A list of the most recent deficiencies for York Manor Nursing Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-10-16 | 2023-11-28 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-10-16 | 2023-11-28 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-10-16 | 2023-11-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-16 | 2023-11-28 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-10-16 | 2023-11-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-16 | 2023-11-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-16 | 2023-11-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-16 | 2023-11-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-16 | 2023-11-28 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-10-16 | 2023-11-28 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-10-16 | 2023-11-28 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-10-16 | 2023-11-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-10-16 | 2023-11-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-16 | 2023-11-28 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-10-16 | 2023-11-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-16 | 2023-11-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-16 | 2023-11-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-03 | 2023-03-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-03 | 2023-03-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-03 | 2022-10-05 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-08-04 | 2022-09-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-04 | 2022-09-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-04 | 2022-09-22 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-08-04 | 2022-09-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-04 | 2022-09-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-08-04 | 2022-09-22 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-08-04 | 2022-09-22 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-08-04 | 2022-09-22 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-08-04 | 2022-09-22 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-08-04 | 2022-09-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-04 | 2022-09-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-04 | 2022-09-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-08-04 | 2022-09-22 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-08-02 | 2022-08-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-10 | 2019-10-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-10 | 2019-10-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-10 | 2019-10-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-05 | 2019-09-12 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-10-16 | 2018-11-16 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-10-16 | 2018-11-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-10-16 | 2018-10-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-16 | 2018-10-19 | N |
