York North Skilled Nursing And Rehabilitation Ctr

Review of Resident 1's admission MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident's physical, mental or psychosocial needs) dated October 6, 2025, revealed Resident 1 has a BIMs of 0, indicating cognitive skills are severely impaired.

Further review of Resident 1's admission MDS revealed Section H.- Bladder and Bowel, subsection H0300 Urinary Incontinence was marked with a 2, indicating the Resident was frequently incontinent of urine instead of being marked with a 3 indicating the Resident was always incontinent of urine. A review of Resident 1's Quarterly MDS dated [DATE], revealed Section H.- Bladder and Bowel, subsection H0300 Urinary Incontinence was marked with a 2, indicating the Resident was frequently incontinent of urine instead of being marked with a 3 indicating the Resident was always incontinent of urine.

Subsection HO400 Bowel was marked with a 2, indicating the Resident was frequently incontinent of bowel movements instead of being marked a 3 indicating the Resident was always incontinent of bowel movements.

During an interview with Employee 14 (Licensed Practical Nurse) on March 25, 2026, at approximately 12:30 PM, Employee 14 confirmed that Resident 1 had always been incontinent of bowel and bladder since admission to the facility.

During an interview with the Nursing Home Administrator (NHA) on March 25, 2026, at 11:00 AM, the NHA said the MDS should be accurate and reflect the Resident's status and that modifications to both MDS's will be entered in the system.

Review of Resident 25's clinical record revealed medical diagnoses that included flaccid neuropathic bladder (bladder dysfunction caused by nerve damage where the bladder muscle cannot contract and results in urine retention, overfilling and constant overflow dribbling) and depression (a mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems).

Review of Resident 25's care plan revealed a focus area Use of Suprapubic indwelling urinary catheter, with a start date of April 3, 2024.

Review of Resident 25's Quarterly MDS with ARD of January 2, 2026, revealed under Section H Bladder and Bowel - Subsection H0100 C, Resident 25 was marked yes for an Ostomy, indicating he had an ostomy.

During interview with Employee 15 (Clinical Reimbursement Coordinator) on March 26, 2026, at 10:27 AM, she expressed that this was incorrect documentation, as Resident 25 had a suprapubic catheter and does not have an ostomy.

She revealed that this will be corrected and submitted under Modification for MDS Quarterly with ARD date of January 2, 2026.

Follow up interview with NHA and Director of Nursing on March 26, 2026, at 11:48 AM, the NHA revealed she would expect Resident 25's MDS Assessments to be coded accurately. 28 Pa.

Code 211.5 (f) Medical Records28 Pa.

Code 211.5(d)(3)(5) Nursing services

395442 03/26/2026

York North Skilled Nursing and Rehabilitation Ctr 1770 Barley Road York, PA 17408

Review of the progress note dated [DATE], at 10:46

11:15 AM, revealed that Resident 81's care plan should have included her choice for discharge or

services

395442 03/26/2026

York North Skilled Nursing and Rehabilitation Ctr 1770 Barley Road York, PA 17408

During an interview with Resident 92 on March 23, 2026, at 11:02 AM, she stated the Eye Doctor was in about a month ago and asked how her the new glasses were working and she stated she hadn't received them. It was revealed, and the surveyor observed, that her glasses were missing the right lens and nose piece, and the left lens was severely scratched.

The Resident stated that not having glasses affects her quality of life because she can't see to read or do activities that she enjoys, and she must sit close to the television to watch it.

She can't watch the television when she is lying in bed. It was revealed that she has been in the facility a year and has been asking for new glasses because they were severely scratched; and since admission the lens fell out and couldn't be found, and then the nose piece fell off.

Further clinical record review documented Resident 92 was admitted on [DATE], current payor source was private pay. Resident 92's care plan included the Resident had vision impairment, macular degeneration, dry eyes, date initiated January 3, 2025, and revised on February 11, 2026.

Interventions included to place glasses within reach in a consistent place and encourage use and consultation with physician for vision evaluation, date-initiated January 3, 2025, and to administer eye medication as ordered, date initiated May 12, 2025.

Eye care consult dated January 23, 2026, read, in part, dry eyes, glaucoma (damage to the optic nerve) suspected both eyes, pseudophakia (lens implant) both eyes, hyperopia (distant objects are usually seen clearly but close objects appear blurry) and presbyopia (inability to focus on close objects) both eyes, and follow up in 3-4 months, new glasses recommended and to be delivered upon approval; encourage use of glasses for distance and reading.

