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 Yorkview Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with difficulty walking and bilateral knee contractures required max assist x 2 for bed mobility, but a nurse aide provided care without a second staff member. The resident rolled out of bed during care, complained of pain, and was later diagnosed with a closed distal femur fracture that required surgery. The NHA confirmed the aide did not follow the resident’s care plan.
A resident with difficulty walking and bilateral knee contractures had a care plan and Kardex directing max assist of 2 for bed mobility. While an aide was providing care with the resident lying on his side, the resident rolled out of bed and sustained pain to the right ankle, knee, and hip. Hospital records showed a closed right distal femur fracture requiring surgery, and the administrator stated the aide did not follow the resident’s plan of care and should have had another staff member assist.
The facility failed to keep care plans current for four residents. One resident’s plan still listed DNR and a pressure ulcer focus despite a CPR order and wound resolution, another resident’s plan did not reflect advanced cataracts and low vision, a third resident’s plan listed full code despite POLST and physician orders for DNR, and a fourth resident’s plan still included a pressure ulcer focus even though no pressure ulcer was present. The DON confirmed the care plans should have been revised to match the residents’ current status.
Failure to Obtain Ordered Daily Weights and Notify Physician of Weight Gains: Two residents with significant medical conditions, including CKD, HTN, ESRD, CHF, and DM II, had physician orders for daily weights and notification for specified weight gains. The MARs showed multiple missed weights, and one resident had several weight increases that met the notification threshold without documentation that the physician was informed. Staff also documented missed weights because the resident was sleeping or equipment was unavailable, with no additional attempts recorded.
Failure to provide and document splinting and ROM services: A resident with muscle weakness and bilateral hand contractures had hand splints observed stored in a basin near the bedside, while the chart lacked a splint wearing schedule and did not show documentation that the splints were applied. OT discharge instructions established a restorative splint and brace program, with staff educated to don and doff the splints, complete skin checks, and provide passive ROM before splint use, but TARs and nurse aide documentation did not reflect the resident wearing the splints.
Inadequate G-tube care and enteral feeding documentation. A resident with CVA-related hemiplegia and dysphagia had orders for NPO status, continuous Jevity 1.5 via G-tube, water flushes, residual checks every shift, and oral care, but the record lacked an order for tube placement verification or shift site care. MAR/TAR review showed no consistent documentation of G-tube site care or residual checks, water flushes were not always documented as ordered, and feeding amounts were recorded in two places with inconsistent entries; nursing notes were also not present for every shift.
A resident with ESRD, CHF, and DM2 had orders for dialysis three times weekly, and the care plan called for open communication with the dialysis center. However, multiple dialysis communication sheets were missing from the clinical record even though the MAR showed the resident went to dialysis on those visits, and the DON confirmed the records were absent.
Food Not Served at Palatable Temperatures: Residents reported meals were not served hot, hot food was cold, and some food did not taste good. During tray line observation and a test tray review, a Food Service Director noted a plate warmer bay was not functioning, and the tray was barely warm to the touch when evaluated. Recorded temperatures for hot items were below what was considered palatable, while cold items such as mandarin oranges and milk were served at 58 degrees and 46 degrees, respectively.
Failure to provide nourishing snacks between meals. Facility policy stated residents could request snacks and all residents were to be offered an evening snack, but the meal schedule created a 15-hour gap between dinner and breakfast. Surveyors found snack bins with only cookies or crackers and no nourishing snacks in unit or RN supervisor refrigerators. Several residents said they were not offered bedtime snacks or were told none were available, including a resident with a history of gastric sleeve surgery who reported hunger between meals and at night.
Food storage and meal service practices were not followed when multiple pantry refrigerators contained resident food items and open products that were not date marked or labeled, and one refrigerator had visible spills and residue. During lunch service, two Dietary Aides handled food with gloves, touched their face and bare arm, and continued serving without changing gloves or performing hand hygiene, which the FSD and NHA confirmed was improper.
A resident with Alzheimer’s dementia, persistent atrial fibrillation, intracardiac thrombosis, and anticoagulant use had a care plan that did not include a focus area for Eliquis or bleeding monitoring. The MDS showed anticoagulant use, and the physician ordered Eliquis 5 mg BID, but the care plan lacked this needed detail despite staff stating care plans are expected to be current and reflect resident care needs.
A resident with TIA and muscle weakness was observed in bed without ordered bilateral heel offloading boots in place, despite a care plan intervention and a physician order for the boots to be worn at all times when in bed. The boots were found on the floor beside the wheelchair on one occasion and in the wheelchair near the bed on another, and the DON stated she would expect the resident to be wearing them as ordered.
A resident with repeated falls and hemiplegia had care plan interventions calling for bilateral fall mats and floor mats on both sides of the bed, but observations showed only a single mat on one side of the bed on two occasions. The DON confirmed the resident should have had bilateral fall mats at the bedside, and no physician order for bedside fall mats was found.
Medication labeling and storage deficiencies were identified in a medication cart and the Subacute Care med room. An opened insulin pen for a resident and an opened multi-dose vial were found without open dates, and several expired medications, including vitamins, aspirin, and melatonin, were stored in the med room. An RN confirmed the unlabeled and expired items, and the NHA stated meds should be labeled, stored properly, and discarded when expired.
Failure to provide ordered meal alternatives and preferred fluids: A resident with class 3 obesity, L hemiplegia, and anxiety reported not liking the food and not getting enough to eat. His meal ticket ordered a heart healthy diet with a fluid restriction and no corn, but the tray observed included no alternate vegetable and did not provide the listed milk or coffee. The RD confirmed an alternate for corn should have been provided, and the NHA was informed of the missed items.
A resident meal was not prepared and served according to the facility diet manual and production sheets. Staff served only two chicken tenders instead of the required three, and a resident with Alzheimer's disease and dysphagia did not receive all items listed on the tray ticket, including a PB&J sandwich and extra gravy or sauce.
A resident with PTSD and depression was assessed by the Social Worker in a hallway while other residents, staff, and visitors were present. The interview included BIMS and PHQ-9 questions about mood, appetite, concentration, hopelessness, and recall, and the DOSS and NHA confirmed this was not best practice.
The facility failed to maintain a safe, clean, comfortable, and home-like interior in two resident rooms. Surveyors observed broken and bent blind slats and dried food around and under a bed in one room, and papers, used cups, dried liquid, and dried food particles ground into the floor with a hazy film in another room. The NHA stated that blind replacement requires a work order and that one resident likes to keep food in his room.
A grievance and meal tray observation showed food and milk were not kept at proper temperatures. Milk was left on top of the cart without ice, and a test tray showed hot items too cool and cold items too warm, with the FSD confirming the temperatures were not acceptable.
The facility did not follow its policy requiring timely receipt of medications from the pharmacy, resulting in a resident with asthma, chronic pain, arthritis, and ADHD not receiving multiple ordered drugs, including Advair, pregabalin (Lyrica), celecoxib (Celebrex), and amphetamine dextroamphetamine (Adderall). Clinical records showed these medications were documented as not available, and the DON confirmed they had not been received from the contracted pharmacy, preventing administration as ordered.
The facility did not ensure that food was served at safe and appetizing temperatures, as confirmed by resident and staff interviews and a test tray evaluation. Hot and cold food items were found to be outside required temperature ranges, and the appearance and texture of the food were also found lacking.
A resident with dementia and muscle weakness was assigned a new roommate without prior written notice to her or her representative, as required. Staff and administration confirmed that the notification did not occur before the roommate change, which was only discovered after a subsequent incident between the residents.
A resident with dementia and behavioral disturbances became combative during incontinence care, leading a nurse aide to raise her hand in a threatening manner, which was observed by another staff member. The aide's actions did not align with facility policy requiring residents to be treated with dignity and respect.
Two residents reported being cold on a unit where room temperatures were found to be below the recommended range, with one resident requiring multiple blankets for warmth. Maintenance confirmed that several rooms had temperatures as low as 64°F, and the unit had not been updated with new HVAC systems. Additionally, window blinds in multiple rooms were broken or missing, further detracting from a homelike environment. The NHA was aware of the need for numerous blind replacements throughout the facility.
