Pennsylvania Department of Health
REST HAVEN-YORK
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

REST HAVEN-YORK
Inspection Results For:

There are 96 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:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights survey completed on March 4, 2024, it was determined that Rest Haven-York was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.20(g) REQUIREMENT Accuracy of Assessments:

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.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:

Based 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.

Review of Resident 7's weights since her admission date of August 28, 2023, failed to reveal a significant weight loss that should have been coded on the quarterly MDS Assessment with ARD of February 6, 2024.

During an interview with the Director of Nursing (DON) on February 28, 2024, at approximately 10:15 AM, the surveyor inquired about Resident 7 being coded for weight loss on her quarterly MDS Assessment.

A follow-up interview with the DON on February 29, 2024, at 11:27 AM, revealed Resident 7 did not have a significant weight loss to be captured on the assessment, and she would have expected resident MDS assessments to be coded accurately.

Review of Resident 8's clinical record revealed diagnoses that included sepsis (a life-threatening complication from infection, causing the body to have a severe inflammatory response to bacteria) and urinary tract infection (UTI - an infection in any part of your urinary system: kidneys, bladder, ureters, and urethra).

Review of Resident 8's clinical record revealed a hospital discharge summary dated January 29, 2024. Further review of the aforementioned document revealed Resident 8 had been hospitalized January 24 through 29, 2024, and was diagnosed with sepsis related to a UTI.

Review of Resident 8's quarterly minimum data set dated February 5, 2024, section I2300 urinary tract infections (UTI) (last 30 days) revealed the facility failed to indicate Resident 8 had a UTI in the last 30 days.

During an interview with the DON on February 29, 2024, at 11:35 AM, in the presence of the Nursing Home Administrator, the DON stated Resident 8's UTI should have been indicated on the MDS and it is the expectation of the facility for MDS assessments to be accurate.

28 Pa. Code 211.12(d)(3)(5) Nursing services

Plan of Correction - To be completed: 04/30/2024

MDS for Resident 7 and Resident 8 have been corrected to show UTI in the last 30 days and to remove the significant weight loss in 30 days.

All MDSs for residents with a UTI in the last 3 months have been reviewed to ensure accuracy. All MDSs for residents with a significant weight loss in the last 3 months have been reviewed to ensure accuracy.

RNAC and staff responsible for documentation on MDS have been educated on the importance of accuracy of assessments and that assessments must accurately assess resident status.

A QA tool has been developed to review 10% of MDSs weekly to ensure accuracy in assessment of UTIs in last 30 days and any significant weight loss. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based 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).

Findings include:

Review of facility policy, titled "Interdisciplinary plan of care- development. Review, and update", last revised October 13, 2017, revealed "It is the policy of this facility to develop an individualized plan of care for each resident, and review and update the care plan as needed ...Care plans will be updated with the quarterly OBRA (Omnibus Budget Reconciliation Act) schedule, as significant changes occur and by the interdisciplinary team as changes arise."

Review of Resident 118's clinical record revealed diagnoses that included post-traumatic stress disorder (PTSD - a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event) and generalized anxiety disorder (condition that causes you to feel anxious about a wide range of situations and issues).

Review of Resident 118's care plan on February 27, 2024, at 11:17 AM, revealed a care plan focus created March 17, 2023, for "I have post-traumatic stress disorder (PTSD) due to", with an intervention of, "I need staff to be aware of my triggers to trauma. My triggers include."

During a staff interview February 28, 2024, at 10:24 AM, with the Director of Nursing (DON) and Nursing Home Administrator (NHA), the surveyor requested additional information regarding Resident 118's PTSD diagnosis indicators and triggers not being identified on the care plan.

During an additional staff interview February 29, 2024, at 12:15 PM, with the NHA, she indicated the facility was unable to determine Resident 118's PTSD triggers due to Resident 118's inability to communicate his triggers and not having any relatives familiar with his diagnosis. The NHA stated that Resident 118's care plan had been updated now, and it was the facility's expectation that the care plan would have been updated timely.

Review of Resident 128's clinical record revealed diagnoses that included congestive heart failure (CHF - excessive body/lung fluid caused by a weakened heart muscle), emphysema (a lung disease which results in shortness of breath due to destruction and dilatation of the alveoli), and acute pulmonary edema (a condition where fluid accumulates in lung tissues causing shortness of breath, wheezing, and coughing up blood).

Review of Resident 128's physician orders on February 26, 2024, revealed an order for, "Diet (Regular) Diet Consistency (regular) Liquid Consistency (Thin) 1200 ml (milliliter- unit of measure) fluid restriction", with a start date of January 9, 2024.

Review of Resident 128's clinical record revealed a fax from Resident 128's cardiology appointment on January 29, 2024, with the following recommendations: "2300 mg (milligram- unit of measure) sodium restriction, 1800 ml fluid restriction."

Review of Resident 128's clinical record revealed an evaluation note on January 30, 2024, that stated, "Fluid restriction updated to 1800, weight changed to three times weekly and fax to HF (heart failure) clinic on Fridays."

Review of Resident 128's care plan on February 28, 2024, at 10:00 AM, failed to reveal that Resident 128 is to follow an 1800 ml fluid restriction and sodium restricted diet.

During an interview with the DON on February 28, 2024, at 1:22 PM, the surveyor requested information on whether Resident 128's fluid restriction should be 1200 ml or 1800 ml, and whether she was on a sodium restricted diet or not.