Interview with Nursing Home Administrator (NHA) and Employee 3 (Registered Nurse Coordinator) on March 24, 2026, at 1:15 PM, it was revealed the bill for the glasses was sent to Resident 92's daughter and must be paid prior to the glasses being delivered.

Employee 2 (Director of Social Services) was asked to follow up with the daughter.

Further review of clinical record revealed Resident 92's daughter wasn't allowed in the facility or to have contact with Resident 92, and that if contact was made the police should be called.

Interview with the NHA on March 25, 2026, at 9:46 AM, revealed there was a history of exploitation by the daughter.

The Resident has a guardian that was assigned to her.

Employee 16 (Business Office Manager) sent the bill to the guardian and the guardian failed to complete the form/paid the bill. It was revealed that Employee 16 reached out to the guardian on March 24, 2026; the form was completed and the bill was paid.

Interview with Employee 16 on March 25, 2026, at 10:15 AM, it was revealed the bill came in the end of last month, she couldn't provide an exact date, and it was mailed to the guardian.

Employee 16 stated she usually emails bills from consultants, but she didn't. It was confirmed she reached out to the guardian March 24, 2026, and the guardian revealed they never received the bill.

She stated that she reached out to the eye Doctor to get another copy of the bill, and she sent it to the guardian on March 24th, 2026.

The guardian signed the paperwork, paid the bill, and the paperwork was sent to the eye Doctor. In the presence of the surveyor, Employee 16 called the Eye Doctor's office, and it was revealed the initial bill was mailed to the facility February 4, 2026. 28 Pa code 211.12(d)(5) Nursing Services

395442 03/26/2026

York North Skilled Nursing and Rehabilitation Ctr 1770 Barley Road York, PA 17408

Review of Resident 7's clinical record revealed diagnoses that included deforming dorsopathy (a spinal disorder characterized by abnormal curvature or structural deformities of the vertebral column, which can lead to pain, mobility issues, and neurological complications) and abnormalities of gait and mobility (abnormal manner or pattern of walking and mobility from issues affecting the brain, spinal cord, muscles, or joints).

Interview with Resident 7 on March 25, 2026, at 9:44 AM, revealed she has only been up to walk with her walker in the hallway 2-3 times since she has been discharged from therapy and it would be nice to walk every day.

Review of Resident 7's physical therapy Discharge summary dated [DATE], revealed Discharge Recommendations & Program Details: plan to refer to restorative ambulation program to provide supervision and support for progression of longer distance ambulation using rolling walker on unit to attend activities as needed.

Review of Resident 7's care plan revealed a focus area Restorative Ambulation: Patient demonstrates a deficit in ambulation with an intervention for Goal: Patient will walk throughout the unit at least two times per day, with a start date of February 16, 2026.

Review of Resident 7's restorative nursing documentation revealed it was marked not applicable on February 25, 26, 27, and 28, 2025; and was also marked not applicable on March 1-5, 7-16, 18, and 21-23, 2025.

Email correspondence with the Director of Nursing (DON) March 25, 2026, at 3:23 PM, he revealed Her restorative program is titled incorrectly but with the right direction which nurse aides can see on the POC (point of care) documentation.

This could be causing confusion for the nurse aides as this resident does not have a prosthesis.

This was locked and unable to be corrected, so we did resolve and updated today.

Review of Resident 7's Restorative Program POC documentation revealed it had been updated to note Correction RNP: walk 100-150 ft.

Further review of Resident 7's restorative program POC documentation revealed it was marked not applicable in the evening of March 25, 2026, after the DON had corrected the POC task.

During an interview with the DON on March 26, 2026, at 10:08 AM, he revealed he would have to follow up to see why the program continued to be marked as not applicable. He further revealed his expectation that restorative programs would be implemented and entered correctly into the electronic health system. 28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services

395442 03/26/2026

York North Skilled Nursing and Rehabilitation Ctr 1770 Barley Road York, PA 17408

Review of Resident 9's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- an ongoing respiratory condition caused by damage to the lungs) and muscle wasting and atrophy (gradual loss of muscle mass and strength).

