Deficiencies per Year
32
24
16
8
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Enforcement
Census: 94
Capacity: 125
Deficiencies: 22
Aug 5, 2025
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and interim review purposes.
Findings
Multiple violations were found related to resident abuse reporting, medication administration, safety and fire drills, resident support plans, and facility compliance with regulatory requirements. The facility was issued a provisional license due to prior violations and is subject to fines and ongoing monitoring.
Deficiencies (22)
| Description |
|---|
| Failure to immediately report suspected resident abuse to the local area agency on aging. |
| Failure to report incidents to the Department within 24 hours as required. |
| Resident abuse incidents including physical abuse and inadequate supervision resulting in injury and hospitalization. |
| Medication administration errors including failure to document administration at the time given and missing signatures. |
| Failure to update resident assessments and support plans to reflect changes in condition and needs. |
| Failure to post current license and violation reports in a conspicuous place. |
| Failure to report incidents of resident found unsupervised outside the facility. |
| Unsafe resident personal equipment such as unsecured bed canes posing entrapment hazards. |
| Trash receptacles outside were overflowing and not properly covered. |
| Food stored uncovered and expired medications found in the medication cart. |
| Insufficient emergency drinking water supply for residents. |
| Fire safety inspection and fire drill documentation deficiencies including incomplete records and excessive evacuation times. |
| Resident non-participation in fire drills and lack of designated meeting place compliance. |
| Incomplete or inaccurate medication records including missing drug allergies and incorrect dosage instructions. |
| Failure to document medication refusals and notify prescribers as required. |
| Failure to follow prescriber's medication orders including missed doses and delayed administration. |
| Failure to safely store medications and medical equipment according to manufacturer instructions. |
| Failure to maintain accurate resident support plans including medication administration support and adaptive equipment use. |
| Use of locking devices without required written approval from authorities. |
| Failure to complete cognitive preadmission screening within required timeframe. |
| Smoking policy violations including unauthorized smoking areas and lack of fire safety safeguards. |
| Transportation vehicle first aid kits missing required supplies. |
Report Facts
License Capacity: 125
Census: 94
Secured Dementia Care Unit Capacity: 20
Residents Served in Secured Dementia Care Unit: 19
Staffing Hours: 135
Waking Staff: 101
Fine Per Resident Per Day: 5
Calculated Fine: 470
Emergency Drinking Water Supply: 155
Required Emergency Drinking Water: 267
Delivered Emergency Drinking Water: 492
Evacuation Times: Array
Inspection Report
Complaint Investigation
Census: 93
Capacity: 125
Deficiencies: 32
Jun 11, 2025
Visit Reason
The inspection was conducted due to an incident complaint involving resident abuse and other regulatory concerns at Amoroso Wellness at York.
Findings
Multiple violations were found including failure to report suspected abuse, medication administration errors, incomplete resident assessments and support plans, safety hazards with resident equipment, and fire safety deficiencies. The facility was issued a provisional license with required plans of correction and follow-up inspections.
Complaint Details
The complaint involved allegations of resident abuse including physical harm and inadequate reporting of incidents. The investigation confirmed multiple violations related to abuse reporting, resident safety, and care planning.
