Heartway at York Manor Health and Rehab

In the surveyor’s words

From the most serious findings on record at Heartway at York Manor Health and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF600Nov 3, 2022

  Based on record review, observation, and interview, the facility failed to ensure residents were free from neglect for one (#1) of three residents reviewed for abuse and neglect. The facility failed to prevent a resident from having been left unattended in the shower room which resulted in a fall that caused a right fibula fracture. The deficient practice was determined to be past-noncompliance since the facility identified the situation and implemented interventions to prevent the recurrence of the situation. The Resident Census and Conditions of Residents documented 41 residents resided in the facility. Findings: An undated facility policy titled Shower/Tub Bath, documented the following: Stay with the resident throughout the bath. […]

• No harm, potential for more than minimal, widespreadF585Sep 15, 2025

  Based on record review and interview, the facility failed to maintain evidence of grievances with resolutions for 1 (#8) of 1 sampled resident sampled reviewed for grievances.The administrator identified 41 residents resided in the facility.Findings:An undated, facility grievances policy, read in part, To provide structure and a forum for residents to voice complaints, grievances and seek their resolution .Procedure: 1. The resident has the right, and the facility will promptly work to resolve the grievance with the resident. 2. Grievances may be communicated orally or in writing. The resident also has the right to file grievances anonymously. 3. The resident will receive the resolution decision in writing. […]

• No harm, potential for more than minimal, widespreadF732Sep 15, 2025

  Based on observation, interview, and record review, the facility failed to include the actual and working hours of licensed and unlicensed staff on the daily posted staffing and failed to ensure disciplines were included on the nurse staffing data for 7 (09/08/25 through 09/14/25) of 7 days reviewed for posted nurse staffing.The DON identified 41 residents resided in the facility.Findings: On 09/15/25 at 3:18 p.m., a dry erase board was observed to show staff names, the shift, the date and the census. The dry erase board did not show the number of hours worked. […]

• No harm, potential for more than minimal, widespreadF812Sep 15, 2025

  Based on observation and interview, the facility failed to ensure kitchen equipment was properly dried before storing, the ice machine was free of debris and build-up and cross contamination was prevented during 2 of 2 meal services observed.The DON identified 41 residents ate meals from the kitchen.Findings:On 09/08/25 at 12:44 p.m., cook #1 was observed to stack wet trays by the steam table and place wet cooking utensils in the drawers. On 09/08/25 at 12:59 p.m., the maintenance supervisor removed the front cover of the ice machine, and a black substance was observed on the back of the cover. A black and red growth were observed in the corners and underneath where the pump was held. […]

• No harm, potential for more than minimal, widespreadF881Sep 15, 2025

  Based on record review and interview, the facility failed to implement an antibiotic stewardship program.The DON identified 41 residents resided in the facility.Findings:An undated facility Antibiotic Stewardship policy, read in part, Develop and implement protocols to optimize the treatment of infections by ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic .Develop, promote and implement a facility-wide system to monitor the use of antibiotics .Facility leadership commitment to safe and appropriate antibiotic use; Appropriate facility staff accountable for promoting and overseeing antibiotic stewardship .Implement policy(ies) or practice to improve antibiotic use; Track measures of antibiotic use and resistance to relevant staff such as… […]