Review of Resident 9's physician orders revealed orders for:Ipratropium-Albuterol Inhalation Solution, 1 vial inhale orally every 6 hours for SOB (shortness of breath)/wheezing, with a start date of March 23,

• Supply oxygen at 1-4 liter per minute via nasal cannula (device that supplies oxygen through the

nose).

May titrate at 1 liters per minute every 3 minutes to maintain a pulse ox greater than 90 as needed for shortness of breath, with a start date of March 23, 2026.

Review of Resident 9's comprehensive care plan revealed a focus area At risk for respiratory complications related to COPD, SOB, wheezing, with an intervention for administer aerosol as ordered indicated and administer oxygen as per physician order.

Interview with Resident 9 on March 24, 2026, at 9:35 AM, revealed she was sick and wanted to see a doctor, she then let out a wet cough.

Observation in Resident 9's room on March 24, 2026, at 9:35 AM, revealed she had a nebulizer machine at her bedside (a piece of medical equipment that a person with a respiratory condition can use to administer medication directly and quickly to the lungs).

Further observation in her room revealed her nebulizer mask was laying out on her bedside table on top of her box of tissues, her nebulizer tubing was on the floor, the tubing was dated March 23, 2026, and her oxygen tubing from her oxygen concentrator to her nasal cannula in her nose was laying across the floor.

Observation in Resident 9's room on March 24, 2026, at 12:34 PM, revealed her nebulizer mask and tubing were now bagged, but the tubing had the same date of March 23, 2026, indicating it had not been changed since being on the floor.

Further observation revealed her oxygen tubing remained touching the floor and the bag used for storage of the equipment was also touching the floor.

Observation in Resident 9's room on March 25, 2026, at 9:42 AM, revealed her nebulizer tubing was in a bag, but it was touching the floor and remained dated March 23, 2026.

Further observation revealed her oxygen tubing remained touching the floor between her oxygen concentrator and her nasal cannula in her nose.

During an interview with the Director of Nursing on March 25, 2026, at 10:09 AM, the surveyor revealed the concern with the storage of Resident 9's oxygen and nebulizer tubing, as well as her nebulizer mask. He revealed he would expect respiratory equipment to be stored and utilized to prevent contamination with microorganisms. 28 Pa.

Code 211.11(d)(3)(5) Nursing services

395442 03/26/2026

York North Skilled Nursing and Rehabilitation Ctr 1770 Barley Road York, PA 17408

Review of Resident 45's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and end-stage renal disease (the final stage of kidney failure where the kidneys function at less than 15% of normal capacity).

Review of Resident 45's physician's orders revealed that the Resident required renal dialysis on Monday, Wednesday, and as needed.

Renal dialysis is defined as a life-sustaining medical treatment that filters wastes, toxins, and excess fluid from the blood when the kidneys have failed.

Review of Resident 45's Hemodialysis Communication Record Form dated March 6, 2026, revealed the dialysis center did not complete the area titled post-dialysis weight.

Review of Resident 45's Hemodialysis Communication Record Form dated March 9, 2026, revealed the dialysis center did not complete the following areas: Blood Pressure, Pre-dialysis weight, post-dialysis weight, Medication Given During Hemodialysis, and Pulse.

An interview with the Director of Nursing on March 26, 2026, at 10:18 AM, confirmed that the missing documentation on the communication forms should have been completed. 28 Pa.

Code 211.12 (d) (1) (2) (5) Nursing services

395442 03/26/2026

York North Skilled Nursing and Rehabilitation Ctr 1770 Barley Road York, PA 17408

During an interview with Resident 41 on March 24, 2026, at 9:42 AM, she revealed her food is always served cold.

Interview with Resident 106 on March 24, 2026, at 10:03 AM, revealed he said the food is cold.

During a group interview with Residents 6, 35, 37, 44, 57, and 66 on March 25, 2026, at 10:08 AM, they expressed concerns with the food, including that it is always served cold.

There was a 14-minute lapse between the time the food cart was competed in the kitchen and test tray temperatures were obtained.