Three residents did not have their care plans properly reviewed or updated following changes in their conditions or treatments. One resident's care plan was not revised after a pressure ulcer resolved, another's care plan listed an incorrect diagnosis for anticoagulant use, and a third resident's care plan failed to include new behaviors and the use of antipsychotic medication. Staff confirmed that care plans should have been updated to reflect these changes.
Several residents with physician-ordered fortified diets did not consistently receive the required fortified foods and supplements, and one resident with significant weight loss was not properly monitored for meal intake or assistance. Staff interviews and documentation reviews confirmed that fortified foods were not being prepared or served as ordered, and meal intake records were frequently incomplete or missing.
The facility did not consistently follow posted menus, failed to document or communicate menu substitutions, and did not provide nutritionally adequate alternatives when items were unavailable. As a result, several residents did not receive the required servings of fruits, vegetables, and beverages, and their requests for missing items were not met. Staff interviews confirmed that menu changes were not properly managed or communicated, and food orders were sometimes reduced by corporate oversight, leading to unmet nutritional needs.
Multiple residents reported that hot foods were not served at appropriate temperatures and that meals were bland or included items they should not receive. A test tray evaluation confirmed that several food items were served below required temperatures, with overcooked vegetables and weak-tasting juice, and the Food Service Director acknowledged the deficiencies.
Surveyors identified multiple deficiencies in food storage and handling, including food stored on the floor, opened items not date marked, expired thickened water, and food without resident identifiers. Staff were observed with hair not fully contained in hairnets and failing to perform hand hygiene after changing gloves. These findings were confirmed through staff interviews and did not meet professional standards for food safety.
Residents were served meals in Styrofoam containers and with beverage pitchers covered in plastic wrap due to a shortage of proper dining supplies. Additionally, two residents did not receive knives with their lunch trays, requiring them to use their fingers and forks to prepare their food, which compromised their dignity during meals.
A resident with multiple chronic conditions was permitted to keep a Combivent Respimat inhaler at bedside for self-administration without any documented assessment by the IDT of their cognitive or physical ability to do so, as required by facility policy.
Two residents received antipsychotic medications without appropriate side effect or behavior monitoring. One resident was prescribed Seroquel without documentation of monitoring, and another was given Risperdal with an inaccurate diagnosis and no evidence of monitoring or clear indication, as confirmed by the DON and NHA.
The facility did not complete required state and federal criminal background checks or timely license and registry verifications for several new hires, including nursing staff, as confirmed by staff interviews and personnel file reviews.
Three residents had inaccurate MDS assessments that did not match their clinical records, including missing documentation of edentulism, hospice care, and a schizophrenia diagnosis. These discrepancies were confirmed by facility leadership and were not consistent with the residents' documented conditions.
A resident with a history of stroke, hemiplegia, contracture, muscle weakness, vascular dementia, and joint pain was observed to have a contracted right hand and reported using a right-hand splint at night as ordered by the physician. Despite documentation of splint use in the MAR, the care plan did not address the resident's hemiplegia, splint use, or pain management, and the DON acknowledged that these should have been included.
Two residents dependent on staff for activities of daily living did not consistently receive showers as scheduled or according to their preferences. One resident missed multiple scheduled showers, with documentation and grievances confirming the lapses, often due to staff shortages and documentation errors. Another resident, who preferred showers and required a Hoyer lift, received bed baths instead on some occasions because of insufficient staffing, despite her preference being documented and discussed with her family and care team.
Two residents did not receive care and services in accordance with physician orders and professional standards. One resident's insulin injections were not documented as administered on two occasions, and another resident with multiple wounds had missing documentation for required wound care treatments on several dates. The DON confirmed that documentation should be completed when medications or treatments are given.
A resident with multiple chronic conditions was not provided with recommended artificial tears for dry eye syndrome after an eye doctor consultation. Although the physician signed off on the consult, the order for the eye drops was not entered promptly, resulting in a delay in treatment.
A resident with chronic pain and a history of spinal fracture and polyneuropathy did not receive scheduled Oxycodone on multiple occasions, as confirmed by medication records and the resident's report. The DON stated staff were expected to administer pain medication as ordered.
A resident receiving dialysis care did not have required emergency equipment at the bedside, and the facility failed to maintain complete and accurate records of dialysis communication. Consult sheets were inconsistently completed and filed, and blood pressure readings were repeatedly documented as being taken from a restricted limb, contrary to physician orders. Staff interviews confirmed these lapses in documentation and care standards.
The facility did not meet the required minimum of 3.20 hours of direct resident care per day for several days, with care hours falling short on four specific days. This was confirmed by staffing records and the DON.
The facility failed to develop comprehensive care plans for three residents, omitting critical focus areas such as dementia, anticoagulant use, diabetes management, atrial fibrillation, and post-fall care. These omissions were identified through staff interviews and clinical record reviews, indicating a lack of adherence to the facility's care planning policy.
The facility failed to provide care according to professional standards for two residents. One resident, on hospice care, lacked current physician orders for hospice services despite being on a care plan. Another resident, who fell and sustained injuries, did not receive immediate follow-up care instructions for a hematoma from the hospital, and the facility delayed obtaining physician orders for wound care.
The facility failed to provide a therapeutic diet and manage fluid restrictions for two residents. One resident with diabetes experienced significant weight loss due to inconsistent provision of prescribed snacks, while another resident with heart failure received improper fluid management, with discrepancies in meal tickets and lack of documentation.
A resident with chronic kidney disease stage five did not have dialysis communication forms for multiple dates, despite receiving dialysis. The facility lacked a policy for dialysis care, and staff interviews revealed that forms were not placed in the physician's communication folder as required.
The facility was found deficient in medication storage practices, with two medication carts not adhering to professional standards. The 300 cart had undated Lantus insulin pens, and the F Wing 2 cart contained unidentified loose pills. The DON confirmed expectations for dating insulin pens and maintaining medication carts in a clean and orderly manner.
The facility failed to provide adequate menu substitutions and did not follow planned menus for lunch meals. On one occasion, residents were served ice cream instead of applesauce, which was not documented as a substitution. Additionally, some residents did not receive the beverages and food items listed on their meal tickets. Staff interviews confirmed that residents should have received the correct items or appropriate substitutions.
The facility failed to store and label food according to professional standards, with multiple instances of improper food storage and labeling observed in the kitchen and nourishment pantries. Items such as American cheese, thawed turkey, and various resident food items lacked date markings and resident identifiers, while cleanliness issues were noted in storage areas.
A facility failed to accurately document the use of a noninvasive ventilator for a resident with sleep apnea, heart failure, and respiratory failure. Despite physician orders for a BiPAP machine, the resident's MDS assessments did not reflect this, as confirmed by staff interviews.
A resident with multiple diagnoses, including dementia and diabetes, was found with long, jagged fingernails due to the facility's failure to provide necessary ADL services. The resident preferred washing up in his room and expressed a desire for nail care. Despite being scheduled for showers, no documentation of showers or baths was found over the past month, and refusals were not properly recorded in the care plan or MDS. The Nursing Home Administrator acknowledged that refusals should be documented, but this was not done.
Failure to Follow 2-Person Assist Care Plan During Bed Mobility
Penalty
Summary
The facility failed to ensure a resident’s right to be free from neglect when one nurse aide provided care to a resident who required bed mobility assistance from 2 staff members. The resident’s care plan and Kardex both identified bed mobility as max assist x 2, and the resident had diagnoses including hypertension, difficulty walking, and contractures of both knees. During care, the resident rolled out of bed onto the floor while the nurse aide was assisting him, and the resident reported that the aide did not bring in 2 people as required. After the fall, the resident complained of pain in the right ankle, right knee, and right hip area and was sent to the hospital for further evaluation. Hospital documentation showed a closed right distal femur fracture, and the resident required surgical intervention to repair the fracture. The facility’s investigation and the nurse aide’s statement indicated that the resident was lying on his side during care and fell when the bed was inflating and his body could not adjust. The Nursing Home Administrator confirmed that the nurse aide did not follow the resident’s plan of care and should have had another staff person assist with care. The report states that the facility displayed past non-compliance in failing to ensure the resident was free from neglect, resulting in actual harm as evidenced by the fracture.
