Yorktown Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected the resident's status for 3 of 16 residents (Residents #6, #28 and #34) reviewed for resident assessments. 1.The Facility failed to ensure Resident #6's active diagnosis of depression and her number of falls between assessments was accurately reflected on her quarterly MDS assessment, dated 01/12/2026. 2. The facility failed to ensure Resident #28's oxygen use was accurately reflected on her Significant Change MDS assessment, dated 01/16/2026. 3. The facility failed to ensure Resident #34's active diagnosis of dysphagia was accurately reflected on his quarterly MDS assessment, dated 12/29/2025 These deficient practices could place residents at risk of missed or inaccurate care. The findings include: Record review of Resident #6's electronic face sheet dated 02/17/2026 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: pressure ulcer of sacral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 2 of 7 residents (Residents #6 and#10) reviewed for infection control. 1. The facility failed to ensure CNA B took off her soiled gloves, sanitized her hands, and put on clean gloves prior to placing a clean brief on Resident #6 during catheter care. 2.The facility failed to ensure the ADON took off and replaced her gown after leaving the room to get more gloves when she performed wound care for Resident #6 who was on EBP. 3. The facility to ensure Resident #10 was on EBP by not having PPE outside his door and a sign on his door when he had a diabetic ulcer which required a dressing. These deficient practices could place residents at risk of cross contamination and infections.The findings included: 1. Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. for 1 resident (Resident #10) of 2 residents observed for wound care. The facility failed to ensure the ADON followed physician orders when she performed Resident #10's diabetic ulcer (slow-healing open sore or wound, most commonly on the feet, that occurs as a complication of diabetes due to nerve damage and poor blood circulation) treatment. This deficient practice could result in a lack or delay in wound healing.The findings included: Record review of Resident #10's electronic face sheet dated 02/20/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: unspecified dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible; for 1 (room [ROOM NUMBER]) of 1 room on hallway with 6 residents residing on hallway reviewed for environment, in that:The facility failed to secure room [ROOM NUMBER] that was being used as storage with 2 unlocked housekeeping carts were not locked that contained potentially unsafe cleaning chemicals.This deficient practice could result in residents coming in contact with potentially unsafe cleaning chemicals.The findings included: Observation on 02/17/2026 at 11:20 a.m. revealed room [ROOM NUMBER] with no lock to the door and it was being used as storage for housekeeping floor cleaning machines along with 2 housekeeping carts in the room. The housekeeping carts had refills for the antibacterial hand foam sitting on the bottom of the carts and were not locked. Housekeeping cart #1 and cart #2 each had a 2-liter antibacterial hand foam bottle with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for 2 (Residents #28 and #36) of 4 residents reviewed for oxygen therapy. The facility failed to ensure oxygen therapy was delivered at the prescribed rate for Resident #28. 2. The facility failed to ensure the oxygen concentrator that delivered oxygen to Resident #36 had a clean filter. These deficient practices could place residents at risk of respiratory distress.The findings included: 2. Record review of Resident #36's electronic face sheet dated 02/18/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: heart failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 medication cart (Station II Medication Cart) reviewed.The facility failed to remove an expired tube of Medi-honey (wound gel, offers protection against invading bacteria, is effective against a wide variety of bacteria, cleans the wound, rapidly lifting dead tissue, reduces wound odor and provides a moist environment for healing) with an expiration date, of 07/01/2025 from Station II's II's medication cart.This deficient practice could result in decreased effectiveness of medications.The findings were: Observation on 02/18/2026 at 12:37 PM of Station II medication cart with LVN C revealed a small tube of Medi-honey with an expiration date of 07/01/2025. During an interview on 02/19/2026 at 12:40 pm, LVN C stated the Medi-honey was house stock and used for residents. During an interview on 02/19/2026 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurate, readily accessible and systematically organized for 2 (Residents #28 and #36) of 19 residents reviewed for clinical records. The facility failed to ensure Resident #28's MAR/TAR reflected her order for receiving oxygen at 2 LPM via nasal cannula for nurses to monitor for proper setting. 