Deficiencies (32)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the local area agency on aging. |
| Failure to report an incident or condition to the Department within 24 hours as required. |
| Resident abuse incidents including physical harm and inadequate supervision resulting in hospitalization. |
| Medication administration record did not include initials of staff administering medication. |
| Resident assessments and support plans were incomplete or not updated to reflect changes in condition or needs. |
| Use of correction fluid on resident medical records. |
| Failure to post current license and inspection summary in a conspicuous place. |
| Failure to report incidents of resident found unsupervised outside the home. |
| Resident personal equipment such as bed canes and enabler bars were not secured properly, posing entrapment hazards. |
| Trash outside the home was not kept in covered receptacles preventing insect and rodent penetration. |
| Food stored uncovered in refrigerator, risking contamination. |
| Insufficient emergency drinking water supply for residents. |
| Fire safety inspection and fire drill documentation deficiencies including incomplete records and excessive evacuation times. |
| Resident did not participate in monthly fire drills; care can no longer be managed by the home. |
| First aid kit in transport vehicle missing required items. |
| Prescription medication administration by unlicensed personnel and family members. |
| Medication administration documentation errors including recording before administration and delayed documentation. |
| Failure to document and report resident refusal of medication to prescriber. |
| Failure to follow prescriber's orders for medication administration and diet. |
| Medication storage issues including expired medications and unlabeled opened medications. |
| Medication labels did not match prescriber instructions. |
| Medication and medical equipment storage procedures not properly implemented. |
| Blood glucose readings not documented in resident records. |
| Medication records missing drug allergies and frequency of administration. |
| Smoking policy not updated to reflect designated smoking area for staff; smoking observed outside designated area. |
| Resident support plans missing documentation of medical, dental, vision, hearing, mental health or behavioral care services. |
| Resident support plans did not document ability to self-administer medications or need for medication reminders. |
| Written cognitive preadmission screening not completed within 72 hours prior to admission to secured dementia care unit. |
| Magnetic lock on secured dementia care unit courtyard gate lacked written approval from regulatory authorities. |
| Resident support plan not developed within 72 hours of admission to secured dementia care unit. |
| Resident support plans did not identify physical, medical, social, cognitive and safety needs accurately. |
| Resident support plans not revised annually or as resident condition changes. |
Report Facts
License Capacity: 125
Residents Served: 93
Residents Served in Secured Dementia Care Unit: 18
Staffing Hours - Total Daily Staff: 127
Staffing Hours - Waking Staff: 95
Fine Per Resident Per Day: 5
Calculated Fine: 470
Census at Inspection: 94
Residents Served: 94
Residents Served in Secured Dementia Care Unit: 19
Staffing Hours - Total Daily Staff: 135
Staffing Hours - Waking Staff: 101
Emergency Drinking Water Supply (gallons): 155
Emergency Drinking Water Required (gallons): 267
Emergency Drinking Water Delivered (gallons): 492
Evacuation Times (minutes:seconds): Array
Inspection Report
Complaint Investigation
Census: 98
Capacity: 125
Deficiencies: 5
May 29, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial review on 05/29/2025 and 05/30/2025 to assess compliance with regulations following complaints.
Findings
Multiple deficiencies were identified including failure to report a serious incident within 24 hours, incomplete resident medical evaluations, improper medication orders without valid medical diagnoses, and failure to complete required preadmission cognitive screenings for secured dementia care unit residents. Plans of correction were accepted and implemented by July 10, 2025.
Complaint Details
The visit was complaint-related as indicated by the inspection information section, with the reason explicitly stated as 'Complaint'.
Deficiencies (5)
| Description |
|---|
| Failure to report an incident involving a resident with a blind cord around their neck to the Department within 24 hours. |
| Resident initial medical evaluation did not include height, weight, pulse rate, blood pressure, and temperature. |
| Resident current medical evaluations did not include height and weight. |
| Residents prescribed medications for symptoms without a valid medical diagnosis, constituting prohibited chemical restraint use. |
| Failure to complete written cognitive preadmission screening within 72 hours prior to admission to secured dementia care unit. |
Report Facts
License Capacity: 125
Residents Served: 98
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 19
Current Hospice Residents: 11
Residents Age 60 or Older: 98
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 34
Total Daily Staff: 132
Waking Staff: 99
Inspection Report
Follow-Up
Census: 102
Capacity: 125
Deficiencies: 2
Apr 22, 2025
Visit Reason
The inspection was conducted as a follow-up to review the submitted plan of correction for the facility after an incident.
Findings
The facility was found to have implemented the plan of correction fully. Two deficiencies were cited: failure to educate a resident on the right to refuse medication and improper use of a restraint on a resident, which resulted in termination of a staff member.
Deficiencies (2)
| Description |
|---|
| Resident was not educated on the right to refuse medication if a medication error is suspected. |
| Staff used a strap to restrain a resident's legs to prevent wandering, which is prohibited. |
Report Facts
Residents Served: 102
License Capacity: 125
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 5
Residents Age 60 or Older: 102
Residents with Mobility Need: 33
Total Daily Staff: 135
Waking Staff: 101
Inspection Report
Complaint Investigation
Census: 102
Capacity: 125
Deficiencies: 4
Feb 5, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at Amoroso Wellness at York on 02/05/2025.