Failure to Provide Required Two-Person Assistance During Bed Care
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance based on his care plan when he was being provided care in bed. The resident had diagnoses including hypertension, difficulty walking, and contractures of both knees, and his care plan and Kardex directed bed mobility with max assist of 2. During care, a nurse aide was assisting the resident while he was lying on his side, and the resident rolled out of bed onto the floor. The resident stated that the aide did not bring in 2 people to help with the care. After the fall, the resident complained of pain in his right ankle, right knee, and right hip area and was sent to the hospital for further assessment. Hospital documentation showed a closed right distal femur fracture after the fall from bed, and the resident required surgical intervention to repair the fracture. The facility administrator stated that the aide did not follow the resident’s plan of care and should have had another staff person to help with care.
Care plans not updated to reflect current code status, vision status, and wound status
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for four residents. Review of the facility policy stated that the interdisciplinary team reviews and updates the care plan, but the records for Residents 7, 20, 94, and 108 showed care plan information that did not match their current conditions or orders. Resident 7 had diagnoses including cerebral infarction with right-sided hemiplegia and hemiparesis, and the record showed a CPR order dated February 19, 2026, while the care plan still identified an advanced directive of Do Not Resuscitate. The DON confirmed the care plan should have been revised when the code status changed from DNR to Full Code, and also confirmed the pressure ulcer care plan should have been revised after the wound resolved because the resident no longer had a pressure ulcer. Resident 20 had diagnoses including hypertension and advanced cataracts, and an observation showed difficulty locating items during lunch and the resident stated she did not want to drink from her neighbor’s cup. A vision consult documented advanced cataracts and that surgery was not indicated, yet the care plan only addressed wearing glasses, which the DON confirmed was no longer accurate because the resident no longer wore glasses. Resident 94’s care plan listed full code with CPR to be performed as needed, but the POLST and physician order both indicated DNR status, and the DON confirmed the care plan should have reflected that preference. Resident 108 had diagnoses including ESRD, chronic systolic CHF, and type II diabetes, but the care plan still included a pressure ulcer focus even though the clinical record did not show a current pressure ulcer; the DON confirmed the care plan should have been revised when the pressure ulcer resolved.
Failure to Obtain Ordered Daily Weights and Notify Physician of Weight Gains
Penalty
Summary
The facility failed to follow physician orders for daily weights and for notifying the physician of significant weight changes for two residents. Resident 98 had diagnoses including chronic kidney disease and hypertension, and had an order dated January 10, 2026 for daily weights with notification for a 2 lb gain in 24 hours or 5 lbs in one week. The record showed multiple missed daily weights across February, March, April, May, and June 2026, including dates when weights were not documented and one instance where a weight was not obtained because the shower door would not open and another because the scale was out of order. The record also showed several weight gains that met or exceeded the ordered notification threshold, including gains of 5.3 lbs, 2.4 lbs, 2.2 lbs, 2.5 lbs, 2.2 lbs, 3.8 lbs, 2 lbs, 2 lbs, and 4.4 lbs, with no documentation that the physician was made aware of these increases. Resident 108 had diagnoses including ESRD, chronic systolic CHF, and diabetes mellitus type II, and had an order dated May 1, 2025 for daily weights and to notify the physician of a 4 lb or greater weight gain. The March through June 2026 MARs showed multiple dates with no daily weight documented. On several dates, documentation stated the resident was sleeping and the weight was not obtained, with no additional attempts documented. During interviews, the NHA and DON confirmed that weights should be obtained as ordered and that appropriate follow-up with the physician should be completed and documented.
Failure to Provide and Document Splinting and ROM Services
Penalty
Summary
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. Resident 7 had diagnoses including muscle weakness and contractures of the right and left hand. Observations on June 23, 2026, June 24, 2026, and June 25, 2026, showed bilateral hand splints in a basin near the resident’s bedside rather than in use. The resident had a physician order for bilateral hand/wrist splint skin checks every shift dated September 7, 2025, but the record did not include an order for a splint wearing schedule. The care plan included a focus for assistance/potential to restore to maximum level of function for mobility, but it did not include interventions for a splinting program. The resident received OT from March 23, 2026, through April 29, 2026, and the OT discharge summary stated the resident could tolerate bilateral resting hand splints for six hours daily, staff were educated on donning and doffing splints and skin checks, and a Restorative Splint and Brace Program was established for daily use. The facility’s restorative education form showed staff were educated that the resident was to wear the splints daily up to eight hours a day and that passive ROM to the fingers, wrists, and elbows was to be provided before donning the splints because the resident was totally dependent on staff for splint donning/doffing and hygiene. However, the treatment administration records and nurse aide task documentation did not show that the resident wore the splints, although nurses documented the ordered skin checks every shift. The DON confirmed there was no order indicating the splint wearing schedule and no documentation showing the splints were applied.
Inadequate G-tube care and enteral feeding documentation
Penalty
Summary
Appropriate care and services were not provided for a resident receiving tube feedings. Resident 7 had diagnoses including cerebral infarction with right-sided hemiplegia and hemiparesis and dysphagia, and had orders for NPO status, continuous Jevity 1.5 enteral feeding via G-tube, water flushes, residual checks every shift, and oral care every six hours. The record also showed a care plan for tube feeding related to dysphagia and interventions for G-tube care every shift and local care to the G-tube site as ordered. Facility records did not show an order for gastrostomy tube placement verification before starting enteral feeding or for site care every shift. Review of the MARs/TARs from August 2025 through June 2026 did not reveal documentation that G-tube site care was provided every shift or that residual feeding was checked and the amount recorded. The ordered four-hour water flushes were not always documented as 150 mL, and there were two separate areas for staff to document the amount of feeding infused, with entries that did not consistently match the ordered amount or each other. Nursing progress notes sometimes stated that tube placement was confirmed by air auscultation, feeding was infusing without difficulty, no residual was noted, and the G-tube site had no signs or symptoms of infection, but these notes were not present for every shift of every day.
Incomplete Dialysis Communication Records
Penalty
Summary
The facility failed to maintain complete and accurate dialysis communication records for one resident with end stage renal disease (ESRD), chronic systolic congestive heart failure, and diabetes mellitus type II. The resident had physician orders for dialysis treatments three times a week on Monday, Wednesday, and Friday, and the care plan included keeping open communication with the dialysis center. Facility policy stated that agreements with the contracted ESRD facility include how information will be exchanged between the facilities. Review of the resident’s dialysis treatment communication sheets showed multiple missing sheets for dialysis visits across March, April, May, and June 2026. Review of the MAR confirmed the resident went to dialysis on those dates. During interview, the DON confirmed the missing dialysis communication sheets were not present in the clinical record and stated that dialysis consult sheets should be completed with each dialysis treatment and kept in the record.
Food Not Served at Palatable Temperatures
Penalty
Summary
Food and drink were not consistently palatable or served at appetizing temperatures. During interviews, Resident 91 stated meals were not served hot, Resident 103 stated the hot food was cold and that no condiments were served with sandwiches, Resident 108 stated she did not like the food because it did not taste good, and Resident 157 stated the resident did not like the taste of the food and did not get enough to eat. During tray line observation, a pan of Chicken [NAME] was pulled from the warmer and placed in a hot well on the tray line at 155 degrees, and the Food Service Director stated one of the bays on the plate warmer was not functioning. A test tray completed the next day showed adequate portion size and palatable taste and texture for a regular diet, but the temperature of the chicken alfredo with noodles, Italian blend vegetables, and mandarin oranges was not palatable. The tray was delivered to the 700-unit with other trays, and 18 minutes elapsed between preparation and evaluation. At the time of evaluation, the recorded temperatures were 139 degrees for chicken [NAME] with noodles, 135 degrees for Italian blend vegetables, 58 degrees for mandarin oranges, 135 degrees for coffee, and 46 degrees for milk. The plate was barely warm to the touch, and the Food Service Director and Nursing Home Administrator stated the temperatures were within the facility's test tray evaluation form parameters. It was also noted that there was a current work order, waiting approval, to fix the plate warmer.
