Yorkview Nursing and Rehabilitation

Inspectors wroteBased on facility policy review, clinical record review, review of facility investigation documentation, review of hospital documentation, and resident and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure each resident the right to be free from neglect for one of four residents reviewed (Resident 2), which resulted in actual harm for Resident 2 as evidenced by a fall with a femur fracture. Findings Include: Review of the facility's policy, titled Abuse, read, in part, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. [...]

Inspectors wroteBased on clinical record review, review of facility investigation documentation, review of hospital documentation, and resident and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that each resident receives adequate supervision and assistance to prevent falls based on individual needs for one of four resident's reviewed (Resident 2), which resulted in actual harm for Resident 2 as evidenced by a fall with a femur fracture. Findings Include: Review of Resident 2's clinical record revealed diagnoses that included hypertension (elevated blood pressure), difficulty walking and contracture of the left and right knees. Review of Resident 2's interdisciplinary plan of care revealed a problem area that read risk of ADL self-care performance deficit. [...]

Inspectors wroteBased on policy review, clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 39 residents reviewed (Residents 7, 20, 94, and 108). Findings Include: Review of the facility's policy, titled Care Plans, Comprehensive Person-Centered, reviewed [DATE], read, The interdisciplinary team reviews and updates the care plan. Review of Resident 7's clinical record revealed diagnoses that included cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) with hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) of the right dominant side and muscle weakness. Review of Resident 7's physician orders revealed an order for Cardiopulmonary Resuscitation dated February 19, 2026. [...]

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to follow physician orders for obtaining weights and notification of weight changes for two of 33 residents reviewed (Residents 98 and 108).

Inspectors wroteBased on facility policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure a resident with limited range of motion received appropriate services, equipment, and assistance to increase range of motion and/or prevent further decrease in range of motion for one of one residents reviewed (Resident 7).

Inspectors wroteBased on facility policy reviews, clinical record review, and staff interviews, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of one resident reviewed (Resident 7).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of two residents reviewed (Resident 108). Findings Include: Review of facility policy, titled End-Stage Renal Disease, Care of a Resident with with a revision date of September 2010 revealed, in part, 4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: b. how information will be exchanged between the facilities. [...]

Inspectors wroteBased on review of select document review, 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 policy review, facility documents, observations, and resident and staff interviews, it was determined there is greater than 14 hours between the evening meal and breakfast the following day. The facility failed to provide and offer a nourishing snack (food from the basic food groups, either singly or in combination with each other) outside of the scheduled meal service times in accordance with resident's needs and agreement from the resident group.

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 three of five pantry refrigerators (subacute, F- east, and [NAME] II) and lack of hand hygiene during the Lunch meal on June 24, 2026.

Inspectors wroteBased on facility policy review, clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to ensure a resident's comprehensive care plan was implemented for one of 39 residents reviewed (Resident 1).

Inspectors wroteBased on review of facility policy, record review, observations, and staff interview, it was determined that the facility failed ensure the resident received care, consistent with professional standards, to treat and prevent pressure ulcers by ensuring heel lifting boots were worn for one of three residents reviewed for pressure ulcers (Resident 92). Findings Include: Review of facility policy, titled Skin and Wound Management System, revised September 2022, revealed, preventative intervention will be implemented for residents identified at risk, as appropriate, for example beds, wheelchair cushions, nutrition, incontinence, therapy, etc. Review of Resident 92's clinical record revealed diagnoses that included trans ischemic attack (TIA- a temporary blockage of blood flow to the brain) and muscle weakness (weakness in the muscles not explained by any medical diagnosis). [...]

Inspectors wroteBased on facility policy review, clinical records review, observations, and staff interview, it was determined that the facility failed to ensure that the resident environment was free of accident hazards by providing bilateral fall mats for one of two Residents reviewed for falls (Resident 49).

Inspectors wroteBased on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to properly label medications in one of six medications carts reviewed ([NAME] 2) and one medication storage room (Subacute Care); and failed to discard expired medications in one of four medication storage rooms observed (Subacute Care).

Inspectors wroteBased on review of facility policies, observations, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to provide residents with food that accommodates resident allergies, intolerances, and preferences for one of 39 residents reviewed (Resident 157).

Inspectors wroteBased on facility documents, clinical record review, observations, and staff interviews, it was determined that the facility failed to provide a nutritionally adequate meal for one of one meal observed (May 18, 2026, lunch meal).

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, it was determined that the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for one of the five residents observed (Resident 5). Findings Include: Review of the facility's Dignity policy, dated August 2009, read, in part, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The policy continued, Staff shall maintain an environment in which confidential clinical information is protected. Review of Resident 5's clinical record revealed an admission date of May 16, 2026. [...]

