Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at York South Skilled Nursing And Rehabilitation Ctr during CMS and state inspections, most recent first.
A resident with a facility-acquired stage IV pressure ulcer of the L heel and vascular dementia had inconsistent wound measurements between facility staff and the wound care specialist. The facility used a camera that auto-entered measurements, while the wound specialist manually measured the wound, resulting in differing length, width, and depth documentation and inconsistent tracking of wound progress. The resident was also non-compliant with heel boots and off-loading while in bed.
Food storage and kitchen sanitation were not maintained in accordance with policy and professional standards. A ceiling opening remained uncovered near the 3-compartment sink after a prior leak, two food items in a nourishment refrigerator were date marked but not labeled with a resident identifier, and another nourishment refrigerator had a red dried liquid on the bottom shelf; staff confirmed the ceiling area should be covered and the refrigerator should be clean.
Food was not consistently served at appetizing temperatures. Resident council minutes and resident interviews reported cold or poor food temperatures, and a test tray showed the turkey, brussels sprouts, and baked potato were below the expected hot holding temperature. The Dining Services Director recorded low temperatures for several items, and the surveyor observed the plate and heated base were only slightly warm and appeared worn.
A resident with cerebral infarction, L hemiplegia, and muscle weakness did not receive personal clothing back from laundry in a timely manner, and he reported having to go to PT in a hospital gown because shirts and pants were missing. Staff reported the laundry machine was out of order and laundry was backed up, and the NHA and DON acknowledged repeated issues with getting the laundry unit fully repaired and operational. The DON noted the resident’s paralysis led to frequent clothing changes due to toileting dependence.
A facility failed to maintain a safe, clean, comfortable, and homelike environment in the 400 Hallway. Surveyors observed damaged wallpaper behind a resident’s bed and in another resident’s room, along with a loose metal threshold at a bathroom doorway that was missing a screw and sticking up from the floor. A resident representative voiced concern about the room conditions and the potential for someone to trip on the threshold.
The facility failed to follow ordered care for two residents. One resident with BPH and UTI findings had an older contaminated urine culture reviewed instead of a new culture because the lab order was not entered correctly and only a UA was obtained. Another resident with a surgical wound and wound vac had the dressing left unchanged even though the order required VAC dressing changes on a set schedule; an RN signed off the treatment as completed after thinking the order only meant checking settings.
Failure to provide restorative nursing services to maintain upper extremity ROM was identified for a resident with Parkinson's Disease and muscle weakness. The PT recommended an RNP for AM/PM upper extremity movement exercises, and the care plan directed staff to supervise, assist as needed, and encourage use of a rubber band during exercises. The resident stated staff had not been doing the exercises, the EHR task section had no documentation showing the service was provided, and the DON confirmed the task should have been in place with daily documentation.
Incomplete dialysis monitoring documentation was found for a resident with HTN and ESRD who had an order for HD at an outside dialysis center. The facility’s Hemodialysis Communication Record forms were not fully completed for multiple treatments, leaving the resident’s pre- and post-HD status, vital signs, weights, and possible complications undocumented, and the DON stated the forms should be accurately completed.
An unlabeled medication cup containing 2 white capsules was found in a medication cart, and expired eye drops were found in the 400 Wing medication storage room, including medications for a resident in the refrigerator and a discharged resident. An LPN said the capsules had been placed there while she was trying to determine what was going on with a resident before administering or discarding them, and the DON stated medications should be labeled and properly stored.
Improperly Contained Dumpster Waste and Debris in Trash Area: Facility policy required exterior dumpster lids to be closed when not in use and the surrounding area to be free of rubbish. Surveyors observed one dumpster full of trash with both lids open, along with a small bag of trash and used gloves on the ground near the dumpster. The DSD and NHA both confirmed the lids should be closed and the area should be free of debris.
A resident with diabetes and atrial fibrillation, whose POLST called for limited additional interventions and antibiotics if life could be prolonged, was incorrectly identified by an on-call provider as being on comfort care. This led to a lack of escalation in care when the resident developed fever and UTI symptoms. Despite no documentation supporting comfort care status, appropriate interventions were delayed, resulting in further decline and death.
A resident with a Foley catheter and multiple diagnoses, including dementia and obstructive uropathy, did not have documented catheter care as required by facility policy. Although physician orders addressed catheter management, there was no specific order or nurse aide task for catheter care, and the DON confirmed the lack of documentation. The resident was treated for a UTI during this period.
The facility failed to document weights for two residents as per physician orders and did not arrange transportation for a resident's dialysis appointment, resulting in a missed treatment. The DON confirmed the lack of documentation and transportation arrangements.