Failure to Provide Nourishing Snacks Between Meals
Penalty
Summary
The facility failed to ensure meals and snacks were served at times in accordance with resident needs, preferences, and requests, and failed to provide or offer a nourishing snack outside of scheduled meal times. Facility policy stated that nourishing snacks are available, residents may request snacks as desired, snacks may be scheduled between meals to match typical eating patterns, and all residents are offered a nourishing evening snack. However, the meal cart delivery schedule showed dinner was served as early as 4:15 PM and breakfast as late as 9:20 AM, creating a 15-hour span between the evening meal and breakfast the next day. Survey observations found that snack bins in multiple unit nourishment pantries contained only items such as graham crackers and cookies, and no peanut butter crackers or nourishing snacks were observed in refrigerators. Additional observations in medication storage room refrigerators and the RN Supervisor office refrigerator found no nourishing snacks or sandwiches. Staff interviews indicated that snacks were delivered to units daily or every other day, and that sandwiches were stored in the RN Supervisor refrigerator for new admissions or resident requests, but the observed refrigerators did not contain those items at the times surveyed. During a resident group meeting, several residents stated they were not offered bedtime snacks and were told none were available when they asked. One resident with a history of gastric sleeve surgery reported eating small meals, feeling hungry between meals and at night, and being told staff did not have any snacks. Another resident stated he did not like the taste of the food, did not get enough to eat, and was usually told there were no snacks when he asked. The record for the resident with gastric sleeve surgery showed a regular diet and intake ranging from 25% to 75%, and a physician note documented prior complaints of nausea and poor oral intake related to a history of gastric bypass surgery.
Food Storage and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to store and serve food and beverages in accordance with professional food safety standards in three of five pantry refrigerators and during the lunch meal service. In the Subacute nourishment pantry, surveyors observed a half-eaten strawberry milk shake and fruit yogurt bowl in the freezer that were not date marked or labeled with a resident identifier, and an open 32 oz container of honey thick milk in the refrigerator that was partially used and not marked with an open or use-by date. In the F-east and west nourishment pantry, two bowls of applesauce were not date marked, and the refrigerator contained a clear liquid in the lower bin and a dried tan liquid on the bottom shelf. In the [NAME] II nourishment pantry, two thawed strawberry Mighty Shakes were not marked with a pull or use-by date, and an open 32 oz carton of Med Pass 2 was partially used and not marked with an open or use-by date. The Food Service Director confirmed that resident items should be marked with a resident identifier and date, open items should be dated, and refrigerators should be clean. During the lunch meal, a Dietary Aide with a gloved hand opened the proofing box, retrieved a hamburger roll, touched the roll to her bare arm, then used the same glove to reach into the pan of hamburgers, place the hamburger in the bun, and serve the sandwich without completing hand hygiene. Another Dietary Aide was observed serving soup and puree items with gloved hands, then picking her teeth, touching inside her mouth, and rubbing her nose with the same glove before returning to service without changing gloves or completing hand hygiene. The Food Service Director and the NHA both confirmed that the staff should have changed gloves and completed hand hygiene.
Care plan did not address anticoagulant use or bleeding monitoring
Penalty
Summary
The facility failed to ensure Resident 1’s comprehensive care plan was implemented for one of 39 residents reviewed. Resident 1 had diagnoses including Alzheimer’s dementia with late onset, persistent atrial fibrillation, intracardiac thrombosis, and long term use of anticoagulants. The resident’s MDS dated June 5, 2026, indicated use of anticoagulant medication, and physician orders included Eliquis 5 mg twice daily related to atrial fibrillation. Review of Resident 1’s care plan showed it did not include a focus area for anticoagulant use or monitoring for bleeding. During interviews with the NHA and DON, the DON stated that care plan input comes from the IDT, unit nurse, DON, therapy, and MDS coordinator, with nursing generally responsible for initiating and updating. The NHA and DON also stated that care plans are expected to be up to date for monitoring resident care needs.
Failure to Use Ordered Heel Offloading Boots
Penalty
Summary
The facility failed to ensure that pressure ulcer prevention and treatment care was provided consistent with professional standards for one resident with pressure ulcer risk factors. Facility policy for Skin and Wound Management System stated that preventative interventions would be implemented for residents identified at risk, including items such as beds, wheelchair cushions, nutrition, incontinence, and therapy. Resident 92 had diagnoses including TIA and muscle weakness, and the care plan identified limited physical mobility with an intervention for bilateral heel offloading boots for positioning/contracture management. Observations showed Resident 92 lying in bed on June 23, 2026, and again on June 25, 2026, without the heel offloading boots in place; on one occasion the boots were on the floor beside the wheelchair, and on another they were sitting in the wheelchair near the foot of the bed. The physician order directed bilateral heel offloading boots at all times when in bed. The DON stated on June 26, 2026, that she would expect the resident to be wearing the boots as ordered.
Missing Bilateral Fall Mats at Bedside
Penalty
Summary
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 had diagnoses that included repeated falls and hemiplegia. The resident’s care plan identified a risk for falls related to stroke and included interventions for bilateral fall mats, and another care plan focus area called for bilateral wedges and floor mats to both sides of the bed. During observations, Resident 49 was seen lying in bed with only a single fall mat on the floor on the left side of the bed on two separate occasions. Review of the resident’s physician orders did not reveal an order for fall mats at the bedside. The Director of Nursing stated that Resident 49 should have had bilateral fall mats on the floor at the bedside.
Medication Labeling and Expired Drug Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not properly labeled and stored in accordance with facility policy and accepted professional principles. During review of the [NAME] 2 medication cart, a Humalog Kwik insulin pen belonging to Resident 141 was observed opened but not dated, and an LPN confirmed it should have been dated when opened. In the Subacute Care medication storage room, an opened Apisol Injectable multi-dose vial was also found not dated, and an RN confirmed it was opened and not dated. The Subacute Care medication storage room also contained expired medications, including Vitamin D3 with an expiration date of March 2025, Vitamin C with an expiration date of April 2026, Aspirin with an expiration date of May 2026, and two bottles of Melatonin with best-by dates of April 2024 and March 2025. The RN confirmed these medications were expired. During interview, the NHA stated she expected medications to be labeled and stored properly and to be discarded when expired according to policy or manufacturer guidelines.
Failure to Provide Ordered Meal Alternatives and Preferred Fluids
Penalty
Summary
The facility failed to provide food that accommodated a resident’s preferences and ordered dietary restrictions for Resident 157. The resident’s clinical record included diagnoses of class 3 obesity, left hemiplegia, and anxiety. During interview, the resident stated he did not like the taste of the food and did not get enough to eat. The resident’s meal ticket for lunch specified a heart healthy diet, a 360 ml fluid restriction, no corn, and listed vegetable soup, saltine crackers, ham steak, green beans, an alternate vegetable, ice cream, milk, and coffee. Observation of the meal tray showed the resident received vegetable soup, a saltine cracker, ham steak, green beans, and ice cream, but did not receive an alternate for corn or the milk and coffee listed on the meal ticket. The resident told the surveyor he wanted an alternate vegetable and milk to drink. The Registered Dietitian stated the resident should have received an alternate item for the corn and said she would speak with the resident regarding his fluid restriction and preferences for fluids when the menu exceeded the physician-ordered allotment for a meal. The Nursing Home Administrator was informed that the resident did not receive an alternate vegetable in place of corn and that the meal tray items met the resident’s fluid allotment for the meal without including a beverage.
Dietary Services: Inadequate portion size and missing tray items
Penalty
Summary
The facility failed to provide a nutritionally adequate meal during one observed lunch meal. The facility's Long Term Care Diet Manual for a regular diet stated that residents on that diet are to receive 3 ounces of protein at lunch, and the production sheets directed dietary staff to serve three chicken tenders. However, during lunch meal service, residents were observed being served only two chicken tenders as the main entree. When the surveyor asked for the chicken portion to be weighed, the Food Service Director stated a scale was not available. After reviewing the Diet Manual and production sheets, the Food Service Director acknowledged that three chicken tenders should have been served, and the Nursing Home Administrator stated the production sheet should be followed to ensure the appropriate serving size was provided. The facility also failed to serve a resident all items listed on the tray ticket. The resident had diagnoses of Alzheimer's disease and dysphagia and had physician orders for a mechanical soft texture diet. During lunch meal service, the resident was served carrots, ground chicken tenders, pudding, ice cream, and juice, but was not served a peanut butter and jelly sandwich or extra gravy or sauce as listed on the meal ticket. A Nursing Assistant confirmed the resident should have received the sandwich and extra gravy or sauce, and the Food Service Director also confirmed those items should have been provided. The Nursing Home Administrator stated the resident should have been served the items per the tray ticket.