Test tray temperatures were taken by Employee 17 (Food Service Director) at 1:14 PM.Test tray temperatures included:Macaroni and cheese 127 degrees F, not palatable for temperatureStewed tomatoes 112 degrees F, not palatable for temperatureColeslaw 47 degrees FCookie was served at room temperatureMilk 50 degrees, not palatable for temperatureOrange juice 59 degrees F, not palatable for temperatureCoffee 150 degrees F Interview with Employee 17 on March 24, 2026, at 1:20 PM, revealed the steam table was functioning and the pan of macaroni and cheese was [NAME] out of the oven not long ago.

Further, she thought both would've registered a higher temperature and felt the milk should've been colder.

During an interview with the Nursing Home Administrator on March 24, 2026, at 1:30 PM, no further information was provided regarding the test tray results. 28 Pa.

Code 201.14.

Responsibility of licensee28 Pa code 211.6 - Dietary Services Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

395442 03/26/2026

York North Skilled Nursing and Rehabilitation Ctr 1770 Barley Road York, PA 17408

Observation March 23, 2026, at 9:20 AM, in the walk-in refrigerator revealed: one 5l pound American cheese package was open and not date marked. At that time, Employee 17 (Food Service Director) stated that the cheese was opened that morning.

Observation in the dish room on March 23, 2026, at 9:23 AM, revealed the fan in the window opening on the clean side of the dish machine, the ceiling, and ceiling vents above the tray line contained a light grey fuzzy substance. At that time, an interview with Employee 17 revealed that maintenance is responsible for cleaning the fan and ceiling vents.

During an interview with the Nursing Home Administrator (NHA) on March 24, 2026, it was revealed that the fan and vents aren't on a routine cleaning schedule.

Observation in the A station nourishment pantry on March 23, 2026, at 9:37 AM, revealed there was dried yellow and red liquid in the microwave. In the refrigerator, there was a half of a submarine sandwich marked with a resident name but was not date marked, and one stromboli without a resident identifier or a date. At that time, interview with Employee 17 revealed she didn't know who was responsible for cleaning the microwaves in the nourishment pantries, and both items should contain a resident identifier and be marked with a date.

Observation in the Medbridge nourishment Pantry on March 23, 2026, at 9:43 AM, revealed there was dried food in the microwave.

Observation in the B station nourishment pantry on March 23, 2026, at 9:46 AM, revealed there was a lunch bag that contained a salad, meal, yogurt and energy drink. At that time, Employee 17 confirmed that the lunch bag wasn't a resident's and that staff shouldn't store anything in the resident refrigerator.

Observation in the C station nourishment pantry on March 23, 2026, at 9:49 AM, revealed one thawed vanilla nutritional shake (the product should be used within 14 days of it being thawed) that didn't contain a pull or use by date, and one energy drink not marked with an identifier.

At that time, Employee 17 revealed she wasn't able to determine when the shake was thawed and felt the energy drink belonged to a staff member.

Observation during tray line service on March 24, 2026, at 12:11 PM, revealed Employees 18, 19, and 20 had a bear and were working in the kitchen without wearing a beard covering. At that time, Employee 17 revealed that the facility policy required a beard net if facial hair was at a particular length.

The surveyor asked for the policy but didn't receive it.

Employees 18 and 20 had a bear that was 1-1/2 to 2 inches long.

Interview with the NHA on March 24, 2026, at 1:30 PM, it was revealed that food should be stored within professional standards, staff food shouldn't be stored in nourishment refrigerators, and resident food should be labeled with an identifier and date marked. At that time, the NHA was made aware of concern with facial hair not being covered, and no further information was provided. 28 Pa code 211.6(f) - Dietary Services

395442 03/26/2026

York North Skilled Nursing and Rehabilitation Ctr 1770 Barley Road York, PA 17408

seven resident halls observed (400 and 500 Halls).

Findings Include:

Review of the facility's policy,

right to a safe, clean, comfortable and homelike environment. An observation in the 500 hall on March 25, 2026, at approximately 12:00 PM, revealed that the handrail affixed on the left side of the hall was loose to touch. An observation in the 400 hall on March 25, 2026, at 1:25 PM, revealed that the handrail affixed on the right side of the hall, near the therapy gym, was loose to touch. An interview with the Maintenance Director on March 25, 2026, confirmed that the loose handrails have been secured by his staff. An interview with the Nursing Home Administrator, on March 26, 2026, at 11:30 AM, confirmed that the handrails should be securely affixed to the walls and that the maintenance department will continue to conduct environmental rounds. 28 Pa.

Code 201.18 (b) (1) Management