A facility failed to provide routine medications to a resident due to unavailability from the contracted pharmacy and lack of emergency supply. The resident, with conditions such as diabetes, hypertension, and insomnia, missed evening doses of Midodrine, insulin, and Trazadone. The DON confirmed the deficiency, which violated the facility's pharmaceutical service policy.
The facility failed to provide and document wound care treatments for four residents with various medical conditions, including malnutrition, CHF, peripheral vascular disease, and diabetes. Treatments were not completed or documented on multiple occasions, as confirmed by the DON.
A CNA at the facility was found to have performed tasks beyond their scope of practice, including passing medications and checking blood sugar levels, under the direction of an LPN. This involved two residents who confirmed receiving medications and blood sugar checks from the CNA. Witness statements from other staff and residents corroborated these actions, although no adverse outcomes were reported.
The facility failed to maintain a safe and clean environment in three resident shower rooms, with issues such as black and pink substances on floors, a cracked shower gurney mat, non-functioning ceiling vents, and a loose sink. Observations were made in the presence of the Director of Housekeeping, and the Nursing Home Administrator was informed of these deficiencies.
The facility failed to report abuse allegations within the required 24-hour timeframe for two residents. One resident with dementia was verbally abused by a nurse aide, and another resident with morbid obesity was verbally abused by a respiratory therapist. Both incidents were reported to authorities well after the required timeframe.
The facility failed to create comprehensive care plans for four residents, including those admitted to hospice care and those with specific medical interventions like catheters and supplemental oxygen. The absence of these care plans was confirmed by the DON, violating facility policy and state regulations.
The facility failed to monitor and document the pH levels of the sanitizer sink and did not store and serve food and beverages according to professional standards. Observations revealed missing documentation for pH levels and improperly labeled and dated food items in the kitchen and nourishment pantries. The Food Service Director confirmed these oversights, indicating a lapse in adherence to facility policies.
The facility failed to implement enhanced barrier precautions for two residents, one with severe ulcers and another with an indwelling catheter. Required signage was missing, and staff did not follow gowning protocols during wound care, as confirmed by the DON.
A facility failed to inform a resident of charges for services not covered under Medicare or Medicaid. The resident, admitted for short-term rehabilitation with conditions like hypertension and heart failure, was not given the SNF-ABN form detailing costs after Medicare A services ended. This left the resident unaware of their financial responsibility for services until discharge.
The facility failed to review and revise care plans for three residents. One resident's care plan included discontinued interventions, another's care plan included discontinued geri-sleeves, and a third resident's care plan was incomplete and not updated with specific information. The DON confirmed these deficiencies.
A resident with Alzheimer's and pleural effusion was not provided necessary grooming assistance, resulting in significant facial hair despite her care plan indicating a need for help with daily hygiene. Observations confirmed the deficiency, highlighting a lapse in care plan implementation.
A resident with pressure ulcers did not receive proper wound care, as an employee reused a paper measuring tape on multiple wounds and failed to change gloves or perform hand hygiene between treatments. The resident had stage 4 pressure ulcers and a non-pressure full thickness ulcer, and the Director of Nursing confirmed the breach in protocol.
A resident with a history of peripheral vascular disease and hypertension was diagnosed with a UTI and prescribed Keflex. Despite treatment, the resident continued to experience burning during urination, but the facility failed to follow up on these symptoms until nearly a month later. The DON confirmed that additional follow-up should have occurred sooner.
A facility failed to provide proper respiratory care for a resident with ALS and COPD, as the Trilogy mask was improperly stored and not cleaned according to standards. Observations showed the mask on the floor and later on a nightstand with a substance in its fold. Staff interviews confirmed the mask should be stored in a plastic bag and cleaned weekly, indicating a lapse in equipment maintenance.
The facility did not complete a required annual performance review for a nurse aide, Employee 2, who was hired over a year ago. The facility's policy mandates annual performance appraisals, which were not conducted for this employee, as confirmed by the NHA during an interview.
A facility failed to educate a resident with type 2 diabetes and hypertension on the influenza vaccination. The resident refused the vaccine for the 2023-2024 season, but there was no documentation of the refusal or evidence of education and a vaccine information statement being provided. The DON confirmed the lack of documentation and education during an interview.
