Pennsylvania Department of Health
REST HAVEN-YORK
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
REST HAVEN-YORK
Inspection Results For:

There are  38 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
REST HAVEN-YORK - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on February 14, 2024, at Rest Haven-York, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: A,B & NEW - Component: 01 - Tag: 0000


Facility ID #440902
Component 01
A, B and New Wing

Based on a Medicare/Medicaid Recertification Survey completed on February 14, 2024, it was determined that Rest Haven-York was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type II (111), protected noncombustible structure, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: A,B & NEW - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of building separating common walls, affecting one of three smoke compartments within the component.

Findings include:

1. Observation on February 14, 2024, at 11:50 AM, revealed the left leaf of double doors of the separation wall, between the 01 Component and the 03 Component (C Wing), failed to close and latch, due to inoperable coordinator.

Interview at the time of the exit conference with the Director of Operations and Administrator on February 14, 2024, at 2:15 PM, confirmed common wall doors failed to close and positively latch.



 Plan of Correction - To be completed: 04/05/2024

The left leaf of double doors of the separation wall between the 01 Component and the 03 Component separating Component 01 from 03 have been adjusted to properly close and latch.

Director of Operation or designee will check all other fire doors to ensure there are no holes, gaps and they properly latch.

A QA tool will be developed to inspect all communicating openings bi-weekly to ensure they maintain the 2-hour fire resistance rating. and latch properly at all times. All findings from the QAs will be reported to the Director of Operations for immediate resolution if needed. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting

NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: A,B & NEW - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors, to be within the allowed gap margins and positively latch in frame, in two of three smoke zones within the component.

Findings include:

1. Observation on February 14, 2024, between 12:05 PM and 12:50 PM, revealed hazardous area doors exceeded minimum gap margins, at the following locations:

a. 12:05 PM, Soiled Utility Room door, by Glow Room, top exceeded 3/16 inch;
b. 12:33 PM, Laundry Room, Washroom, left leaf, top exceeded 3/16 inch;
c. 12:50 PM, New Wing, Boiler Room door, top and latch side exceeded 3/16 inch.

Interview at the time of the exit conference with the Director of Operations and Administrator on February 14, 2024, at 2:15 PM, confirmed hazardous area doors exceeded the allowed gap margins.

2. Observation on February 14, 2024, between 12:35 PM and 12:37 PM, revealed hazardous area doors failed to close and positively latch in the frame, at the following locations:

a. 12:35 PM, Laundry Room, left leaf, inoperable door closure;
b. 12:37 PM, Laundry Room, right leaf, inoperable coordinator.

Interview at the time of the exit conference with the Director of Operations and Administrator on February 14, 2024, at 2:15 PM, confirmed hazardous area doors failed to close and positively latch.



 Plan of Correction - To be completed: 04/05/2024

The Soiled Utility Room door, by Glow Room, has been adjusted to reduce the gap to less than 3/16 inch. The Laundry Room, Washroom, left leaf, has been adjusted to reduce the gap to less than 3/16 inch. The New Wing, Boiler Room door and frame will be replaced and requires a TLW. The expected completion date of installation will be no later than 06/04/2024. The New Wing, Boiler Room door will have intumescent edge seal placed until the installation of the new door and frame is completed. The Laundry Room, left leaf and right leaf, have been adjusted to be operable.

All other hazardous area doors will be checked in the facility for proper closure and the gap between the door and doorstop will not exceed minimum gap margins.

Director of Operations or designee will complete monthly audits on all hazardous doors to ensure hazardous doors properly close and the gap between the door and doorstop will not exceed minimum gap margins.

The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.

NFPA 101 STANDARD Smoke Detection:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: A,B & NEW - Component: 01 - Tag: 0347

Based on document review and interview, it was determined the facility failed to provide monthly smoke detector's maintenance and inspection documentation in accordance with the manufacturer's instructions, affecting the entire component.

Findings include:

1. Review of documentation and interview on February 14, 2024, between 8:00 AM and 10:00 AM, revealed the facility lacked documentation for monthly battery-operated smoke detectors, which are installed in the residential rooms.

Interview at the time of the exit conference with the Director of Operations and Administrator on February 14, 2024, at 2:15 PM, confirmed the facility lacked battery operated smoke detector documentation.




 Plan of Correction - To be completed: 04/05/2024

All battery-operated smoke detectors in resident rooms have had new batteries installed and have been checked.

The Director of Operations or designee will replace the batteries semi-annually.

The QAPI Coordinator or designee will complete weekly audits to ensure the battery-operated smoke detectors are properly working. All findings from the QAs will be reported to the Director of Operations for immediate resolution if needed. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: A,B & NEW - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to provide maintain the automatic sprinkler system, to be free of obstructions, in one of one laundry room within the component.

Findings include:

1. Observation on February 14, 2024, between 12:27 PM and 12:30 PM, revealed sprinkler heads covered with debris, at the following locations:

a. 12:27 PM, Laundry Room, Dryer Room, 2 sprinkler heads;
b. 12:30 PM, Laundry Room, Washroom, 2 sprinkler heads.

Interview at the time of the exit conference with the Director of Operations and Administrator on February 14, 2024, at 2:15 PM, confirmed debris covering sprinkler heads.



 Plan of Correction - To be completed: 04/05/2024

The Laundry Room, Dryer Room, 2 and Laundry Room, Washroom, 2, sprinkler heads have been cleared of debris.

