York South Skilled Nursing and Rehabilitation CTR

In the surveyor’s words

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

• Actual harm, isolatedF684Jun 6, 2025

  Based on clinical record review, facility document review, and staff interview, it was determined that the facility failed to provide care and services consistent with the resident comprehensive plan of care, which resulted in harm as evidenced by a decline in health status for one of three residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed diagnoses that included diabetes mellitus type II (decreased ability of the body to utilize insulin) and atrial fibrillation (irregular heart rate). […]

• Actual harm, isolatedF686Aug 3, 2023

  Based on observation, facility policy review, clinical record review, wound assesment review, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to identify pressure ulcers and to promote healing of a pressure ulcer for two of two residents reviewed for pressure ulcers (Residents 24 and 71); resulting in the deterioration of a pressure ulcer for one of two residents reviewed (Resident 24). […]

• Actual harm, isolatedF690Apr 7, 2023

  Based on clinical record review, staff interviews, policy review, and hospital record review, it was determined that the facility failed to ensure that residents with foley catheters received appropriate treatment and services consistent with professional standards during catheter care by irrigating into the wrong port causing the catheter balloon to break, resulting in actual harm as evidenced by pain, hematuria (blood in the urine), transfer to the hospital, and administration of antibiotics for 10 days for one of seven residents reviewed with urinary catheters (Resident 1). […]

• Actual harm, isolatedF726Apr 7, 2023

  Based on policy review, select facility documents, clinical and hospital record review, and staff interviews, it was determined that the facility failed to ensure that a licensed agency nurse had the specific competencies and skills necessary to perform catheter care irrigation resulting in irrigation into the wrong port causing harm, as evidenced by pain, hematuria, (blood in urine), transfer to the hospital, and prophylactic administration of antibiotics for 10 days to one of 7 residents reviewed with urinary catheters (Resident 1). Findings include: Review of the Pennsylvania Nursing Practice Act for Licensed Practical Nurses (LPN), Chapter 21.145. revealed Functions of the LPN. […]

• Actual harm, isolatedF880Aug 18, 2022

  Based on observations, facility document and policy review, Center for Disease Control recommendations review, clinical record review, and staff interviews, it was determined that the facility failed to ensure each staff person correctly wears personal protection equipment for two of two staff persons (Employees 17 and 18), failed to ensure infection prevention practices during medication administration for one of three residents observed (Resident 89), and failed to ensure appropriate isolation of COVID-19 positive residents in one of six nursing units (Arcadia), resulting in actual harm from symptoms of contracting COVID-19 for one of 37 residents residing on the Arcadia unit (Resident 281). […]