Inconsistent Wound Measurements for a Resident With a Stage IV Heel Pressure Ulcer
Penalty
Summary
The facility failed to maintain an accurate method of wound measurement assessment between facility staff and the wound provider specialist for one resident with a facility-acquired stage IV pressure ulcer of the left heel and vascular dementia. Review of the resident’s record showed the resident was non-compliant with keeping heel boots in place or off-loading heels while in bed. The facility’s documented wound measurements and the wound care specialist’s measurements did not match on multiple dates, including June 11, June 4, and May 28, 2026, with differing length, width, and depth findings and differing documentation of wound progress. The facility policy stated that the plan of care should reflect assessment findings from the comprehensive patient assessment and wound evaluation. During interview, the DON confirmed the measurements were not consistent because the facility and the wound care specialist used different measurement methods. The DON stated the wound care specialist manually measured the wound, while the facility used a camera that automatically entered measurements that were not consistent with the manual measurements. A review of the wound tracking sheet showed the facility was documenting its own measurements rather than the wound care specialist’s measurements.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store and serve food and beverages in accordance with professional food safety standards in two pantry refrigerators and in the kitchen area. Facility policy for Safe Handling for Foods from Visitors stated that food intended for later consumption must be labeled with the resident name and current date, and the Department Sanitation policy stated that all non-food contact equipment must be clean and free of debris. On observation, the ceiling to the right of the 3-compartment sink had a square opening without a cover after a leak had occurred several months earlier; staff interviews confirmed the cover or metal panel had not been replaced. In the 500/600-unit nourishment refrigerator, two plastic bags dated June 13 contained half-eaten chicken and rice and a portion of a quesadilla, but neither bag was marked with a resident identifier. In the 700/800-unit nourishment refrigerator, a red dried liquid was observed on the bottom shelf, and staff confirmed the refrigerator should be clean. The administrator also acknowledged the ceiling area should be covered and that resident items should be marked with an identifier.
Food Served at Improper Temperatures
Penalty
Summary
The facility failed to provide foods that were palatable and at appetizing temperatures. Review of the Facility Test Tray Evaluation form dated May 1, 2023, showed that hot entree, vegetable, and starch items should be served at 140 degrees Fahrenheit. Resident council meeting minutes dated April 20, 2026, documented that breakfast was cold, and interviews with Resident 3 and Resident 7 on June 15, 2026, revealed that the temperature of the food was often poor and not good. A test tray completed on June 16, 2026, showed adequate portion size and that the food was palatable for taste and texture on a regular diet, but the temperature of the turkey, brussels sprouts, and baked potato was not palatable. The tray was placed on a meal cart and delivered to the 700 unit with other trays, and 10 minutes had elapsed between preparation from the service line and presentation for evaluation. The Dining Services Director took temperatures at the time the tray was served for evaluation and recorded roast turkey at 130 degrees F, brussels sprouts at 112 degrees F, baked potato at 122 degrees F, peach cobbler at 45 degrees F, coffee at 130 degrees F, milk at 48 degrees F, and apple juice at 48 degrees F. The surveyor also observed that the plate was slightly warm and the heated base was barely warm and appeared worn. During interview, the Dining Services Director stated that residents had concerns with food temperatures several months prior and the facility replaced the pellet warmer, and the Nursing Home Administrator confirmed that the machine that heats the pellets was replaced but not the pellets.
Missing Laundry Delayed Resident Clothing Return
Penalty
Summary
The facility failed to promote care for residents in a manner that enhances dignity for Resident 138 when his personal clothing was not returned from laundry in a timely manner. Facility policies required resident clothing processed by the service location to be cleaned and returned promptly, allowed residents to use personal belongings to preserve individuality and dignity, and encouraged residents to dress in their own clothes rather than hospital-type gowns. Review of grievance logs showed multiple grievances from January 2026 through June 2026 related to missing clothing and laundry items, with items either later located, replaced by family, or replaced by the facility. Resident 138 had diagnoses including cerebral infarction, hemiplegia affecting the left nondominant side, and muscle weakness. During interview, he reported that 6 shirts and 3 pairs of pants were missing after being sent to laundry and stated he had to go to physical therapy in a hospital gown because his personal clothing had not been returned. He later reported that all clothing had been returned except a pair of white, lightweight sweatpants. Staff reported the laundry washing machine had been out of order and laundry was backed up, and the NHA and DON acknowledged there had been numerous issues with getting the laundry unit fully repaired and operational. The DON also stated the resident’s left-sided paralysis caused frequent clothing changes due to dependence with toileting.
Unsafe and Damaged Resident Room Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in the 400 Hallway area, including resident rooms and bathroom entry areas. Facility policy stated that residents have the right to a safe, clean, comfortable, and homelike environment and that housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior. During interviews and observations, Resident 79’s representative expressed concern about the condition of the wallpaper behind the resident’s bed, which was observed to be scratched up and bubbling away from the wall on multiple occasions. The representative also raised concern about the metal bar separating the bathroom floor from the room floor, stating someone could trip over it and get hurt.