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior for two rooms on two of nine units (Units B and C). Observation in Resident 7's room on May 18, 2026, at 10:17 AM, revealed the multiple slats on the blinds were broken off or bent, dried food was observed around and under the bed. Observation in Resident 8's room on May 18, 2026, at 10:45 AM, revealed the papers, used cups, dried liquid, red and brown and dried food particles ground into the floor, and the floor note to contain a hazy film. Interview with Nursing Home Administrator on May 18, 2026, at 2:40 PM, revealed that when blinds need to be replaced, a work order should be submitted, and that Resident 8 likes to keep food in his room. 28 Pa.

Inspectors wroteBased on review of select grievances, observation, staff interview, 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.

Inspectors wroteBased on policy review, clinical record review, and staff interview, it was determined that 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 one of the four residents reviewed (Resident 2). Findings Include: Review of the facility's policy, titled Medication Ordering and Receiving from Pharmacy read Medications and related products are received from the dispensing pharmacy on a timely basis. The policy continued, Timely delivery of new orders is required so that medication administration is not delayed. [...]

Inspectors wroteBased on resident and staff interviews, facility policy review, 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.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure each resident the right to receive notice in advance of the resident's room or roommate change for one of six resident records reviewed (Resident 4). Findings Include:Review of the facility's policy, titled Resident Rights, revised June 2023, reads, Employees shall treat all residents with kindness, respect, and dignity. Review of Resident 4's clinical record revealed diagnoses that included dementia (Dementia is the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) and muscle weakness (a lack of muscle strength). Review of Resident 4's clinical record revealed she received a new roommate on October 23, 2025. [...]

Inspectors wroteBased on facility policy, investigation reports, clinical records, and staff interviews, it was determined the facility failed to ensure residents are treated with respect and dignity for one of three residents reviewed (Resident 1).

Inspectors wroteBased on observations and staff and resident interviews, it was determined that the facility failed to provide a comfortable and homelike environment on two of nine nursing units (100 and 200 hall).

Inspectors wroteBased on review of facility policy, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that the comprehensive care plan is reviewed and revised for three of 35 residents reviewed (Residents 43,108, and 166).

Inspectors wroteBased on review of facility procedure for fortified foods, observations, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to provide physician ordered fortified food program for three of 35 residents reviewed (Resident 28, 85, and 99); and failed to ensure proper monitoring for acceptable parameters of nutritional status for one of seven residents reviewed for nutrition (Resident 166).

Inspectors wroteBased on policy review, review of the facility provided diet manual, observations, and resident and staff interviews, it was determined that the facility failed to note or update menu changes and notify Residents of a change to the posted menu; and failed to provide a nutritionally adequate menu substitution for two of two meals observed (lunch meal on May 19th, and 21st, 2025).

Inspectors wroteBased on facility Test Tray form, resident and staff interviews, observations, 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.

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 in the kitchen.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that a resident right to a dignified existence during two of three meals observed (breakfast and lunch May 19, 2025).

Inspectors wroteBased on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to determine a resident's right to self-administer medications was clinically appropriate for one of 35 residents reviewed (Resident 97).

Inspectors wroteBased on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure residents received adequate monitoring to ensure the right to be free from chemical restraints for two of five residents reviewed for unnecessary medications (Residents 19 and 166).

Inspectors wroteBased on facility policy review, personnel file review, and staff interviews, it was determined that the facility failed to ensure that residents were protected from the potential for abuse by failing to determine and complete appropriate criminal history background checks for three of five personnel files reviewed (Employees 13, 15, and 16); failing to complete a license or registry verification at time of hire for two of three nursing staff reviewed (Employees 15 and 16); and by failing to perform a FBI (Federal) criminal history background check prior to hire for one of five personnel files reviewed (Employee 17).

Inspectors wroteBased on review of facility policy, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident status for three of 35 residents reviewed (Residents 11, 24, and 26).

Inspectors wroteBased on observation, resident and staff interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 35 records reviewed (Resident 122).

Inspectors wroteBased on clinical record review, resident and staff interviews, and facility documentation review, it was determined that the facility failed to maintain adequate personal hygiene and grooming per resident preference for residents dependent on staff for assistance with these activities of daily living for two of 35 residents reviewed (Residents 11 and 122 ).

Inspectors wroteBased on review of the clinical record and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that met each resident's physical, mental, and psychosocial needs for two of 35 residents reviewed (Residents 43 and 78).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure each resident receives proper treatment to maintain vision for one of two residents reviewed (Resident 11).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to provide pain management consistent with professional standards of practice for one of two residents reviewed for pain (Resident 143).

Inspectors wroteBased on facility policy review, clinical record review, observation, and staff interviews, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication, and failed to provide professional standards of practice for the care of a dialysis resident for one of two residents reviewed (Resident 181). Findings Include: Review of facility policy, titled End-Stage Renal Disease, Care of a Resident with with a revision date of September 2010, and a last review date of January 2025, revealed, in part, 4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: b. how information will be exchanged between the facilities. [...]

