Amoroso Wellness at York.

“Resident's bed cane was not securely fastened to the bed, creating a gap of approximately 4 inches when moved, creating a hazard.”

“Resident self-administers medications but has not been assessed by a physician, physician's assistant, or certified registered nurse practitioner regarding ability to self-administer and the need for medication reminders.”

“Resident participated in the development of a support plan but the resident and assessor did not sign and date the support plan.”

“Multiple violations resulted in the revocation of the facility's Certificate of Compliance License #33779 and issuance of a FIRST PROVISIONAL license effective October 24, 2025 through April 24, 2026, based on the facility's acceptable plan to correct violations.”

“Violation cited with Class II severity. Daily fine of $5 per resident ($470 based on 94 residents at time of inspection) assessed.”

“Violation cited with Class II severity. Daily fine of $5 per resident ($470 based on 94 residents at time of inspection) assessed.”

“Violation cited with Class II severity. Daily fine of $5 per resident ($470 based on 94 residents at time of inspection) assessed.”

“An allegation of resident-to-resident abuse (resident #2 pushing resident #1 to the ground and into a wall, causing a red mark on resident #1's head) was reported to the home's Administrator and Director of Nursing but was not reported to the local area agency on aging as required by the Older Adult Protective Services Act.”

“An allegation of resident-to-resident abuse was not reported to the Department's personal care home regional office or complaint hotline within 24 hours as required. The incident regarding resident #1 was not reported to the Department until June 16, 2025.”

“Multiple violations resulted in the revocation of the facility's Certificate of Compliance License #33779 and issuance of a FIRST PROVISIONAL license effective October 24, 2025 through April 24, 2026, based on the facility's acceptable plan to correct violations.”

“An allegation of resident-to-resident abuse (resident #2 pushing resident #1 to the ground and into a wall, causing a red mark on resident #1's head) was reported to the home's Administrator and Director of Nursing but was not reported to the local area agency on aging as required by the Older Adult Protective Services Act.”

“An allegation of resident-to-resident abuse was not reported to the Department's personal care home regional office or complaint hotline within 24 hours as required. The incident regarding resident #1 was not reported to the Department until June 16, 2025.”

“Violation cited with Class II severity. Daily fine of $5 per resident ($470 based on 94 residents at time of inspection) assessed.”

“Violation cited with Class II severity. Daily fine of $5 per resident ($470 based on 94 residents at time of inspection) assessed.”

“Violation cited with Class II severity. Daily fine of $5 per resident ($470 based on 94 residents at time of inspection) assessed.”

“Staff observed a resident with a blind cord wrapped around their neck after the resident expressed suicidal ideation. Staff took a video of the incident but failed to report this critical incident to the Department within 24 hours as required.”

“A resident's initial medical evaluation did not include height, weight, pulse rate, blood pressure, and temperature as required by regulation.”

“Two residents' annual medical evaluations were not completed in a timely manner and were missing required vital measurements (height and/or weight) as required by regulation.”

“Two residents were prescribed medications (orders to give by mouth every 6 hours and every 4 hours as needed) for purposes that are not specific medical diagnoses, constituting prohibited chemical restraints.”

“A resident was admitted to the Secured Dementia Care Unit without completion of the required written cognitive preadmission screening within 72 hours prior to admission.”

“A resident admitted to the home had not been educated regarding their right to refuse medication if they believed there may be a medication error, as required by regulation.”

“During the third shift, a staff member used a strap to fasten a resident's legs to their wheelchair to prevent wandering. The resident remained restrained until approximately 6:30 AM when another staff member discovered and removed the restraint. The staff member was terminated.”

“The facility failed to report an incident to the Department within 24 hours. A resident with a documented care plan requiring supervision outside the home and a wander guard was found wandering unsupervised outside the home perimeter without the wander guard.”

“A resident was physically abused when another resident grabbed and bruised their wrist, resulting in visible bruising. This constitutes neglect as the facility failed to prevent mistreatment.”