Failure to Follow Ordered Urine Testing and Wound Vac Care
Penalty
Summary
The facility failed to ensure that treatments and care were provided in accordance with orders and professional standards for two residents. For Resident 9, who had diagnoses including benign prostatic hyperplasia, muscle weakness, and mononeuropathy, the clinical record showed a lab result note stating the resident had a positive urinary tract infection, hematuria was improving, and there were no complaints of dysuria. However, the urine culture reviewed by the physician was an older contaminated culture dated weeks earlier, and the DON later stated the new culture was never ordered because a mistake was made on the lab slip and only a urinalysis was obtained. The DON also stated the order was never entered into the computer as required by facility process. For Resident 109, who had diagnoses including a closed fracture in routine healing, long-term anticoagulant use, and difficulty walking, the physician order required wound vac settings at 125 mmHg continuous with dressing changes on Monday, Wednesday, and Friday. The resident reported concern that the wound vac had not been changed as ordered, and the June treatment record showed an RN signed off that the wound treatment was completed. The RN stated he thought the order only required checking the wound vac settings and did not change the dressing. The DON stated she would have expected the wound vac to have been changed as ordered.
Failure to Provide and Document Restorative ROM Services
Penalty
Summary
Failure to provide restorative nursing services to maintain upper extremity motion was identified for one resident with Parkinson's Disease and muscle weakness. The resident's record showed that on April 2, 2026, the physical therapist recommended a restorative nursing program to maintain the ability to move the upper extremities freely with AM/PM care for 15 minutes per day, six days per week. The restorative care plan, also initiated on April 2, 2026, directed staff to encourage the resident to use a rubber yellow band, provide supervision with the task, assist as needed, encourage big movement during exercises as tolerated, and explain each step prior to doing it. During an interview on June 15, 2026, the resident stated that staff had not been providing therapy exercises and could not remember the last time the task was performed. Review of the electronic health record task section did not show any restorative task documentation to indicate the service had been provided. When the DON was asked on June 17, 2026 to provide documentation showing the restorative task had been provided since April 2, 2026, no documentation was available. The task section was added on June 17, 2026, and the DON later confirmed that the restorative task should have been present since April 2, 2026, with daily documentation expected.
Incomplete Dialysis Monitoring Documentation
Penalty
Summary
The facility failed to ensure that a resident who required dialysis received care consistent with professional standards of practice, including ongoing assessment before and after treatments and monitoring for complications. The facility’s policy for hemodialysis provided by a certified dialysis facility required ongoing assessment and oversight before and after HD treatments and ongoing communication and collaboration with the dialysis facility regarding care and services. Resident 108 had diagnoses including hypertension and end stage renal disease and had a physician order for dialysis at an outside dialysis center on Tuesday, Thursday, and Saturday. Review of the facility’s Hemodialysis Communication Record forms showed incomplete documentation of the resident’s status while at the dialysis facility and after return to the facility on multiple dates in April, May, and June 2026. The form was intended to document pre- and post-dialysis weights, temperature, pulse, blood pressure, and complications such as nausea, fatigue, and dizziness. The DON stated on June 17, 2026, that the Hemodialysis Communication Record forms should be accurately completed.
Improper Medication Storage and Unlabeled Capsules
Penalty
Summary
Medications and biologicals were not stored properly in one of three medication carts observed on the 400 Wing and in one of three medication rooms observed on the 400 Wing. Facility policy stated that medications and biologicals are to be stored properly according to manufacturer or provider pharmacy recommendations, and that outdated, contaminated, discontinued, or deteriorated medications are to be disposed of according to procedure. During observation of the 400 Wing medication cart with an LPN, a medication cup containing 2 white capsules was found in the top drawer with no markings on the cup. The LPN stated the medication had been placed there while she was trying to determine what was going on with a resident before administering or discarding it. During observation of the 400 Wing medication storage room with staff, a bottle of Cetirizine 10 mg stock was present with an expiration date of February 2026, a bottle of Latanoprost 0.005% for one resident was found expired in the refrigerator, and a bottle of Xalatan 0.005% for another resident who had been discharged was also found expired. The staff member confirmed the medications were expired and discarded them. During interview, the DON stated she would expect medications to be labeled and properly stored.