All ceilings have been checked to ensure sprinkler heads are free of obstruction and clean of debris.

The QAPI Coordinator or designee will complete 10% weekly audits of sprinkler heads to be free of obstruction and clean. All findings from the QAs will be reported to the Director of Operations for immediate resolution if needed. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. Decreasing frequency or percentage of review will be directed by the QA committee.

Initial comments:Name: D,E,F,G - Component: 02 - Tag: 0000


Facility ID #440902
Component 02
D, E, F and G Wings

Based on a Medicare/Medicaid Recertification Survey completed on February 14, 2024, it was determined that Rest Haven-York was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type II (111), protected noncombustible structure, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: D,E,F,G - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors, to be within the allowed gap margins, in one of one soiled utility room within the component.

Findings include:

1. Observation on February 14, 2024, at 11:10 AM, revealed the Soiled Utility Room door, by Resident Room 653, exceeded minimum gap margins, top, greater than 3/16 inch.

Interview at the time of the exit conference with the Director of Operations and Administrator on February 14, 2024, at 2:15 PM, confirmed hazardous area doors exceeded the allowed gap margins.



 Plan of Correction - To be completed: 04/05/2024

The Soiled Utility Room door, by Resident Room 653, has been adjusted to reduce the gap to less than 3/16 inch.

All other hazardous area doors will be checked in the facility for proper closure and the gap between the door and doorstop will not exceed minimum gap margins.

Director of Operations or designee will complete monthly audits on all hazardous doors to ensure hazardous doors properly close and the gap between the door and doorstop will not exceed minimum gap margins.

The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.

NFPA 101 STANDARD Smoke Detection:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: D,E,F,G - Component: 02 - Tag: 0347

Based on document review and interview, it was determined the facility failed to provide monthly smoke detector's maintenance and inspection documentation in accordance with the manufacturer's instructions, affecting the entire component.

Findings include:

1. Review of documentation and interview on February 14, 2024, between 8:00 AM and 10:00 AM, revealed the facility lacked documentation for monthly battery-operated smoke detectors, which are installed in the residential rooms.

Interview at the time of the exit conference with the Director of Operations and Administrator on February 14, 2024, at 2:15 PM, confirmed the facility lacked battery operated smoke detector documentation.



 Plan of Correction - To be completed: 04/05/2024

All battery-operated smoke detectors in resident rooms have had new batteries installed, have been inspected and documented.

The Director of Operations or designee will inspect and document all smoke detectors in residential rooms.

The QAPI Coordinator or designee will complete weekly audits to ensure the battery-operated smoke detectors are properly working. All findings from the QAs will be reported to the Director of Operations for immediate resolution if needed. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified.
NFPA 101 STANDARD Electrical Systems - Receptacles:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: D,E,F,G - Component: 02 - Tag: 0912

Based on observation and interview, it was determined the facility failed to maintain power receptacles to be Ground Fault Interruption (GFI) protected, within six feet of a water source, in one of one Beauty Shop within the component.

Findings include:

1. Observation on February 14, 2024, between 11:30 AM and 11:32 AM, revealed outlets were not GFI protected, and within six feet of a water source, at the following locations:

a. 11:30 AM, Beauty Shop, North Wall;
b. 11:32 AM, Beauty Shop, South Wall.

Interview at the time of the exit conference with the Director of Operations and Administrator on February 14, 2024, at 2:15 PM, confirmed outlets were not GFI protected.



 Plan of Correction - To be completed: 04/05/2024

The Beauty Shop, North Wall and the Beauty Shop, South Wall outlets are GFI protected.

All other power receptacles will be checked and GFI protected if within six feet of a water source.

The DOO or designee will complete 10% monthly audits of outlet heads to be GFI protected, if within six feet of water. All findings from the QAs will be reported to the Director of Operations for immediate resolution if needed. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. Decreasing frequency or percentage of review will be directed by the QA committee.

Initial comments:Name: C WING - Component: 03 - Tag: 0000


Facility ID #440902
Component 03
C Wing

Based on a Medicare/Medicaid Recertification Survey completed on February 14, 2024, it was determined that Rest Haven-York had deficiencies that have the potential for minimal harm as related to the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).


This is a two-story, Type III (200), unprotected ordinary structure, which is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: C WING - Component: 03 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting two of two floors within the component.

Findings include:

1. Observation on February 14, 2024, at 10:15 AM, revealed the building was a two-story, Type III (200), unprotected ordinary structure. Buildings of this type of construction are not permitted to be greater than one story, in height.

Interview at the time of the exit conference with the Director of Operations and Administrator on February 14, 2024, at 2:15 PM, confirmed the construction type is not permitted in healthcare.



 Plan of Correction - To be completed: 04/05/2024

Facility requests that the DOH DSI conduct the FSES.
NFPA 101 STANDARD Number of Exits - Story and Compartment:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4
Observations:
Name: C WING - Component: 03 - Tag: 0241

Based on observation and interview, it was determined the facility failed to provide not less than two exits, remote from each other, for each floor or fire section, affecting one of two floors within the component.

Findings include:

1. Observation on February 14, 2024, at 10:20 AM, revealed the facility lacked two acceptable exits, remote from each other, on the 2nd floor.

Interview at the time of the exit conference with the Director of Operations and Administrator on February 14, 2024, at 2:15 PM, confirmed the lack of acceptable exits.



 Plan of Correction - To be completed: 04/05/2024

Facility requests that the DOH DSI conduct the FSES.

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