YORK Post Acute

In the surveyor’s words

From the most serious findings on record at YORK Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Jun 29, 2023

  Based on staff interview, record review, and policy review, the facility failed to ensure the physician was notified for a change of condition for one of 44 residents (Resident (R) 129). This failure to notify the physician when R129 was found to have low blood pressure, shallow breathing, and lethargy, resulted in Immediate Jeopardy at level 4 isolated on [DATE]. A Plan of Correction was reviewed for Past non-compliance and the Immediate Jeopardy was removed on [DATE]. Findings include: Review of R129's printed Face Sheet from the electronic medical record (EMR) Reports tab showed a facility admitted [DATE] with medical diagnoses that included acute and chronic respiratory failure, chronic obstructive pulmonary disease, type II diabetes, hypertension, pneumonia, abnormal electrocardiogram… […]

• Immediate jeopardy, isolatedF678Jun 29, 2023

  Based on staff interview and record review, the facility failed to ensure a resident's end of life wishes were clarified and consistent in the medical record for one of 44 residents (Resident (R) 129). The facility staff did not initiate CPR or call Emergency Medical Services (EMS) when R129 was found without a pulse or respirations. This resulted in Immediate Jeopardy at level 4 isolated on [DATE]. A Plan of Correction was reviewed for Past non-compliance and the Immediate Jeopardy was removed on [DATE]. […]

• Actual harm, isolatedF689Nov 21, 2023

  Based on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure a safe environment resulting in harm for one resident (Resident # 1) in a survey sample of 4 residents. This was cited at past non-compliance. Findings included: For Resident # 1, the facility staff failed to ensure the bed frame was free of jagged edges resulting in a large laceration on the right lower leg requiring stitches and hospitalization that was sustained during a transfer from Geri-chair to bed on 10/28/2023, resulting in harm for Resident #1. […]

• Actual harm, isolatedF600Jun 29, 2023

  Based on interview, record review, and review of facility policy, the facility failed to protect the resident's right to be free from physical abuse by staff CNA C and CNA D for one (Resident (R) 42) of two residents reviewed for abuse. CNA C and CNA D caused bruising on R42's lower arms. This is harm. Findings include: Review of R42's Face Sheet printed from the electronic medical record (EMR) Resident Info tab showed medical diagnoses that included generalized muscle weakness, abnormalities of gait and mobility, and dementia. Review of a facility investigation showed that on 12/04/22 CNA C and CNA D were going to change R42 using a blue brief (incontinent product). R42 requested a pull up style product and relayed she was told No and that she would be changed whether she liked it or not. […]

• Actual harm, isolatedF689Dec 29, 2022

  Based on observation, Resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide safe assistance for transfers for 2 Residents (Resident #1, Resident #2) in a sample size of 3 Residents. Resulting in harm for Resident #1. The findings included: 1) For Resident #1, the facility staff failed to safe transfer from the bed to the wheelchair on 11/10/2022 resulting in right distal femoral fracture which required surgical intervention. This is harm. On 12/28/2022 and 12/29/2022, Resident #1's clinical record was reviewed. […]