Improperly Contained Dumpster Waste and Debris in Trash Area
Penalty
Summary
The facility failed to ensure that waste was properly contained in the dumpster and that the area surrounding the dumpster was free from debris for one of two dumpsters. Facility policy titled "Dispose of Garbage and Refuse," revised February 2025, stated that the Dining Services Director coordinates with the Director of Maintenance to keep the exterior dumpster area free of rubbish or other debris and that all trash is to be properly disposed of in exterior receptacles with lids covered when not in use. Observations of the trash area on June 15 and June 16, 2026, at 9:00 AM showed the first dumpster was full of trash and both lids were open. On June 16, 2026, there was one small bag of trash at the base of the dumpster and three used gloves on the ground. During an observation with the Dining Services Director on June 16, 2026, at 10:32 AM, one lid was up and there were three used gloves and a small bag of trash in front of the dumpster. The Dining Services Director stated the lids should be closed and there should not be items on the ground. The Nursing Home Administrator stated on June 17, 2026, at 1:04 PM that trash is collected 2-3 times a week and confirmed the lids should be closed and the area should be free of rubbish.
Failure to Follow Resident's Plan of Care and POLST Directives
Penalty
Summary
The facility failed to provide care and services consistent with a resident's comprehensive plan of care, resulting in a decline in health status. The resident had diagnoses including diabetes mellitus type II and atrial fibrillation, and had a POLST indicating limited additional interventions, use of IV fluids and cardiac monitoring as indicated, and use of antibiotics if life could be prolonged. Despite these directives, clinical documentation and staff interviews revealed that the contracted on-call provider incorrectly identified the resident as being on comfort care measures, which led to a lack of escalation in care when the resident developed a fever and symptoms suggestive of a urinary tract infection (UTI). Progress notes showed that the resident experienced a fever and foul-smelling urine, and although the on-call provider was notified, documentation stated that only comfort care measures were to be provided, with no escalation of care. This was not consistent with the resident's POLST or physician orders, which did not indicate comfort care status at that time. The resident continued to decline, exhibiting lethargy, poor oral intake, and eventually was found to have a confirmed UTI and acute kidney injury. Orders for antibiotics and IV fluids were eventually given, but only after a significant delay and further deterioration in the resident's condition. Interviews with facility staff, including the DON, confirmed that there was no documentation or order placing the resident on comfort care during the period in question. The failure to follow the resident's established plan of care and advanced directives resulted in delayed and insufficient medical intervention, contributing to the resident's decline and subsequent death.
Failure to Provide and Document Catheter Care for Incontinent Resident
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident who was incontinent of bladder and had an indwelling Foley catheter. Facility policy required catheter care to be performed twice daily and as needed, with documentation of care provided, urine output if ordered, and any abnormal findings. Review of the resident's clinical record showed diagnoses including obstructive uropathy, congestive heart failure, and dementia. The resident had a Foley catheter placed for urinary retention, and the care plan included interventions for skin care and use of a moisture barrier after each incontinent episode. Physician orders included instructions for catheter management, but there was no specific order or nurse aide task for catheter care. Further review of the clinical record did not reveal documentation that catheter care was being provided as required by facility policy. The resident was treated with antibiotics for a urinary tract infection during the review period. During an interview, the DON was unable to locate documentation indicating that catheter care was completed, and stated that she would expect such care to be performed and documented according to policy.
Failure to Document Weights and Arrange Transportation for Dialysis
Penalty
Summary
The facility failed to ensure that its residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered plan of care. For Resident 1, who had diagnoses including Alzheimer's disease and acute pancreatitis, there was a physician's order to monitor daily weight and notify cardiology or the primary care physician if there was a significant weight increase. However, there were no documented weights for Resident 1 on specified dates, indicating a failure to adhere to the physician's orders. Similarly, Resident 3, diagnosed with end-stage renal disease and a history of falling, had a physician's order to be weighed on specific days before dialysis. The facility did not document weights on the required dates, and Resident 3 missed a scheduled dialysis appointment due to transportation issues. The Director of Nursing confirmed the lack of documentation for the ordered daily weights and the missed dialysis appointment, as well as the absence of notification to the physician about the missed treatment.
Failure to Provide Routine Medications
Penalty
Summary
The facility failed to provide routine drugs and pharmaceutical services to meet the needs of its residents, specifically for one resident. The facility's policy, titled Provider Pharmacy Requirements, dated 2007, mandates regular and reliable pharmaceutical services, including accurate dispensing of prescriptions and providing routine and emergency pharmacy services. However, a review of a resident's clinical record revealed that on a specific date, the resident missed their evening medications, including Midodrine, long-acting insulin, and Trazadone, because the medications were not available from the pharmacy. An interview with the Director of Nursing confirmed that the resident did not receive the medications as they were not available from the facility's contracted pharmacy, nor were they available in the facility's emergency medication supply. The resident's diagnoses included diabetes mellitus Type II, hypertension, and insomnia, which necessitated the timely administration of these medications. The failure to provide these medications was a direct violation of the facility's policy and state regulations regarding pharmacy and nursing services.