Findings
The inspection found multiple deficiencies including failure to report an incident of a resident wandering unsupervised, an abuse incident involving bruising from staff, inadequate resident assessments, and failure to provide required discharge notices. Plans of correction were accepted and implemented by 03/24/2025.
Complaint Details
The visit was complaint-related, investigating incidents including resident wandering unsupervised and abuse resulting in bruising. The abuse incident was reported to the Department of Health and AAA on 10/06/2024.
Deficiencies (4)
| Description |
|---|
| Failure to report an incident of a resident wandering outside the home unsupervised and not wearing a wander guard. |
| Resident was physically abused by staff resulting in bruising to the wrist. |
| Resident's current assessment did not reflect total immobility and lacked a support plan to address it. |
| Failure to provide a 30-day advance written notice to resident or designated person prior to discharge. |
Report Facts
Residents Served: 102
License Capacity: 125
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 17
Residents Age 60 or Older: 102
Residents with Mobility Need: 46
Total Daily Staff: 148
Waking Staff: 111
Inspection Report
Complaint Investigation
Census: 102
Capacity: 125
Deficiencies: 8
Oct 8, 2024
Visit Reason
The inspection was conducted as a complaint and interim review, unannounced, to investigate allegations and compliance issues at the facility.
Findings
Multiple deficiencies were found including failure to report incidents, breaches in record confidentiality, abuse incidents, lack of emergency telephone numbers, unsecured medications, mislabeled medications, unavailable prescribed medications, and missing directions for key-locking devices. Plans of correction were accepted and implemented with ongoing audits scheduled.
Complaint Details
The visit was complaint-related and interim in nature. Specific abuse allegations were investigated and substantiated with documented incidents of resident altercations and injuries.
Deficiencies (8)
| Description |
|---|
| Failure to report an incident involving staff arguing to the Department within 24 hours. |
| Controlled substance binders were unlocked, unattended, and accessible containing resident medication information. |
| Resident abuse incidents involving physical altercations and injuries were documented. |
| No emergency telephone numbers posted by the telephone in the second floor lounge area. |
| Loose pills and medications were unlocked, unattended, and accessible in resident rooms and medication carts. |
| Prescription medications were not labeled correctly according to pharmacy standards. |
| Medications prescribed were not available in the home to be administered. |
| Directions for operating key-locking devices at the Secure Dementia Care Unit were not conspicuously posted. |
Report Facts
License Capacity: 125
Residents Served: 102
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 12
Residents Age 60 or Older: 101
Residents with Mobility Need: 46
Residents with Physical Disability: 1
Total Daily Staff: 148
Waking Staff: 111
Inspection Report
Renewal
Census: 104
Capacity: 125
Deficiencies: 27
Aug 6, 2024
Visit Reason
The inspection was conducted as a full, unannounced review for renewal, complaint, and incident reasons on 08/06/2024 and 08/07/2024.
Findings
The inspection identified multiple deficiencies including failure to report resident abuse, improper medication management, inadequate staff training, privacy violations, safety hazards, and record-keeping issues. Plans of correction were accepted and implemented with follow-up trainings and audits scheduled.
Complaint Details
The inspection included complaint and incident investigations related to resident abuse, medication errors, and failure to report incidents as required.