Resident Assessed in Hallway in View of Others
Penalty
Summary
The facility failed to treat one resident with respect and dignity and to provide care in a manner and environment that promotes quality of life and recognizes individuality. Resident 5 was admitted on May 16, 2026, and had diagnoses that included trauma related to PTSD and depression. The facility’s dignity policy stated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality, and that staff shall maintain an environment in which confidential clinical information is protected. On May 18, 2026, Employee 5, the Social Worker, was observed conducting a BIMS and PHQ-9 assessment with Resident 5 in the hallway while other residents, staff, and visitors were present. The assessment included questions about mood, appetite, concentration, feeling down, depressed, or hopeless, and the resident’s ability to recall and repeat words. Employee 5 stated the resident was assessed in the hallway because she had a recent fall and was not in her room. The Director of Social Services confirmed that it is not best practice to interview residents in the hall regarding cognitive and mood status, and the Nursing Home Administrator confirmed awareness that the assessment was not best practice.
Unsafe and Unclean Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and home-like interior in two resident rooms on Units B and C. In Resident 7's room, surveyors observed multiple slats on the blinds that were broken off or bent, along with dried food around and under the bed. In Resident 8's room, surveyors observed papers, used cups, dried liquid, red and brown dried food particles ground into the floor, and a hazy film on the floor. During interview, the Nursing Home Administrator stated that when blinds need to be replaced, a work order should be submitted, and that Resident 8 likes to keep food in his room.
Food Served at Improper Temperatures
Penalty
Summary
The facility failed to provide foods that were palatable, attractive, and at appetizing temperatures during a meal service observation and test tray review. A grievance submitted on behalf of Resident 6 documented that milk was left on top of the food cart for two hours without ice, and the family was concerned it would be reused. During an observation on the C unit, the breakfast cart was delivered with milk on top of the cart and not on ice. A test tray completed later that morning showed hot and cold items outside the facility’s stated temperature standards, with chicken tenders at 102 F, fries at 97 F, coleslaw at 66 F, fruit cocktail at 74 F, and milk at 60 F. The Food Service Director stated the temperatures were not as they should be, and the hot items should have been warmer and the cold items cooler.
Failure to Obtain and Provide Ordered Medications From Pharmacy
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident. Facility policy titled "Medication Ordering and Receiving from Pharmacy" stated that medications and related products are to be received from the dispensing pharmacy on a timely basis and that timely delivery of new orders is required so that medication administration is not delayed. For one resident, clinical record review showed physician orders dated March 17, 2026, for multiple medications, including Advair HFA inhalation aerosol for asthma, pregabalin (Lyrica) for pain, celecoxib (Celebrex) for arthritis, and amphetamine dextroamphetamine (Adderall) for ADHD. Review of the resident’s interdisciplinary progress notes showed that these ordered medications were documented as "not available" on the date of admission. Further interview with the Director of Nursing on March 31, 2026, confirmed that the medications marked as not available had not been received from the contracted pharmacy and therefore were not administered as ordered by the physician. This failure to obtain and have the medications available for administration constituted noncompliance with the facility’s own policy and with regulatory requirements for pharmacy and nursing services.
Failure to Serve Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at safe and appetizing temperatures during one observed meal. Resident and staff interviews revealed concerns regarding the temperature, texture, and appearance of the food. A test tray evaluation showed that the breaded chicken patty, mixed vegetables, and potato salad were not at appropriate temperatures, with the chicken patty also noted as visually unappealing and dry. The recorded temperatures for these items were below the facility's policy requirements for hot and cold foods. The test tray had been on a meal cart for 20 minutes before being evaluated, and the Food Service Supervisor confirmed the substandard temperatures at the time of service.
Failure to Provide Advance Notice of Roommate Change
Penalty
Summary
The facility failed to provide advance written notice to a resident or her representative prior to a change in roommate assignment. Review of the clinical record for a resident with dementia and muscle weakness showed that she received a new roommate on October 23, 2025. There was no documentation indicating that the resident or her responsible party was notified before this change occurred. The lack of notification was confirmed during a care plan meeting following a resident-to-resident incident involving the new roommate, where it was documented that the responsible party had not been informed of the new roommate placement. Interviews with facility staff, including the Director of Social Services and the Nursing Home Administrator, confirmed that the usual practice is to notify residents and their representatives of room or roommate changes. However, in this instance, neither the resident nor her representative was notified prior to the new roommate moving in. The deficiency was identified through clinical record review and staff interviews, and it was acknowledged by facility leadership.
Failure to Ensure Resident Dignity During Incontinence Care
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during the provision of incontinence care. The resident, who had diagnoses including dementia with behavioral disturbance and adult failure to thrive, was assessed as having moderately impaired cognitive status and a history of verbally abusive behaviors related to dementia. During an incident, a nurse aide entered the resident's room to provide care, and the resident became combative, scratching and hitting the staff member. Another nurse aide entered the room and observed the first aide with her hand raised above her head as if to strike the resident, though the aide lowered her hand when the second aide entered. The resident verbally challenged the aide, saying "go ahead and hit me." The event was immediately reported to administration, and the resident was assessed with no new skin issues identified. The facility's policy required that residents be treated with dignity and respect at all times, including maintaining and enhancing self-esteem and self-worth. Staff interviews and written statements confirmed that the aide's actions, specifically raising her hand in a threatening manner, did not align with the policy of treating residents with dignity. The resident was unable to be interviewed due to cognitive deficits, but the incident was corroborated by staff statements and facility documentation. The Director of Nursing and Nursing Home Administrator acknowledged that the aide should have left the room and reapproached the resident later, rather than escalating the situation.
Failure to Maintain Comfortable Temperatures and Homelike Environment
Penalty
Summary
The facility failed to provide a comfortable and homelike environment on two of nine nursing units, specifically the 100 and 200 halls. On the 200 hall, two residents reported being very cold, with one resident stating that only maintenance could adjust the room temperature using pliers. Observations confirmed that cold air was blowing in the room, and one resident was covered with three blankets. Temperature readings taken by the Director of Maintenance showed that several rooms on the 200 hall were below the recommended range, with temperatures as low as 64 degrees Fahrenheit. Other rooms on the same unit also had temperatures below 71 degrees Fahrenheit, while the rest of the facility maintained temperatures within the acceptable range. The Director of Maintenance noted that the 200 hall had not yet been updated with new split units. Additionally, during the initial tour, window blinds in five out of twenty rooms on the 200 hall were found to be in disrepair, with broken, missing, or dangling slats. Similar issues were observed with window blinds on the 100 hall, as seen from outside the building. The Nursing Home Administrator acknowledged awareness of the problem and indicated that an additional 27 window blinds throughout the facility needed replacement. These deficiencies contributed to an environment that was not safe, clean, comfortable, or homelike for the residents.
Failure to Review and Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised as required for three residents. For one resident with diagnoses including diabetes mellitus, chronic kidney disease, and peripheral vascular disease, a pressure ulcer developed and resolved, but the care plan was not updated to reflect the resolution of the wound, despite a subsequent assessment indicating no unhealed pressure ulcers. Another resident with a prothrombin gene mutation and hypertension was receiving anticoagulant medication, but the care plan incorrectly listed pulmonary embolism as the diagnosis for anticoagulant use, even though there was no history of pulmonary embolism in the medical records. A third resident, admitted with repeated falls, dementia, and cervical spondylosis, used a neck collar for a period and later began exhibiting behaviors that led to the initiation of an antipsychotic medication. The care plan for this resident included the use of the neck collar but was not updated to include the new behaviors or the use of antipsychotic medication, despite quarterly assessments being completed. Staff interviews confirmed that the care plans should have been revised at the time of these changes or assessments.
