York Healthcare & Wellness Centre

In the surveyor’s words

From the most serious findings on record at York Healthcare & Wellness Centre, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Dec 7, 2023

  Based on observation, interviews, and record reviews, the facility failed to provide treatments and services for two of two sampled residents (Residents 1 and 2) by failing to: 1. Ensure Resident 1's food allergy and allergic reaction to fish were transcribed and verified in the resident's Dietary Profile and Meal Ticket, in accordance with the facility's policy and procedure on Food Allergies and Reference Sheets, and Diet Record Maintenance to alert facility staff of the resident's food allergies. 2. […]

• Immediate jeopardy, isolatedF806Dec 7, 2023

  Based on observation, interview and record review, the facility failed to ensure meals did not contain food allergens (a substance that causes an allergic reaction) for two (2) of 2 sampled residents (Residents 1 and 2) with known food allergies, in accordance with the facility's policy and procedures titled Food Allergies and Reference Sheets, by: 1. Serving fish and fish containing products to Resident 1 who was allergic to fish. The facility was aware Resident 1 had fish allergy but Resident 1 was served fish on [DATE] (tuna salad sandwich) and [DATE] (lemon ginger fish). 2. Serving wheat (a cereal that yields a fine white flour used chiefly in breads, baked goods, and pastas) containing foods to Resident 2 who was allergic to wheat. […]

• Actual harm, isolatedF689May 16, 2025

  Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 1), who was at risk for fall due to poor safety awareness and history of repeated falls was provided care and services to prevent recurrent falls in accordance with the facility's policy and procedures (P&P). The facility failed to: 1. Ensure a fall assessment and reassessment was conducted to identify the risk factors and cause of each fall, in accordance with the facility ' s Fall Management Program. 2. […]

• Actual harm, isolatedF692Jan 5, 2021

  Based on interview and record review, the facility failed to ensure one of seven sampled residents, Resident 1, who had a gastrostomy tube (GT, a device inserted into the stomach through the abdomen for nutrition and fluids), received sufficient fluid intake to maintain proper hydration and health. The facility failed to: Follow Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in Resident 1 not receiving the required amount of fluids daily for 34 days. On [DATE], Resident 1 experienced a change in mental status with shortness of breath requiring transfer to a General Acute Care Hospital 1 (GACH 1). […]

• No harm, potential for more than minimal, widespreadF814May 9, 2024

  Based on observation, interview, and record review, the facility failed to ensure one of two outdoor refuse containers (a waste container that a person controls that includes dumpsters, trash cans, garbage pails, and plastic trash bags) was placed in covered garbage cans. This failure had the potential to attract insects and harbor rodents and pests in the refuse area that can cause a wide spread of diseases and affect the residents, staff, and visitors. Findings: During a concurrent observation and interview on 5/6/24 at 9:05 AM, with Dietary Aide (DA) 2 at the facility's parking lot, the outdoor refuse container was observed with no secured lid covered. […]