York Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at York Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 19, 2025

  Based on review of facility policy, facility documentation, resident clinical records, observations, and staff interviews, it was determined the facility failed to provide adequate supervision for one of three residents assessed as at risk for elopement (Resident R223). Resident R223 exited the second-floor nursing unit via elevator and walked out the back rear entrance of the facility. Resident R223 was located by local law enforcements approximately four hours after the resident exited the facility, approximately 1.5 miles away in a busy [NAME] area. This failure resulted in actual harm to Resident R223 who was admitted to the hospital with hypothermia and resulted in an Immediate Jeopardy situation. […]

• Immediate jeopardy, isolatedF600Oct 30, 2023

  Based on the review of clinical records, facility policies, interviews with resident and staff, it was determined that the facility failed to ensure that the residents were free from verbal and mental abuse, which resulted in a staff member verbally and mentally abusing a resident (Resident R178) with documented history of mental health disorders. This failure caused the resident to experience fear and intimidation for one of 39 residents reviewed (Resident R178). This failure also put the resident at risk for potential physical abuse and bodily injury and resulted in an immediate jeopardy situation. This deficiency was identified as past non-compliance. […]

• Actual harm, isolatedF600Apr 3, 2025

  Based on interviews with staff, review of clinical records, facility policies and facility documentation, it was determined the facility failed to implement interventions to assure one resident (Resident R3) was free from physical abuse resulting in actual harm to Resident R3 who was struck by Resident R4 in the face with a leg rest, and sustained a chipped tooth for one of 10 resident records reviewed. (Resident R3 and Resident R4) Findings include: Review of facility policy titled, Abuse revised December 13, 2024, revealed, each resident will be free from abuse including verbal, mental, sexual, or physical abuse. […]

• Actual harm, isolatedF600Apr 19, 2023

  Based on review of facility policy, review of clinical records, review of facility documentation and resident and staff interviews, it was determined that the facility failed to ensure that Resident R1 was free from resident abuse, which resulted in physical and psychosocial harm to Resident R1 who sustained pain and redness to right wrist, and emotional anguish for one of six residents reviewed. (Resident R1) Findings include: Review of undated facility policy title Abuse revealed that abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, and kicking. […]

• Actual harm, isolatedF600Oct 6, 2022

  Based on a review of clinical records, facility documentation and policies, interviews with resident and staff, it was determined that the facility failed to protect one of 38 residents (Resident R172) from Resident R91 who displayed behavioral disturbances. This failure resulted in actual psychological and physical harm to Resident R172 who was punched on the face by Resident R91. Findings include: Review of facility policy Freedom from Abuse, Neglect, and Exploitation, not dated, stated, The facility will provide a safe resident environment and protect residents from abuse . this includes freedom from verbal, mental .or physical abuse. […]