Inspectors wroteBased on staff interviews, facility policy review, and clinical record review, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for three of 34 residents reviewed (Residents 12, 142, and 163) .

Inspectors wroteBased on review of the clinical record, observations, and staff and resident 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 34 residents reviewed (Residents 140 and 163).

Inspectors wroteBased on facility policy, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to provide a therapeutic diet, per physician's order, for two of 34 residents reviewed (Resident 74 and 137).

Inspectors wroteBased on document review, clinical record review, and staff interviews, 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 resident reviewed for dialysis (Resident 46).

Inspectors wroteBased on observations, facility policy review, manufacturer label review, and staff interviews, it was determined that the facility failed to store medications in a manner consistent with professional standards for two of five medication carts observed (300 medication cart and F Wing 2 medication cart).

Inspectors wroteBased on clinical record review, document review, observations, and resident and staff interviews, it was determined that the facility failed to provide a nutritionally adequate menu substitution for one of two meals observed (June 3rd and 4th, 2024, lunch meal) and failed to follow the menu for lunch meals observed on June 3, 2024, for one of seven resident areas observed (Rosemont Hall).

Inspectors wroteBased on review of facility policy, observations, and 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 two of two nourishment pantries observed (B/C unit and Wedge [NAME] 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 one of 34 residents reviewed (Resident 5).

Inspectors wroteBased on observations, review of clinical records, and resident and staff interviews, it was revealed that the facility failed to provide necessary individualized services to maintain Activities of Daily Living (ADL- wash face, brush teeth, eating, brush hair) regarding fingernail care for one of 34 residents reviewed (Resident 110).

Inspectors wroteBased on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure the resident received care, consistent with professional standards, to prevent pressure ulcers for one of 37 residents reviewed (Resident 140). Findings Include: Review of facility policy, titled Wound Care, revised October 2010, revealed Steps in the Procedure, 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during the procedure on the clean field. Also, 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. [...]

Inspectors wroteBased on document review and staff interview, it was determined that the facility failed to complete a performance review of every nurse aide at least once every 12 months for two of five nurse aide documents reviewed (Employees 12 and 13). Findings Include: A review of Employee 12's personnel information revealed a hire date of May 13, 1991. A review of Employee 12's most recent Competency Evaluation revealed a review and completion date of May 6, 2023. A review of Employee 13's personnel information revealed a hire date of April 9, 2013. A review of Employee 13's most recent Competency Evaluation revealed a review and completion date of April 5, 2023. An interview with the Director of Nursing on June 6, 2024, at 12:15 PM, revealed the evaluations provided are the most recent and additional information will be sought. [...]

Inspectors wroteBased on staff interview and document review, it was determined the facility failed to develop a water management program based on a risk analysis of the facility for the prevention, detection, and control of water-borne contaminants, such as Legionella, a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia).

Inspectors wroteBased on observation and resident and staff interviews, it was determined that the facility failed to ensure each resident's bedside is equipped to allow for residents to call for staff assistance through a communication system for one of seven resident areas reviewed (Rosemont Hall). Findings Include: Observations on the Rosemont Hall in one room occupied by Residents 16 and 135 on June 4, 2024, at 9:24 AM, revealed no call bell cords leaving the Resident wall above the beds. Interviews with Residents 16 and 135 revealed they have no call bells available to call for staff assistance. An interview with the Nurse Aide (Employee 19) on June 4, 2024, at 9:28 AM, confirmed the lack of call bells available to Residents 16 and 135 in their room. [...]

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 five of six nursing units (Rosemont, A wing, B wing, C wing, Wedge [NAME] 1, and F wing west).

Inspectors wroteBased on a test tray and staff interviews, it was determined that the facility failed to provide food and beverage that are at a safe and appetizing temperature for one of one meal observed on the C Wing.

Inspectors wroteBased on observations, staff interviews, and pests service report review, it was determined that the facility failed to maintain an effective pest control program so that the facility is free from pests in the kitchen and the boiler room.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure a safe, functional, and sanitary environment for residents, staff, and the public in the dish room and boiler room.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior for three Resident's rooms (Residents 2, 4, and 8).

Inspectors wroteBased on clinical record reviews, facility documentation, and staff interviews, it was determined the facility failed to ensure necessary treatment and services, consistent with professional standards of practice to promote healing and prevent infection for two of four residents reviewed (Residents 1 and 3).

Inspectors wroteBased on facility scheduled meal times, staff and resident interviews, and observations, it was revealed that the facility failed to serve meals routinely at regular mealtimes comparable to normal mealtimes in the community or in accordance with resident needs, preferences, and requests for one of one meal observed (November 3, 2023, lunch meal, F-West unit).

Inspectors wroteBased on observations, review of facility policy, and resident and staff interviews, it was determined that the facility failed to provide food and beverage that are at a safe and appetizing temperature for one of one meal observed (F-West unit; November 3, 2023, lunch).