Deficiencies (27)
| Description |
|---|
| Failure to immediately report suspected resident abuse involving a resident found on the floor with injuries. |
| Failure to submit a final incident report following a resident injury requiring hospitalization. |
| Failure to obtain written receipts for cash disbursements from residents. |
| Failure to send quarterly financial statements to residents or designated persons since 2022. |
| Failure to provide assistance with instrumental activities of daily living as indicated in resident assessments, resulting in residents found unattended outside the home. |
| Resident contracts were not signed or marked by residents. |
| Quality management meetings did not address reportable incidents, complaint procedures, staff training, licensing violations, and plans of correction. |
| Resident abuse incident involving a resident pushed to the floor causing injury and pain. |
| Use of video cameras with audio recording in common areas violating resident privacy. |
| Staff member did not receive required annual training in falls and accident prevention. |
| Resident's bedside assistive device was not secured to the bedframe. |
| Poisonous materials were not locked and accessible to residents not assessed to safely use or avoid them. |
| Bathroom ventilation fan was not working in a bathroom without an operable window. |
| Emergency telephone numbers were not posted on or by telephones in the second-floor common area. |
| Blocked and locked sliding patio door in the ground-level dining area obstructed egress. |
| Combustible materials stored near heat sources in the maintenance room. |
| Smoking area behind the building was not properly maintained with cigarette butts on the ground. |
| Medication cart was unattended and accessible with loose pills present. |
| Medications and syringes were not properly locked or stored in resident rooms. |
| Expired and discontinued medications were found in medication carts and administered to residents. |
| Medications were not stored in an organized manner; damaged blister packs and loose pills found. |
| Over-the-counter medications and CAM were not labeled with resident names. |
| Medication administration records did not include diagnosis or purpose for prescribed medications. |
| Medications were administered contrary to prescriber's orders, including discontinued medications. |
| Lack of documentation that resident and designated person did not object to admission to secured dementia care unit. |
| Direct care staff in secured dementia care unit did not receive required dementia care training. |
| Medication office and medication carts were unlocked and unattended, allowing unauthorized access to resident records and controlled substance logs. |
Report Facts
License Capacity: 125
Residents Served: 104
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 19
Current Hospice Residents: 11
Residents Age 60 or Older: 104
Residents with Mobility Need: 53
Inspection Report
Follow-Up
Census: 84
Capacity: 125
Deficiencies: 2
Dec 11, 2023
Visit Reason
The inspection visit on 12/11/2023 was a partial, unannounced follow-up to review the submitted plan of correction related to an incident at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing medication security and storage procedures. Deficiencies related to unsecured medications and failure to count controlled substances between shifts were corrected with staff training, audits, and procedural changes.
Deficiencies (2)
| Description |
|---|
| Medication was found unattended and accessible in a resident's room despite the resident being unable to self-administer medications. |
| Controlled substance medications were not counted at the end of a shift, violating the home's policy requiring counts at shift changes. |
Report Facts
License Capacity: 125
Residents Served: 84
Residents in Secured Dementia Care Unit: 17
Hospice Residents: 8
Total Daily Staff: 152
Waking Staff: 114
Residents with Mobility Need: 68
Inspection Report
Complaint Investigation
Census: 85
Capacity: 125
Deficiencies: 2
Sep 14, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at Amoroso Wellness at York on 09/14/2023 and 09/15/2023 to review compliance and the submitted plan of correction.
Findings
Two deficiencies were identified: one involving abuse where Resident 1 was found on the floor and Resident 2 was verbally aggressive, and another involving safeguarding a resident's money and property where valuable rings went missing after being placed in a lockable nightstand. Plans of correction were accepted and implemented by October 2023.
Complaint Details
The visit was complaint-related involving allegations of abuse and neglect between two residents who are husband and wife, and a safeguarding issue regarding missing personal property. The abuse incident was reported promptly and addressed with separation of residents and staff training. The safeguarding issue led to new policies for handling valuables.
Deficiencies (2)
| Description |
|---|
| Resident 1 was found on the floor and Resident 2 was screaming to 'shut up' repeatedly, indicating possible abuse and neglect. |
| Resident 1's rings were placed in a lockable nightstand but were discovered missing during the inspection. |
Report Facts
License Capacity: 125
Residents Served: 85
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 19
Current Hospice Residents: 8
Residents with Mobility Need: 32
Residents Age 60 or Older: 85
Residents with Physical Disability: 2
Inspection Report
Complaint Investigation
Census: 91
Capacity: 125
Deficiencies: 0
Jul 13, 2023
Visit Reason
The inspection was conducted as a complaint investigation at Amoroso Wellness at York on 07/13/2023.
Findings
No regulatory citations or deficiencies were identified as a result of this complaint inspection.
Complaint Details
The inspection was complaint-driven and no deficiencies or regulatory citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 125
Residents Served: 91
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 10
Resident Age 60 or Older: 91
Residents with Mobility Need: 38
Inspection Report
Renewal
Census: 89
Capacity: 125
Deficiencies: 3
Jun 21, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility's license on 06/21/2023 and 06/22/2023 by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
The inspection identified deficiencies related to sanitary conditions, trash receptacles, and medication storage procedures. Plans of correction were submitted and accepted, with implementation dates provided, and the submitted plan of correction was determined to be fully implemented.