Failure to Document and Complete Wound Care Treatments
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for four residents with wound care orders. Resident 15, diagnosed with severe protein-calorie malnutrition and congestive heart failure, had multiple wound care orders documented in the July 2024 Treatment Administration Record (TAR). However, there was no evidence that the treatments were completed on several dates, including July 15, 17, 18, 19, 20, 22, and 24, 2024. Resident 17, with diagnoses of peripheral vascular disease and congestive heart failure, also had wound care orders documented in the July 2024 TAR. The treatments for wounds on the buttocks and left buttocks were not completed on July 27 and 28, 2024, during the night shift. Additionally, nursing progress notes indicated that treatments were not completed on July 9 and 28, 2024, due to time constraints. Resident 18, diagnosed with malignant neoplasm of the colon and sarcopenia, had an order for Calazime skin protectant application every shift, but there was no evidence of treatment completion on July 10 and 19, 2024, during the evening shifts. Resident 19, with peripheral vascular disease and diabetes mellitus, had missing documentation for treatments on July 1 and 17, 2024. The Director of Nursing confirmed the lack of additional information regarding the missing documentation of wound treatments.
Unqualified Staff Performing Out-of-Scope Tasks
Penalty
Summary
The facility failed to ensure that services provided to residents were conducted by staff with the appropriate skills, experience, and qualifications. Employee 3, a Certified Nursing Assistant (CNA), was found to have assisted Employee 4, a Licensed Practical Nurse (LPN), in tasks beyond the CNA's scope of practice. These tasks included passing medications, obtaining blood sugar readings using a glucometer, and turning off alarming IV pumps. Witness statements from other staff members and residents confirmed that Employee 3 was involved in these activities, which are not within the scope of practice for a CNA. Residents 20 and 21 were directly affected by these actions, as they received medications and had their blood sugar levels checked by Employee 3. Resident 20 confirmed receiving medications and having blood sugar checks conducted by Employee 3, while Resident 21 reported that Employee 3 administered medications and checked blood sugar levels on weekends. Another resident, Resident 22, witnessed Employee 3 giving medications to a roommate. Despite these actions, the facility's investigation revealed no adverse outcomes from Employee 3's actions. However, the facility acknowledged that Employee 3 acted outside of his scope of practice, leading to his termination and the barring of Employee 4 from returning to the facility.
Deficiency in Maintaining Safe and Clean Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and home-like environment in three of four resident shower rooms located on the first and second floor nursing units. During observations conducted on June 26, 2024, in the presence of the Director of Housekeeping, it was noted that the second floor men's shower room had a black substance on the floor at the base of the wall in two of the three showers. Similarly, the second floor women's shower room had a pink and black substance on the floor at the base of the wall on all three sides of the shower, a cracked blue mat on the shower gurney with exposed foam, and a non-functioning ceiling vent in front of the shower on the right. In the first floor shower room, a black substance was observed on the floor at the base of the wall on two sides, the sink was found to be separated from the wall and loose, and the ceiling vent on the right was not functioning. Interviews with the Director of Housekeeping revealed that shower rooms are cleaned every other day and as needed, and a request had been submitted to Maintenance to replace the silicone in the women's shower room on the second floor about a week prior. The Nursing Home Administrator was informed of these issues, and it was revealed that work orders for maintenance would be submitted and housekeeping contacted.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or mistreatment within the required 24-hour timeframe to the appropriate authorities, as per their policy. In the case of Resident 40, who had diagnoses including dementia and anxiety, a physical therapist reported that a nurse aide verbally abused the resident by making derogatory comments. The facility substantiated the verbal abuse but did not report the incident to the Area Agency on Aging until 24 days later, which was beyond the required reporting timeframe. Similarly, for Resident 61, who had diagnoses including morbid obesity and muscle weakness, an incident occurred where a respiratory therapist made derogatory remarks to the resident. The facility's investigation confirmed verbal abuse, and the therapist was barred from returning to the facility. However, the incident was not reported to the local authorities until six days after it occurred, again failing to meet the 24-hour reporting requirement. These failures were acknowledged by the Nursing Home Administrator during an interview.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for four residents, as required by their policy. Resident 38, diagnosed with dementia and hypertension, was admitted to hospice care and had an external urinary catheter placed, yet no care plans were developed to address these needs. Similarly, Resident 67, with peripheral vascular disease and gastro-esophageal reflux disease, was admitted to hospice care without a corresponding care plan. Interviews with the Director of Nursing confirmed the absence of these necessary care plans. Resident 68, diagnosed with chronic obstructive pulmonary disease and neuromuscular dysfunction of the bladder, was observed using supplemental oxygen and a urinary catheter, but their care plan lacked guidance for these interventions. Resident 82, with Alzheimer's disease and peripheral vascular disease, had an active physician order for catheter care, yet no care plan was developed to address the use of the catheter. The Director of Nursing acknowledged the lack of care plans for these residents, which is a violation of the facility's policy and state nursing service regulations.