“The resident's assessment dated did not reflect the resident's current medical evaluation stating the resident is totally immobile, and the assessment did not include an updated support plan to address the resident's total immobility.”

“The facility discharged a resident without providing the resident or designated person with a written 30-day advance notice, as required by regulation, and without documented physician or Department certification of emergency justification.”

“A resident was found on the floor in the secured care unit after being pushed by another resident, suffered injuries, was screaming in pain, and did not receive proper abuse reporting to local area agency on aging, Pennsylvania Department of Aging, or local police department.”

“A resident was hospitalized with serious injuries following an incident but the home did not file a follow-up report including the nature and extent of injuries suffered.”

“The home holds money for residents but does not obtain written receipts or signatures from residents for cash disbursements at the time of disbursement.”

“The home holds money for residents but has not sent out quarterly statements to residents or designated persons since 2022.”

“Two residents requiring supervision and attendance when outside the home were found at a nearby business without the required staff accompaniment or monitoring. One resident was returned to the home by police.”

“Resident contracts were not properly signed or marked by the residents themselves.”

“The home's quality management meeting did not address reportable incidents, complaint procedures, staff training, licensing violations and plans of corrections.”

“A resident was found on the floor in the secured dementia care unit after being pushed by another resident, suffered injuries, and was screaming in pain. This is a repeated violation from 9/14/23.”

“Prescription medication for wound healing was left unattended and accessible on a resident's bedside table. The resident, who was assessed as unable to self-administer medications, was observed with the white paste substance on lips, teeth, tongue, and fingernails, indicating ingestion of the medication.”

“Controlled substance medication (tramadol) was delivered and signed for but could not be located in the home. Additionally, nursing staff failed to count controlled medications at the end of their shift on the date specified, violating the facility's policy requiring such counts.”

“Enabler bars partially covered on beds of Residents 1 and 3 with openings greater than 4 3/4 inches as required by FDA standards, creating a hazard.”

“FitRIght Aloe Cleansing Cloths with poison control labeling were unlocked, unattended, and accessible to Residents 4, 5, 6 and 7 in the Memory Care Unit. These residents have not been assessed as capable of recognizing and using poisons safely.”

“Bathrooms in Rooms 107, 110, 112, 129 and 137 had pungent urine odor with staining around toilet bases. Room 125 toilet contained dried feces stains. Sanitary conditions were not maintained.”

“Carpets in Bedrooms 236 and 240 were deeply stained with food and/or liquids, not maintaining clean bedrooms as required.”

“Bedroom 107 had broken blinds and Bedroom 123 had no blinds or shades, failing to provide window coverings that are clean, in good repair, and provide privacy.”

“Documentation of Medical Evaluation form for Resident 3 was missing date of evaluation, date form completed, blood pressure, height, weight, pulse rate, and sections 8-10. Resident 5's form was missing medical professional name and signature date.”

“Resident 1 and Resident 2 did not have annual medical evaluations completed within required timeframe, with significant gaps between their previous and most recent evaluations.”

“Support plans for Residents 1 and 3 did not document the need for enabler bars/bed canes or plans to protect these residents from potential hazards of use, despite these devices being present in their bedrooms.”

“Resident 1 was found on the floor while Resident 2 was screaming at them to shut up repeatedly. Resident 1 appeared fearful of Resident 2, constituting potential neglect and verbal abuse.”

“Resident's rings were placed in a lockable nightstand after hospital return and were discovered missing. The facility failed to properly safeguard the resident's property.”

“A soiled disposable undergarment was found on the floor in Resident 1's bathroom, indicating unsanitary conditions were not being maintained.”

“A full, uncovered, unattended trash can was observed in the kitchen at 10:30 AM, failing to prevent penetration of insects and rodents.”

“Medication Administration Records (MAR) and glucometer readings did not match for multiple residents, with several blood sugar readings documented on the MAR that were not listed on the glucometer, and one medication (Maalox Lidovisc) prescribed for Resident 3 was not found in the home.”