Deficiencies (3)
| Description |
|---|
| Soiled disposable undergarment observed on the floor in Resident 1's bathroom. |
| Full, uncovered, unattended trash can in the kitchen. |
| Medication Administration Record (MAR) and Glucometer readings were inconsistent or missing for Resident 2 and Resident 3; medication not found in the home for Resident 3. |
Report Facts
License Capacity: 125
Residents Served: 89
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 18
Current Hospice Residents: 5
Residents Age 60 or Older: 89
Residents with Mobility Need: 40
Total Daily Staff: 129
Waking Staff: 97
Inspection Report
Follow-Up
Census: 96
Capacity: 125
Deficiencies: 2
Apr 20, 2023
Visit Reason
The inspection visit was a partial, unannounced follow-up review triggered by an incident at the facility to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. The report details two deficiencies: an abuse incident involving a staff member and a resident resulting in hospitalization, and a direct care staff member providing unsupervised ADL services without completing required training. Both deficiencies were addressed with corrective actions and training completed by the proposed dates.
Deficiencies (2)
| Description |
|---|
| Abuse incident where a resident was hit by a staff member after an altercation, resulting in the resident falling and hitting their head, requiring hospital evaluation. |
| Direct Care Staff Person provided unsupervised ADL services without completing the Department-approved direct care training course and competency test. |
Report Facts
License Capacity: 125
Residents Served: 96
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 6
Residents Age 60 or Older: 96
Residents with Mobility Need: 41
Total Daily Staff: 137
Waking Staff: 103
Inspection Report
Complaint Investigation
Census: 92
Capacity: 125
Deficiencies: 1
Mar 2, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 03/02/2023.
Findings
The inspection found that Resident 1 had unlocked and accessible medications in their room despite not being assessed to self-administer medications. The facility implemented a plan of correction to remove medications from rooms without self-administration orders and to educate staff and residents on proper procedures.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The submitted plan of correction was fully implemented as of 03/13/2023.
Deficiencies (1)
| Description |
|---|
| Resident 1 had unlocked and accessible prescription and OTC medications in their room without being assessed to self-administer medications. |
Report Facts
License Capacity: 125
Residents Served: 92
Residents in Secured Dementia Care Unit: 20
Hospice Residents: 8
Total Daily Staff: 129
Waking Staff: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| JM | Executive Director | Named in plan of correction implementation removing medications and overseeing room checks. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 125
Deficiencies: 9
Jan 25, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulatory requirements at Amoroso Wellness at York.
Findings
Multiple deficiencies were identified including unsafe resident personal equipment, unsecured poisonous materials accessible to residents, unsanitary bathroom conditions, stained carpets, broken or missing window coverings, incomplete medical evaluations, and incomplete support plans. Plans of correction were submitted and determined to be fully implemented by the follow-up date.
Complaint Details
The inspection was conducted due to a complaint. The submitted plan of correction was reviewed and determined to be fully implemented as of 01/25/2023.
Deficiencies (9)
| Description |
|---|
| Enabler bars that were partially covered were found on the beds of Resident 1 and 3 with openings greater than FDA requirements. |
| FitRight Aloe Cleansing Cloths labeled poisonous were unlocked and accessible to residents in the Memory Care Unit who were not assessed as capable of safely using or avoiding poisonous materials. |
| Bathrooms in multiple rooms had pungent urine odor and staining around toilet bases; one toilet contained dried feces stains. |
| Carpets in Bedrooms 236 and 240 were deeply stained with food and/or liquids. |
| Bedroom windows had broken blinds or no window coverings in rooms 107 and 123. |
| Documentation of Medical Evaluation forms for Residents 3 and 5 were incomplete or missing required information. |
| Annual medical evaluations for Residents 1 and 2 were not completed within required timeframes. |
| Support plans for Residents 1 and 3 did not indicate the need for enabler bars or plans to protect residents from hazards. |
| Support plan for Resident 4 was developed but the assessor did not sign the support plan. |
Report Facts
License Capacity: 125
Residents Served: 89
Memory Care Unit Capacity: 20
Memory Care Unit Residents Served: 20
Hospice Current Residents: 6
Residents Age 60 or Older: 89
Residents with Mobility Need: 21
Staffing Hours - Total Daily Staff: 110
Staffing Hours - Waking Staff: 83
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