Failure to Provide Physician-Ordered Fortified Foods and Monitor Nutritional Status
Penalty
Summary
The facility failed to provide physician-ordered fortified food diets to several residents and did not ensure proper monitoring of nutritional status for at least one resident. Specifically, three residents with orders for fortified foods did not consistently receive the prescribed fortified items at meals. Observations and tray ticket reviews showed that these residents were missing required fortified foods and supplements, such as super cereal, super mashed potatoes, super pudding, and additional beverages. Staff interviews confirmed that fortified foods were not being prepared or served prior to the survey, despite the necessary products being available in the facility. Additionally, one resident with significant weight loss and a history of dementia, muscle weakness, and lack of coordination was not properly monitored for nutritional intake. Documentation of meal intake and assistance provided was frequently missing for this resident across multiple months. There were also instances where the resident was coded as refusing or consuming no meals, yet there was no consistent follow-up or documentation to address these refusals. The resident's care plan required monitoring and assistance with meals, but these interventions were not reliably documented or implemented. Interviews with staff, including the Registered Dietitian and the Nursing Home Administrator, confirmed a lack of awareness regarding the failure to provide fortified foods and acknowledged the missing documentation for meal intake and assistance. The facility's own policies required physician orders for fortified diets and specified the components of the fortified food program, but these were not followed. The deficiencies were identified through clinical record reviews, resident and staff interviews, and direct meal observations.
Failure to Follow and Document Menu Changes, Resulting in Nutritional Deficiencies
Penalty
Summary
The facility failed to ensure that menus met the nutritional needs of residents, were prepared and followed as written, and that any changes were properly documented and communicated. Observations and interviews revealed that menu substitutions were not consistently recorded on the Menu Substitution Log, and residents were not notified of changes to the posted menu. The last documented substitution was over a month prior to the survey, and the substitution made did not meet the nutritional guidelines for a regular diet, resulting in insufficient servings of fruit on that day. Multiple residents did not receive the food and beverages listed on their tray tickets during observed meals. Instead, they were served alternative items without proper documentation or notification. Residents reported that the posted menu often did not match what was served, and that sometimes no substitute was offered when items were unavailable. Specific examples included residents not receiving fruit cocktail, mandarin oranges, chocolate milk, iced tea, or fortified mashed potatoes as listed, and their requests for these items were not fulfilled. Interviews with staff, including the Food Service Director and Registered Dietitian, confirmed that menu changes were not always communicated or documented, and that substitutions were not always of similar nutritional value. The Food Service Director indicated that food orders were sometimes altered by the corporate office to meet budget constraints, which contributed to the unavailability of menu items. As a result, the minimum daily meal pattern for a regular diet was not met on multiple days, with residents receiving fewer servings of fruits and vegetables than required.
Failure to Provide Palatable and Properly Tempered Food and Beverages
Penalty
Summary
The facility failed to provide food and beverages that were palatable, attractive, and served at safe and appetizing temperatures. Resident interviews revealed concerns about the temperature of hot foods, with multiple residents reporting that their meals were not served hot enough. One resident also reported that the food was bland and that she was served items, such as milk and coffee, that she should not receive. A review of the facility's Culinary and Nutrition Test Tray form indicated required temperature standards for hot and cold items, as well as evaluation for taste and appearance. A test tray evaluation found that the pork, potato wedges, and green beans were not palatable due to low temperatures, with recorded temperatures of 105°F for pork roast and 90°F for both potato wedges and green beans. The green beans were also noted to be overcooked and very soft. The apple juice was found to be weak in taste and served at 55°F, above the required cold beverage temperature. The Food Service Director confirmed that the hot foods should have been warmer and that the apple juice was prepared from concentrate. These findings were corroborated by staff and resident interviews, as well as direct observation.
Food Storage and Handling Deficiencies Identified
Penalty
Summary
The facility failed to store and serve food and beverages in accordance with professional standards for food safety in multiple areas, including two of four pantry refrigerators and the kitchen. Observations revealed that cases of food such as oatmeal cream pies, egg noodles, and mayonnaise were stored directly on the floor in dry storage, and some opened food items like rotini and elbow pasta were not date marked. In the walk-in freezer, peas and carrots were not securely closed or date marked, and in the walk-in refrigerator, several open items including shredded lettuce, sliced cheese, ham, and containers of fruit punch and tomato juice were also not date marked. In the nourishment pantries, there were instances of dried spills, expired thickened water, and food items without resident identifiers or date markings, such as chocolate bars and peanut butter and jelly sandwiches. During tray line service, staff members were observed with hair not fully contained in hairnets, and one cook changed gloves after they became soiled but did not perform hand hygiene. Additional issues in the dry storeroom included loose and uncovered cereal and an open container of sugar. Interviews with staff confirmed that these practices did not align with facility policy or professional standards, as food should be stored off the floor, opened items should be date marked, and staff should follow proper hand hygiene and hair restraint protocols.
Failure to Provide Dignified Dining Experience Due to Inadequate Supplies
Penalty
Summary
During two of three observed meals, residents were not provided with appropriate dining supplies, which compromised their right to a dignified existence. At breakfast, two residents received their meals in Styrofoam containers due to a shortage of plates, and both hot and cold beverage containers were covered with plastic wrap instead of their proper lids. The Food Service Director confirmed that the use of Styrofoam containers and plastic wrap was due to insufficient supplies, including a lack of scoop plates and lids for beverage carafes and pitchers. At lunch, similar issues persisted, with hot and cold beverage containers again covered with plastic wrap and certain menu items served in Styrofoam bowls. Additionally, two residents did not receive knives on their meal trays, which prevented them from properly cutting and preparing their sandwiches. Both residents had to use their fingers and forks to manage their food. The Food Service Director was unaware that knives were missing from the trays, and the Nursing Home Administrator confirmed that all required utensils should be provided to residents.
Failure to Assess Appropriateness of Self-Administration of Medication
Penalty
Summary
The facility failed to assess whether a resident's right to self-administer medication was clinically appropriate, as required by facility policy. Specifically, the policy states that the interdisciplinary team (IDT) must evaluate each resident's cognitive and physical abilities to determine if self-administration of medications is safe and appropriate. In the case reviewed, a resident with diagnoses including lung cancer, hypertension, and COPD had a physician's order for a Combivent Respimat inhaler to be kept at bedside for self-administration as needed. Despite the presence of the inhaler at the resident's bedside and the standing order allowing self-administration, there was no documented assessment in the clinical record of the resident's cognitive or physical ability to self-administer the medication. Staff confirmed that no such assessment had been completed to determine if self-administration was clinically appropriate for this resident.
Failure to Monitor Psychotropic Medication Use and Indications
Penalty
Summary
The facility failed to ensure adequate monitoring for the use of psychotropic medications for two residents. For one resident with diabetes mellitus type 2 and hypertension, there was an active order for Seroquel, an antipsychotic medication, but the clinical record lacked evidence of side effect monitoring or behavior monitoring to track the targeted behaviors for which the medication was prescribed. The Director of Nursing confirmed that neither side effect nor behavior monitoring was in place for this resident. For another resident admitted with dementia and adjustment disorder with mixed anxiety and depressed mood, there was an order for Risperdal, an antipsychotic, initially documented for anxiety/agitation/combative behaviors. The order was later revised to indicate schizophrenia, despite no supporting documentation of this diagnosis in the clinical record. There was no evidence of identified behaviors, ongoing behavior monitoring, or side effect monitoring for the use of Risperdal. A pharmacist's recommendation requested clarification of the medication's indication, and the DON confirmed that the order had been corrected and that appropriate monitoring should have been initiated when the medication was first ordered.
Failure to Complete Timely Background Checks and License Verifications
Penalty
Summary
The facility failed to ensure that residents were protected from potential abuse by not completing required criminal history background checks and license or registry verifications for several employees at the time of hire. Specifically, three employees who indicated they had not resided in Pennsylvania for the past two consecutive years only had state criminal background checks completed, rather than both state and federal checks as required. Additionally, one employee did not have a federal background check initiated prior to hire, and the facility could not provide residency information for this individual. Further deficiencies were identified in the verification of professional credentials. Two nursing staff members did not have their license or registry verifications completed at the time of hire, with one nurse aide's registry check and one registered nurse's license verification being delayed by several weeks to months after their respective hire dates. Interviews with facility staff confirmed these lapses, with the Human Resources Director acknowledging misunderstandings about the timing and requirements for background checks and the Nursing Home Administrator confirming that appropriate checks and verifications had not been completed as required.
Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of three residents. For one resident with hypertension, chronic diastolic heart failure, and type II diabetes, a dental consult documented that the resident was edentulous, but the Annual Comprehensive MDS did not indicate this status in the oral and dental section. For another resident with dementia, malnutrition, and a history of stroke, a Significant Change Assessment was scheduled due to the resident signing onto hospice services, but the MDS did not reflect that the resident was receiving hospice care. In both cases, the discrepancies between the clinical records and the MDS assessments were confirmed by facility leadership during interviews. Additionally, a third resident with Alzheimer's disease and schizoaffective disorder had quarterly MDS assessments that failed to document the diagnosis of schizophrenia, despite this being present in the clinical record. The DON confirmed that the MDS assessments should have included this diagnosis. These findings demonstrate that the information recorded in the MDS assessments did not consistently match the residents' clinical records, progress notes, or observed conditions, as required by facility policy.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Hemiplegia
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex diagnoses, including cerebral infarction, hemiplegia, contracture of the right lower leg, muscle weakness, vascular dementia, and joint pain in the right hand. Observation revealed the resident's right hand was slightly contracted, and the resident reported wearing a right-hand splint at night, which she felt was beneficial. Physician orders specified the use of a right resting hand splint during the night shift, and the MAR confirmed its application and removal times. However, prior to May 22, 2025, the resident's care plan did not address right-sided hemiplegia, the use of the right-hand splint, or pain management. The DON confirmed that a care plan for these issues should have been in place.
Failure to Provide Scheduled Showers and Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to provide adequate personal hygiene and grooming in accordance with resident preferences for two residents who were dependent on staff for assistance with activities of daily living. One resident, with diagnoses including muscle weakness, chronic diastolic heart failure, and diabetes mellitus type II, reported not receiving scheduled showers on multiple occasions. Documentation confirmed missed showers on several scheduled days, and grievances were filed by the resident regarding these missed showers. Investigations into the grievances revealed issues such as staff shortages and miscommunication regarding the resident's shower schedule, as well as documentation errors related to the electronic kiosk and Kardex updates. Another resident, with a history of cerebral infarction, COPD, diabetes, contracture, muscle weakness, vascular dementia, and cognitive communication deficit, expressed a preference for showers over bed baths and required a Hoyer lift and staff assistance for bathing. Despite this preference being documented in the care plan and discussed in care plan meetings, the resident received bed baths instead of showers on some scheduled days due to insufficient staffing. Interviews with staff and review of documentation confirmed that the resident and her family had to advocate for showers, and the care plan indicated the importance of honoring the resident's bathing preference.
Failure to Administer and Document Medications and Wound Care per Orders
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for two residents with complex medical needs. For one resident with diabetes mellitus, the Medication Administration Record (MAR) showed that prescribed doses of Lantus SoloStar (Insulin Glargine) were not documented as administered on two separate dates, despite an active physician order for nightly subcutaneous injections. There was no evidence in the MAR that the medication was given as ordered on those dates. Another resident with multiple diagnoses, including diabetes mellitus with foot ulcer, congestive heart failure, peripheral vascular disease, lymphedema, and MRSA infection, had physician orders for specific wound care treatments to multiple sites. Review of the Treatment Administration Record (TAR) and MAR revealed missing documentation for wound care treatments on several dates. Additionally, progress notes did not contain information regarding the completion of these wound treatments on the specified dates. The Director of Nursing confirmed that documentation should be completed when medications or treatments are administered.
Failure to Provide Timely Vision Treatment Following Specialist Recommendation
Penalty
Summary
A deficiency occurred when a resident with a history of hypertension, chronic diastolic heart failure, and type II diabetes was not provided with recommended treatment to maintain vision. The resident had been evaluated by an eye doctor, who diagnosed her with dry eye syndrome in both eyes and recommended artificial tears twice daily. Despite this recommendation, a review of the resident's physician orders did not show any order for artificial tears, and the resident reported waiting several weeks for the prescribed eye drops. Further review of the clinical record and staff interviews revealed that although the physician had signed off on the vision consult, the order for artificial tears was not entered at that time. The Assistant Director of Nursing acknowledged that the order should have been completed when the physician signed off, and the Nursing Home Administrator confirmed this oversight. The lack of timely entry and implementation of the physician's order resulted in the resident not receiving the recommended treatment for her vision needs.
Failure to Administer Ordered Pain Medication
Penalty
Summary
The facility failed to provide pain management consistent with professional standards of practice for a resident with a history of thoracic vertebral fracture and polyneuropathy, who had a physician's order for daily Oxycodone to manage chronic pain. Clinical record review showed that the resident did not receive her scheduled pain medication on multiple occasions due to the medication being unavailable or not administered as ordered. The medication administration record, progress notes, and controlled substance declining count sheet confirmed missed doses on several specific dates. During an interview, the resident reported not receiving her scheduled pain medication at times, and the Director of Nursing confirmed that it was the facility's expectation for staff to administer pain medication as ordered.
Failure to Maintain Accurate Dialysis Records and Adhere to Care Standards
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication and did not adhere to professional standards of practice for the care of a dialysis resident. Specifically, the care plan for a resident with end-stage renal disease (ESRD), chronic systolic congestive heart failure, and type II diabetes mellitus did not include the presence of an emergency kit at the bedside for potential bleeding or catheter dislodgement. Observation confirmed that no emergency equipment was present in the resident's room, despite this being a necessary precaution for dialysis care. Additionally, the facility did not ensure proper documentation and communication with the dialysis center. Review of consult sheets revealed incomplete and undated forms, and staff interviews confirmed that consult sheets were not consistently returned or filed in the clinical record. Blood pressure readings were documented as being taken from the resident's right arm on multiple occasions, despite physician orders for limb precautions prohibiting this. The DON acknowledged that staff were inaccurately documenting the site of blood pressure readings and confirmed the absence of required emergency equipment and incomplete consult documentation.
Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.20 hours of direct resident care per resident per day for four out of six days reviewed. Specifically, on January 3, 2025, the facility provided 3.16 hours, on January 4, 2025, 3.09 hours, on January 5, 2025, 3.02 hours, and on January 6, 2025, only 2.70 hours of direct care per resident. This deficiency was confirmed through a review of the facility's staffing documentation and an interview with the Director of Nursing, who acknowledged the shortfall in meeting the required care hours on those dates.
Plan Of Correction
Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law. 1. Residents received required care and there were no negative outcomes from the staffing level falling slightly below 3.2 ppd. 2. The facility has identified that all the residents have the potential to be affected by the average nursing care hours falling below 3.2 in a 24-hour period of direct resident care for each resident. 3. Facility will implement the critical staffing plan and will begin to utilize agency contracts to ensure the average nursing care hours are a minimum of 3.2 hours of direct resident care for each resident in a 24-hour period. Facility will ensure resident quality of care continues. 4. HR Director/Designee will conduct 3 random audits weekly for 1 month, and then 3 random audits monthly, to ensure that a minimum of 3.2 hours of direct resident care is provided for each resident in a 24-hr period. HR/Designee will report audit results monthly for Quality Assurance and Performance Improvement Committee to address any trends or patterns, need for further review, and or recommendations. 5. Date of compliance 2/3/25.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for three residents, as required by their policy. Resident 12's care plan did not include focus areas for their diagnoses of vascular dementia and the use of anticoagulant medication, despite having physician orders for apixaban. Similarly, Resident 142's care plan lacked a plan for managing type 2 diabetes mellitus, even though the resident was receiving insulin treatments. These omissions indicate a failure to incorporate identified problem areas into the residents' care plans. Additionally, Resident 163's care plan did not address the management of atrial fibrillation or the use of a blood thinner, despite the resident receiving coumadin. Furthermore, after a fall resulting in a hematoma, the care plan failed to include monitoring or wound care for the injury. These deficiencies highlight the facility's failure to ensure that care plans were developed accurately and timely, as expected by the facility's policy.
