistance to be provide for each resident. The 9/24/2020 Significant Change Minimum Data Set assessment (MDS; [...]

Inspectors wroteBased on observations, record reviews and interviews conducted during a recertification survey, it could not be ensured that the facility provided timely medical supervision for 1 of 6 residents (Resident #88) reviewed for nutrition. Specifically, the Physician and/or the Nurse Practitioner (NP) were unaware of and therefore did not address the resident's unplanned significant weight loss. Review of facility policy and procedure (P/P) dated 4/2018, revised 1/2020 and titled, Weights documented that, the Dietitian/designee will notify the nurse manager, Medical Doctor (MD), care team of any significant weight variance.

Inspectors wroteBased on record review and interview conducted during a recertification survey, the facility did not electronically transmit in a timely manner encoded and completed MDS (Minimum Data Set; a federally mandated process for clinical assessment of residents in Medicare or Medicaid certified nursing homes) to CMS (Centers for Medicare and Medicaid Services) as required for quality measure purposes. This was evident for 9 out of 11 residents reviewed for Resident Assessments (Residents #1, 2, 3, 4, 5, 6, 7, 9, 11, 12, and 34). According to the MDS 3.0 Resident Assessment Instrument User's Manual, Comprehensive Assessments must be submitted no later than the comprehensive care plan date plus 14 days. All of the assessments must be submitted not later than the MDS completion date plus 14 calendar days.