York Nursing And Rehabilitation Center

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident Resident R223 was located at the local hospital. Subsequently, NHA and nurse aide verified Resident Resident R223's identity at the local hospital. On 12/16/2025 it was determined that Resident Resident R223 was picked up by Emergency Medical Services (EMS) about 1.2 miles from the facility and taken to the local hospital at approximately 10:13 p.m. on 12/15/2025. On 12/16/2025 and ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was held with department heads. Whole house wander guard audit was completed to verify placement and function for resident's to have been assessed as needing one on 12/16/2025. Whole house elopement assessments completed on 12/16/2025 with no new residents identified as being at risk for elopement. Elopement binder reviewed and audited to ensure book is up to date and current with completion of new assessments on 12/16/2025. Every 1-hour loading dock door checks initiated on 12/16/2025 and are ongoing. Facility contacted wander guard service provider on 12/16/2025 to obtain quotes to add wander guard sensors to elevators, stairwells, and service hallways. On 12/17/2025 it was determined that the resident exited out of the loading dock doors. Frequency of loading dock door check increased to every 30-minutes. On 12/16/2025, education on Code Yellow-Responding to Elopement initiated at 12:35 a.m. with in-house nursing staff. Elopement policy reviewed on 12/17/2025. On 12/17/2025 education initiated with all facility staff on signs and symptoms of elopement and supervision of residents with dementia and history of exit seeking behaviors, how to identify residents and where wander guard sensors are located within the facility. This will be added to new hire orientation. 85% of facility staff will be educated by 12/18/2025. Facility is completing loading dock and font entrance door audits every 30 minutes daily for 30 days. Facility will review findings of audits during QAPI meeting. Resident Resident R223 at hospital and will be re-assessed upon re-admission.Review of facility documentation confirmed all other residents were accounted for on 12/15/2025.Review of facility documentation confirmed loading dock and front door entrance audits were completed.Review of facility documentation confirmed audits were completed for residents with wander guards to ensure placement and functionality. Further, audits were completed to ensure all residents had accurate/up to date elopement assessments. No new residents were identified.Elopement binder maintained at the front desk was reviewed and confirmed to be accurate/up to date with residents at risk for elopement.Interviews were conducted with 26 staff members from all departments on December 18, 2025. Interviews confirmed staff were educated on signs and symptoms of elopement and supervision of residents with dementia and history of exit seeking behaviors, how to identify residents and where wander guard sensors are located within the facility. Further staff confirmed they were educated on a code yellow responding to an elopement.The Immediate Jeopardy was lifted on December 18, 2025, at 3:40 p.m.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.10 (d) Resident care policies

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