Deficiencies in Hospice Care Orders and Post-Fall Treatment
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards for two residents. Resident 140, who was diagnosed with malignant neoplasm of the colon and diabetes, was observed to be on hospice care. However, a review of the resident's current physician orders did not reveal any orders for hospice care and services, despite the care plan indicating hospice care was initiated and revised in March 2024. The Nursing Home Administrator confirmed that Resident 140 was receiving hospice services upon admission but lacked current physician orders for these services. Resident 163, diagnosed with atrial fibrillation and diabetes, was observed with a bandage on her forehead and bruising on her face, which she attributed to a fall two weeks prior. The fall investigation report confirmed the resident fell from her wheelchair, resulting in a hematoma and a fracture of the left shoulder. Although neurological checks were conducted, there were no instructions from the hospital regarding the care of the hematoma upon discharge. The facility later obtained physician orders to manage the wound, but the Nursing Home Administrator expected staff to follow up with the physician when no discharge instructions were provided.
Failure to Provide Therapeutic Diet and Fluid Management
Penalty
Summary
The facility failed to provide a therapeutic diet as per physician's orders for two residents. Resident 74, diagnosed with diabetes mellitus, experienced a significant weight loss of 27 pounds over six months. Despite physician orders for a consistent carbohydrate diet and a significant afternoon snack, Resident 74 did not consistently receive the prescribed peanut butter and jelly sandwich. Observations and interviews revealed discrepancies between the meal tray contents and the physician's orders, with the resident receiving inappropriate food items and the snack not being documented or provided on several occasions. Resident 137, diagnosed with hypokalemia and heart failure, was on a fluid restriction of 2000 ml per day. However, observations showed that the resident was provided with a Styrofoam cup of water daily, and there was a lack of documentation and communication regarding fluid administration guidelines. The meal ticket did not match the physician's orders, and fluid intake during meals was not recorded by nursing staff, only during medication passes. These deficiencies indicate a failure to adhere to physician orders and facility policies, impacting the residents' nutritional and fluid management.
Failure to Ensure Proper Dialysis Communication for Resident
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice. The facility's Nursing Home Dialysis Transfer Agreement mandates that all appropriate medical, social, administrative, and other information accompany residents at the time of transfer to the dialysis center. This includes medical records, treatment details, and any changes in the resident's condition. However, for a resident with chronic kidney disease stage five and dependent on renal dialysis, the facility did not have dialysis communication forms for multiple dates in April, May, and June 2024, despite the resident having received dialysis on those dates. Interviews with staff revealed that the communication forms were supposed to be placed in the physician's communication folder upon the resident's return from dialysis, but no forms were found. The Nursing Home Administrator admitted that the facility lacked a policy for dialysis care. The Director of Nursing later confirmed that the missing forms were obtained from the dialysis center, indicating a lapse in the immediate acquisition of these forms upon the resident's return, as expected by the facility.
Medication Storage Deficiencies in Facility
Penalty
Summary
The facility failed to store medications in accordance with professional standards, as observed in two of the five medication carts inspected. The 300 medication cart contained two partially used Lantus insulin pens without an opened date, contrary to the manufacturer's requirement that such pens be discarded after 28 days when in use and non-refrigerated. This indicates a failure to adhere to the facility's policy, which mandates that nursing staff date insulin pens upon opening. Additionally, the F Wing 2 medication cart was found with a medicine cup filled with small, round, green tablets, which a Licensed Practical Nurse identified as likely iron supplements but was unsure due to not having placed them there. The cart also contained multiple loose pills in two drawers, violating the facility's policy that medications should be stored in the manufacturer's supplied container. The Director of Nursing confirmed that medication carts are expected to be cleaned frequently, at least once a month by the nightshift nursing staff, and that medications should be stored in their original containers.
Failure to Provide Adequate Menu Substitutions and Follow Planned Menus
Penalty
Summary
The facility failed to provide a nutritionally adequate menu substitution for one of two meals observed and did not follow the planned menu for lunch meals on June 3, 2024, in one of the resident areas, Rosemont Hall. The planned lunch menu for June 3, 2024, included chicken tenders, dipping sauce, French fries, coleslaw, cinnamon applesauce, and assorted beverages. However, the facility ran out of applesauce during the F-west unit food cart delivery, and the remaining residents were served ice cream instead. This substitution was not documented in the menu substitution log. Additionally, Resident 24 and Resident 115 did not receive the cinnamon applesauce, 2% milk, coffee, or hot tea as documented on their meal tickets. On June 4, 2024, the planned lunch menu included kielbasa, buttered noodles, sauteed cabbage, dinner roll, watermelon, and assorted beverages. The menu extension sheet indicated that puree diets should have been served applesauce instead of watermelon. Resident 58, who was on a fortified foods diet with puree texture, did not receive the puree dinner roll or applesauce as documented on the tray ticket. Instead, diced peaches were served, which were not given to the resident. Interviews with staff, including the Food Service Director and Nursing Home Administrator, confirmed that the residents should have received food items per the extension sheet or applicable substitutions, as well as items listed on the meal tickets.
Improper Food Storage and Labeling in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen and nourishment pantries. Observations revealed multiple instances of improper food storage and labeling. In the walk-in refrigerator, American cheese and thawed sliced turkey were not date marked, and a tray of fruit servings lacked date markings. The dry storeroom contained Styrofoam bowls of dry oat cereal that were not date marked, and the cart with these bowls had crumbs of raisin bran cereal. Additionally, the chemical room's dustpan contained food particles, indicating a lack of cleanliness. In the B/C-unit nourishment pantry, several items were improperly stored and labeled. Freezer-burned orange slices and a ham and egg croissant sandwich lacked resident identifiers and dates. An open container of butter pecan nutritional supplement was left at room temperature without a date mark. The refrigerator contained various items, including sweet tea with an expired use-by date and other foods without resident identifiers or dates. Similar issues were observed in the Wedge [NAME] 1 nourishment pantry, where items like Chinese takeout and beef tacos were not properly labeled. Interviews with the Food Service Director and the Nursing Home Administrator confirmed these deficiencies.
Inaccurate Resident Assessment for Noninvasive Ventilator Use
Penalty
Summary
The facility failed to ensure that the resident assessment accurately reflected the resident's status for one of the residents reviewed. Resident 5, who had diagnoses including sleep apnea, heart failure, and respiratory failure, was prescribed a BiPAP machine with oxygen at bedtime starting June 2, 2022. However, the resident's annual and quarterly MDS assessments did not document the use of a noninvasive ventilator. During interviews, both the Registered Nurse Assessment Coordinator and the Nursing Home Administrator acknowledged that the assessments should have been coded to reflect the use of the noninvasive ventilator.
Failure to Maintain Resident's ADL Due to Inadequate Documentation and Care
Penalty
Summary
The facility failed to provide necessary individualized services to maintain activities of daily living (ADL) for a resident, specifically regarding fingernail care. The resident, who has diagnoses including diabetes mellitus, macular degeneration, anxiety, and dementia, was observed with long and jagged fingernails. The resident expressed a preference for washing up at the sink in his room and mentioned a desire to have his fingernails trimmed or to be provided with an emery board to do it himself. Despite being scheduled for showers on Thursday evenings, no showers or baths were documented over the past 30 days, with refusals noted on two occasions. The resident's care plan and quarterly MDS failed to document any rejection of care, and progress notes from April 6th through June 6th also lacked documentation of care refusal. An interview with the Nursing Home Administrator revealed that nursing assistants are expected to trim fingernails during scheduled showers and that refusals of care should be documented. However, the resident was documented as independent with bathing, and there was no record of care refusals in the care plan or MDS.
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What surveyors actually found near you
We read the 241 citations issued within 25 miles in the last 12 months — including the 6 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.
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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) |
|---|---|---|---|---|
| Rest Haven-york | 1.1 mi | ★★★★★ | 8 | 0 |
| Normandie Ridge | 2.7 mi | ★★★★★ | 0 | 0 |
| Margaret E. Moul Home | 2.7 mi | ★★★★★ | 0 | 0 |
| York South Skilled Nursing And Rehabilitation Ctr | 3.1 mi | ★★★★★ | 10 | 0 |
| Misericordia Nursing & Rehabilitation Center | 3.3 mi | ★★★★★ | 0 | 0 |
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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.