Deficiencies in Food Safety and Sanitization Monitoring
Penalty
Summary
The facility failed to properly monitor and document the pH levels of the sanitizer sink used for manual ware-washing, as well as to store and serve food and beverages according to professional standards. The facility's policy required the use of quaternary test strips to measure the concentration of the sanitizer, which should range between 200-400 parts per million. However, observations revealed that there was no documentation of pH levels for May and June 2024, and the facility did not have the necessary pH test strips. Employee 4, the Food Service Director, confirmed that the contracted chemical supply company had not delivered the pH strips, and the facility was supposed to document the pH of the solution three times a day. Additionally, the facility did not adhere to its policies regarding the labeling and dating of food and beverages. In the kitchen area, a thawed chocolate nutritional supplement was not date-marked with a pull date from the freezer. In the second-floor nourishment pantry, several items in the freezer were not marked with a resident identifier, and pre-packaged hot dogs in the refrigerator were not date-marked. Similarly, in the Arcadia unit nourishment pantry, an open container of nectar thick cranberry juice and thawed nutritional shakes were not date-marked. Employee 4 acknowledged these oversights, indicating that the items should have been properly labeled and dated according to the facility's policies.
Infection Control Deficiencies in Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection control practices for two residents, leading to deficiencies in the implementation of enhanced barrier precautions. Resident 78, who had diagnoses including congestive heart failure and peripheral vascular disease, was found to have multiple severe ulcers. Despite the facility's policy requiring enhanced barrier precautions for residents with chronic wounds, no sign was posted on Resident 78's door, and during a wound dressing change, an employee did not wear a gown as required. The Director of Nursing confirmed these lapses in protocol. Similarly, Resident 82, diagnosed with Alzheimer's disease and peripheral vascular disease, had an indwelling catheter and was supposed to be under enhanced barrier precautions. However, no sign was posted on their door until observed by surveyors, despite the precautions being in place since the catheter was inserted. The Director of Nursing acknowledged that the signage should have been posted earlier, indicating a failure to adhere to the facility's infection control policies.
Failure to Inform Resident of Non-Covered Service Charges
Penalty
Summary
The facility failed to periodically inform a resident of charges for services not covered under Medicare or Medicaid. Resident 239, who was admitted for short-term rehabilitation with diagnoses including hypertension and heart failure, was not provided with the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) form. This form should have detailed the estimated cost of the facility's inpatient skilled nursing services starting from January 31, 2024, after the termination of Medicare A services on January 30, 2024. Consequently, Resident 239 was unaware of their financial responsibility for services from January 31, 2024, until their discharge on February 14, 2024. An interview with the Nursing Home Administrator revealed that the facility was aware of the failure to issue the SNF-ABN form to residents and began taking steps towards compliance in February 2024.
Care Plan Review and Revision Deficiencies
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised appropriately for three residents. Resident 32's care plan included interventions for a palm protector and a cam boot, which were no longer in use. The palm protector was discontinued, and the cam boot was removed from the care plan, but these changes were not reflected in the care plan. Observations confirmed that the resident was not wearing these items, and the Director of Nursing (DON) confirmed that they should have been removed from the care plan. Resident 62's care plan included the use of geri-sleeves to prevent skin tears, but these were discontinued and not removed from the care plan. The resident's physician orders did not include the use of geri-sleeves, and the DON confirmed that they should have been removed from the care plan. The care plan also included interventions for skin tears, which were documented in the physician orders. Resident 70's care plan was incomplete, as it was entered as a template and not updated with specific information for the resident. The care plan included interventions for assistance with activities of daily living, but the specific details were not filled in. The DON acknowledged that the care plan should have been revised and updated with resident-specific information.
Failure to Assist Resident with Grooming Needs
Penalty
Summary
The facility failed to provide adequate grooming care for a resident, identified as Resident 72, who was unable to perform activities of daily living (ADLs) due to medical conditions including Alzheimer's disease and pleural effusion. The facility's policy on ADLs, revised in May 2023, mandates that residents who cannot perform ADLs independently should receive necessary assistance to maintain personal hygiene. However, observations on two consecutive days revealed that Resident 72 had significant facial hair, which she expressed a desire to have removed but was unable to do so herself. The resident's care plan, which noted an ADL self-care deficit due to weakness related to pleural effusion, included an intervention to assist with daily hygiene and grooming. Despite this, the resident was observed with unaddressed facial hair, indicating a lapse in the implementation of her care plan. Interviews with the resident and the Director of Nursing confirmed the oversight, as the resident had not been shaved as required by her care plan.
