Rest Haven-York

Inspectors wroteBased on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to labeling and storage of medical supplies for one of two residents reviewed with gastrostomy tubes (Resident 14). The facility also failed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections during two of two meal observations in the Royal Garden Cafe.

Inspectors wroteBased on facility policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure a resident has the right to a dignified existence, including in an environment that promotes maintenance or enhancement of his or her quality of life, for one of 29 residents reviewed (Resident 7).

Inspectors wroteBased on observation, policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that the interdisciplinary team determined a resident was safe to self-administer medications for one of the 29 residents reviewed (Resident 10). Findings Include: Review of the facility's policy, titled Medication- Self Administration-Assessment, Review, Care Planning, Documentation, revised April 2022, read, the purpose of the policy is To provide a uniform process through which residents are assessed and reviewed to self-administer medication and care-planning, and documentation is completed. [...]

Inspectors wroteBased on facility policy, staff interviews, and clinical record reviews, it was determined that the facility failed to provide an explanation of the risks and benefits of psychotropic medications use and obtain consent prior to administering psychotropic medications for two of three residents reviewed for psychotropic medication use (Residents 15 and 45).

Inspectors wroteBased on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 29 residents reviewed (Residents 45 and 92). Findings Include: Review of Resident 45's clinical record revealed diagnoses that included chronic kidney disease (the long-term, irreversible loss of kidney function) and dementia (a general term for severe mental function loss). Review of Resident 45's Quarterly MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated November 11, 2025, indicated in Section I2300. Urinary Tract Infection (UTI) (LAST 30 DAYS) that Resident 45 had a UTI in the previous 30 days. [...]

Inspectors wroteBased on policy review, observations, and staff interviews, it was determined that the facility failed to provide respiratory services for two of two residents reviewed for respiratory care (Residents 141 and 144).

Inspectors wroteBased on facility policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of two residents reviewed that received dialysis services (Resident 12). Findings Include: Review of facility policy, titled Dialysis Care of Resident- transport, communication, observation, documentation, last revised January 2, 2017, read, in part, the facility is to communicate with dialysis facility. Prior to dialysis, pre-dialysis observation will be completed and sent with or faxed to dialysis center. Upon return from dialysis, a post-dialysis observation will be completed, and physician and dialysis center will be notified as needed. [...]

Inspectors wroteBased on review of the ice machine equipment manual, observations, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety for one of three pantry refrigerators and one of three ice machines.

Inspectors wroteBased on policy review, observations, clinical record reviews, facility document review, and staff interviews, it was determined that the facility failed to protect the residents' right to privacy for three of three residents reviewed for the use of video/audio monitoring (Residents 16, 27, and 65).

Inspectors wroteBased on facility policy review, observation, review of select facility documentation, and staff interviews, it was determined that the facility failed to utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen.

Inspectors wroteBased on observations, facility policy review, and staff interviews, it was determined that the facility failed to ensure staff implemented infection control policies to prevent the spread of infection by doffing PPE (personal protective equipment) prior to exiting the resident room in two of seven resident care areas observed (100 and 700 hall), and failed to properly disinfect resident areas after one of two dressing changes observed (Resident 12). Findings Include: [...]

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like environment for one of 30 resident's reviewed (Resident 106).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to conduct a Significant Change Minimum Data Set (MDS - standardized assessment tool utilized to identify a resident's physical, mental, and psychosocial needs) for one of four residents reviewed for hospice status (Resident 70).

Inspectors wroteBased on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming for one of 30 residents reviewed (Resident 7).

Inspectors wroteBased on clinical record review, hospital record review, and staff interviews, it was determined that the facility failed to provide care and services that met professional standards for one of 30 residents reviewed (Resident 240).

Inspectors wroteBased on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure residents receive treatment and services consistent with professional standards to promote healing and prevent infection for one of two residents reviewed for pressure ulcers (Resident 37).

Inspectors wroteBased on facility policy review, clinical records review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the resident environment was free of accident hazards for one of 30 Residents reviewed (Resident 26).

Inspectors wroteBased on review of facility investigation, clinical record review, and staff interviews it was determined that the facility displayed past noncompliance, in that they had failed to ensure residents receive treatment and care in accordance with professional standards of practice and physician orders for one of seven residents reviewed (Resident 6 ). Findings Include: Review of Resident 6's clinical record revealed diagnoses that inlcuded Diabetes Mellitus Type II (a problem in the way the body regulates and uses sugar as a fuel) and vascular dementia (Brain damage caused by multiple strokes) Review of Resident 6's physician orders revealed an order that read Ozempic (semaglutide) pen injector; 0.25 mg or 0.5 mg .subcutaneous once a day on Friday. [...]

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident's status for two of 28 residents reviewed (Residents 7 and 8). Findings Include: Review of Resident 7's clinical record revealed diagnoses that included vitamin D deficiency, osteoporosis (a condition that weakens bones and increases the risk of fractures), and chronic pain. Review of Resident 7's quarterly Minimum Data Set (MDS - assessment tool utilized to identify residents' physical, mental and psychosocial needs), with an assessment reference date (ARD - last day of the assessment period) of February 6, 2024, revealed Resident 7 was coded as having had a weight loss of 5% or more in the last month or 10% or more in the last six months. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 28 residents reviewed (Residents 118 and 128).

Inspectors wroteBased on clinical record review, observations, and staff interviews, it was determined that the facility failed to precisely and effectively monitor hydration status and implement a therapeutic diet for one of 28 residents reviewed (Residents 128).

Inspectors wroteBased on review of facility policy, observations, record review, and resident and staff interviews, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for one of 28 residents reviewed (Resident 65).