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🔎 York Nursing And Rehabilitation Center

Inspection Results


Inspection Overview

York Nursing And Rehabilitation Center has been cited for a total of 50 deficiencies since we began saving each survey.

In Virginia, the average facility has **66.27 deficiencies** per survey cycle. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2023-06-29
Correction Date: 2023-08-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2023-06-29
Correction Date: 2023-08-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2023-06-29
Correction Date: 2023-08-13
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-06-29
Correction Date: 2023-08-13
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2023-06-29
Correction Date: 2023-08-13
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Survey Date: 2023-06-29
Correction Date: 2023-08-13
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Survey Date: 2023-06-29
Correction Date: 2023-08-13
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Survey Date: 2023-06-29
Correction Date: 2023-08-13
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Survey Date: 2023-06-29
Correction Date: 2023-08-13
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: J

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2023-06-29
Correction Date: 2022-07-11
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: G

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2023-06-29
Correction Date: 2023-08-13
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2023-06-29
Correction Date: 2023-08-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: J

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Survey Date: 2023-06-29
Correction Date: 2022-09-30
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-12-29
Correction Date: 2023-02-10
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Survey Date: 2022-12-29
Correction Date: 2023-03-21
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-12-29
Correction Date: 2023-02-10
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Survey Date: 2022-12-29
Correction Date: 2023-03-21
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2021-04-15
Correction Date: 2021-05-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2021-04-15
Correction Date: 2021-05-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2021-04-15
Correction Date: 2021-05-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2021-04-15
Correction Date: 2021-05-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2021-04-15
Correction Date: 2021-05-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2021-04-15
Correction Date: 2021-05-26
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2021-04-15
Correction Date: 2021-05-26
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2021-04-15
Correction Date: 2021-05-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2021-04-15
Correction Date: 2021-05-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2021-04-15
Correction Date: 2021-05-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2021-04-15
Correction Date: 2021-05-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2021-04-15
Correction Date: 2021-05-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2021-04-15
Correction Date: 2021-05-26
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2021-04-15
Correction Date: 2021-05-26
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: B

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Survey Date: 2018-08-16
Correction Date: 2018-08-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2018-08-16
Correction Date: 2018-08-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2018-08-16
Correction Date: 2018-08-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2018-08-16
Correction Date: 2018-08-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: B

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Survey Date: 2018-08-16
Correction Date: 2018-08-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2018-08-16
Correction Date: 2018-08-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2018-08-16
Correction Date: 2018-08-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2018-08-16
Correction Date: 2018-08-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives.

Survey Date: 2017-06-08
Correction Date: 2017-06-30
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2017-06-08
Correction Date: 2017-06-30
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Keep residents' personal and medical records private and confidential.

Survey Date: 2017-06-08
Correction Date: 2017-06-30
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

Survey Date: 2017-06-08
Correction Date: 2017-06-30
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Have a program that investigates, controls and keeps infection from spreading.

Survey Date: 2017-06-08
Correction Date: 2017-06-30
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Survey Date: 2017-06-08
Correction Date: 2017-06-30
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility.

Survey Date: 2017-06-08
Correction Date: 2017-06-30
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Ensure laboratory services, blood blanks and transfusion services provided on site meet requirements for certified laboratories; or have an agreement to obtain services from an offsite laboratory, that meets the same requirements.

Survey Date: 2017-06-08
Correction Date: 2017-06-30
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Provide or obtain laboratory services only when ordered by the attending physician.

Survey Date: 2017-06-08
Correction Date: 2017-06-30
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Train all employees on what to do in an emergency, and carry out unannounced staff drills.

Survey Date: 2017-06-08
Correction Date: 2017-06-30
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.

Survey Date: 2017-06-08
Correction Date: 2017-06-30
Category: Administration Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**