Failure to Ensure Proper Wound Care and Hygiene
Penalty
Summary
The facility failed to provide appropriate treatment and services to promote healing and prevent infection for a resident with pressure injuries. The resident, who had diagnoses including congestive heart failure and peripheral vascular disease, was observed to have a stage 4 pressure ulcer on the sacrum, a stage 4 pressure ulcer on the right heel, and a non-pressure full thickness ulcer on the lower right leg. During a wound treatment change, an employee used the same paper measuring tape for all wounds without changing it between measurements, which is against proper protocol. Additionally, the employee did not change gloves or perform hand hygiene between handling different wounds and dressing changes. This was observed during the application of a dressing to the right lower leg wound, the removal of the sacral dressing, the cleansing of the sacral wound, and the application of a new dressing to the sacral wound. The Director of Nursing confirmed that disposable items should not be reused on multiple wounds and that proper hand hygiene and glove changes should occur between wound treatments.
Failure to Follow Up on UTI Symptoms in Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who was incontinent of bladder, leading to a deficiency in preventing urinary tract infections (UTIs). The resident, who had diagnoses including peripheral vascular disease and hypertension, was diagnosed with a UTI on April 30, 2024. The resident was prescribed Keflex, an antibiotic, to be taken three times a day for seven days, with the last dose administered on May 8, 2024. Despite the treatment, a progress note on May 8, 2024, indicated that the resident continued to experience burning during urination, a symptom of UTI. The facility's interdisciplinary plan of care for the resident included an intervention to report signs and symptoms of UTI, such as burning during urination. However, there was no documented follow-up on the resident's continued symptoms until a urine culture was ordered on June 6, 2024. During an interview, the Director of Nursing confirmed that there was no follow-up on the progress note from May 8, 2024, and acknowledged that additional follow-up should have been completed before June 6, 2024.
Failure in Respiratory Care Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care and oxygen services consistent with professional standards of practice for a resident diagnosed with amyotrophic lateral sclerosis (ALS), chronic obstructive pulmonary disease (COPD), and other conditions. The facility's policy on Bi-level Positive Airway Pressure (Bi-PAP) and Continuous Positive Airway Pressure (CPAP) devices, including the Trilogy device, lacked information on cleaning and storage of equipment. This omission contributed to improper handling and storage of the Trilogy mask used by the resident. Observations revealed that the Trilogy mask was found on the floor and later on the nightstand with a light tan substance in its fold, indicating inadequate cleaning and storage. Interviews with the resident and staff confirmed that the resident required assistance with the mask, and the mask should have been stored in a plastic bag and cleaned weekly. The Nursing Home Administrator also confirmed the mask should be stored properly and cleaned as needed, highlighting a failure in adhering to the facility's standards for respiratory care equipment maintenance.
Failure to Conduct Annual Performance Review for Nurse Aide
Penalty
Summary
The facility failed to complete a performance review for one of the five nurse aides reviewed, specifically Employee 2, within the required 12-month period. According to the facility's policy, titled HR616 Performance Appraisal, managers are required to meet with their employees at least annually to conduct a performance appraisal or have a performance-based conversation. This policy also states that in-service education will be provided based on the outcomes of these reviews. Employee 2 was hired on December 10, 2022, and as of June 26, 2024, no yearly performance evaluation had been conducted for this employee. During a staff interview, the Nursing Home Administrator confirmed that Employee 2 did not have a performance evaluation conducted, acknowledging that employees should have performance reviews conducted yearly.
Failure to Educate Resident on Influenza Vaccination
Penalty
Summary
The facility failed to ensure that a resident was educated on the influenza vaccination. A review of the clinical record for a resident with diagnoses of type 2 diabetes mellitus and hypertension revealed that the resident was admitted to the facility and subsequently refused the influenza vaccination for the 2023-2024 season. However, there was no documentation of the resident's declination of the vaccine or evidence that the resident was provided with education and a vaccine information statement regarding the influenza vaccination. During a staff interview, the Director of Nursing confirmed the lack of documentation and education provided to the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 219 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near York
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Misericordia Nursing & Rehabilitation Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Rest Haven-york | 2.1 mi | ★★★★★ | 8 | 0 |
| Kingston Court Skilled Nursing And Rehabilitation | 2.6 mi | ★★★★★ | 1 | 0 |
| Pleasant Acres Rehabilitation And Nursing Center | 3 mi | ★★★★★ | 8 | 0 |
| Yorkview Nursing And Rehabilitation | 3.1 mi | ★★★★★ | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.