2. The facility failed to ensure LVN A accurately documented in Resident #36's TAR that his oxygen concentrator filter was not cleaned when she initialed that it was. These deficient practices could result in inaccurate clinical records and decreased continuity of care.The findings included: 2. Record review of Resident #36's electronic face sheet dated 02/18/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: heart failure (chronic condition where the heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility ice machine that provided ice for resident beverages at meals had visible rust on the outside and inside of the machine and contained large sections of yellow and brown ice. This failure could place residents who drink beverages with ice from the kitchen at risk for becoming sick from contaminated ice. The findings were: During an observation, 04/22/2025 at 11:02 a.m., the ice machine utilized by the kitchen for resident beverages was observed to have large sections of yellow and brown colored ice inside of the machine and rust stains on the inside and outside walled surfaces of the ice machine. During an interview with the Dietary Cook, 04/22/2025 at 11:42 a.m., the Dietary [NAME] stated the facility only had one ice maker and the facility residents were served ice from the ice maker for all beverages at meals. The Dietary [NAME] stated maintenance was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the kitchen. The facility failed to ensure dietary staff used proper hand hygiene during meal preparation. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 11/20/2024 at 11:20 a.m. revealed the DM assisting with the meal tray preparation. The DM had washed her hands and put on gloves for cutting the bread, after cutting the bread she assisted with taking plates from the cook and placed them on trays. The cook asked for diet tickets on the other side of the DM in which the DM reached and grabbed tickets handed them to the cook, and continued to assist with putting plates on trays and placing bread on plates using tongs. The DM then proceeded to reach in a bread bag, grabbed a large stack of bread, placed her gloved hand on the bread, cut the bread in half and continued to place bread on trays.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) level 1 residents with mental illness were provided with a PASRR level 2 evaluation for 1 of 4 residents (Resident #5), reviewed for resident assessment. Resident #5's PASRR level 1 screening form did not indicate mental illness and the resident did not have a PASRR level II evaluation. This could place residents at risk of not receiving necessary specialized services to meet their individual needs. The findings were: Record review of Resident #5's face sheet dated 11/20/24 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included major depressive disorder recurrent severe with psychotic symptoms (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life with hallucinations, delusions, disorganized thoughts, speech, and actions), psychotic disorder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #23) reviewed for quality of care. Resident #23's tube feeding was not labeled with the required information. This failure could place residents at risk of decreased continuity of care, errors in tube feeding, and nutritional deficits. The findings were: Record review of Resident #23's face sheet dated 11/21/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included anoxic brain damage (damaged caused by a complete lack of oxygen to the brain), dysphagia following cerebral infarction (difficulty swallowing following a stroke that disrupted blood flow to the brain due to problems with the blood vessels that supply it), and aphasia (aphasia is a language disorder that affects your ability to speak and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 residents (Resident #18) reviewed for pharmacy services. Resident #18's Tramadol (narcotic) medication was left unsupervised in the top drawer of the medication cart in a paper pill cup after it was popped out of the medication card. This could put residents at risk of pain, medication errors, and drug diversion. The findings were: Record review of Resident #18's face sheet dated 11/21/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included unspecified dementia unspecified severity with agitation (general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life and include agitation), muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 dining rooms reviewed, in that: A supply cabinet located in the facility dining room was unlocked and contained potentially dangerous materials. This deficient practice could place residents, staff, and the public at risk of exposure to potentially dangerous materials. The findings were: Observation on 09/26/2023 at 12:58 p.m. revealed a supply cabinet located in the facility dining room was closed but unlocked, and contained three containers of cleaning wipes labeled, Warning, Keep Out of Reach of Children, and six cans of shaving cream labeled, Warning, Keep Out of Reach of Children. During an interview with Housekeeper A on 09/26/2023 at 1:01 p.m., Housekeeper A confirmed a supply cabinet located in the facility dining room was closed but unlocked, and contained three containers of cleaning wipes labeled, Warning, Keep Out of Reach of Children and six cans of shaving cream labeled, Warning,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.