Email correspondence with the DON on February 29, 2024, at 10:40 AM, revealed that Resident 128 should have had the 1800 ml fluid restriction starting January 30, 2024, and she explained the facility process of following a low sodium diet.

During an interview with the DON on February 29, 2024, at 11:29 AM, she revealed Resident 128's care plan should have been updated to reflect the 1800 ml fluid restriction and sodium restriction.

28 Pa. Code 211.12(d)(5)Nursing services

Plan of Correction - To be completed: 04/30/2024

F0657

Resident R118 and Resident 128 have had their care plans reviewed and revised by the interdisciplinary team to ensure completion and accuracy.

All residents with a behavior care plan have had their care plans reviewed and revised for accuracy and addition of any triggers. All residents' diets and care plans have been reviewed for accuracy in diet and any fluid restrictions ordered by physician.

All nursing staff and dietician educated on care plan policy, including addition of triggers for residents with behaviors or other mental health concerns and accuracy of diet on care plan and meal tickets.

A QA tool has been developed to review 10% of care plans weekly to ensure addition of triggers with behavior care plans and accuracy of diet and any fluid restrictions. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Observations:

Based 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).

Findings include:

Review of Resident 128's clinical record revealed diagnoses that included congestive heart failure (CHF - excessive body/lung fluid caused by a weakened heart muscle), emphysema (a lung disease which results in shortness of breath due to destruction and dilatation of the alveoli), and acute pulmonary edema (a condition where fluid accumulates in lung tissues, causing shortness of breath, wheezing, and coughing up blood).

Review of Resident 128's physician orders on February 26, 2024, revealed an order for, "Diet (Regular) Diet Consistency (regular) Liquid Consistency (Thin) 1200 ml (milliliter- unit of measure) fluid restriction", with a start date of January 9, 2024.

Review of Resident 128's clinical record revealed a fax from Resident 128's heart failure clinic appointment on January 29, 2024, with the following recommendations: "2300 mg (milligram- unit of measure) sodium restriction, 1800 ml fluid restriction".

Review of Resident 128's clinical record revealed an evaluation note on January 30, 2024, that stated, "Fluid restriction updated to 1800, weight changed to three times weekly and fax to HF (heart failure) clinic on Fridays."

Observation of Resident 128 in her room, eating her lunch, on February 27, 2024, at 12:36 PM, revealed she had a 240 ml can of soda on her lunch tray and mug of water on her tray table.

Observation of Resident 128 in her room, eating her breakfast, on February 28, 2024, at 9:12 AM, revealed she had a 240 ml cup of coffee on her lunch tray and mug of water on her tray table.

Observation of Resident 128 in her room, eating her lunch, on February 28, 2024, at 12:31 PM, revealed she had a 240 ml can of soda on her lunch tray, a 360 ml Styrofoam cup of water, and mug of water on her tray table.

Review of copies of Resident 128's meal tickets from lunch on February 27, 2024; breakfast on February 28, 2024; and lunch on February 28, 2024, revealed she was on a 1200 ml fluid restriction, and should only have been provided 180 ml of fluids per meal from dietary. The meal tickets failed to reveal indication that Resident 128 was on a sodium restricted diet.

During an interview with the Director of Nursing (DON) on February 28, 2024, at 1:22 PM, the surveyor requested information on how Resident 128's fluid restriction was monitored, whether it should have been 1200 ml or 1800 ml, and whether she was on a sodium restricted diet or not.

Email correspondence with the DON on February 29, 2024, at 10:40 AM, revealed they do not break down fluid restrictions by shift, and that nurse aides and licensed practical nurses document how many milliliters of fluid the resident consumes throughout the day. The DON also revealed that Resident 128 should have been following an 1800 ml fluid restriction, starting January 30, 2024, and she explained the facility process for following a sodium restricted diet.

During a follow-up interview with the DON on February 29, 2024, at 11:29 AM, the surveyor revealed the concern with Resident 128's diet order not being updated to reflect the cardiology recommendations from January 29, 2024, observations of extra fluids provided by dietary at meals, and inadequate monitoring and implementation of the fluid restriction. The surveyor inquired how the nursing staff would know how many fluids to provide the resident each shift, and the DON replied, "they wouldn't". She further revealed that Resident 128's diet order and meal tickets should have been updated to reflect the 1800 ml fluid restriction and sodium restriction.

28 Pa. Code 211.12(d)(1)(3)(5)Nursing services

Plan of Correction - To be completed: 04/30/2024

F0692

Resident 128 has been assessed to ensure acceptable parameters have been maintained for her individual nutritional status; including body weight and electrolyte balance.

All residents have been assessed to ensure acceptable parameters have been maintained for their individual nutritional status; including body weight and electrolyte balance.

Nursing staff and dietician have been educated on the importance of maintaining each residents individual nutritional status; including body weight and electrolyte balance.

A QA tool has been developed to review 10% residents weekly to ensure acceptable parameters have been maintained for their individual nutritional status; including body weight and electrolyte balance. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based 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).

Findings include:

Review of facility policy, titled "Aerosol Therapy- Ordering, Administering, Documenting", last revised August 14, 2014, revealed, "It is the policy of this facility to order, administer, and document aerosol therapy per physician's order ...Clean mask/mouthpiece after each use with soap and water and wrap in a dry paper towel. Place on bedside table with nebulizer machine."

Review of Resident 65's clinical record revealed diagnoses that included chronic kidney disease (CKD - a condition characterized by a gradual loss of kidney function), type 2 diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and osteoporosis (a condition that weakens bones and increases the risk of fractures).

Observation of Resident 65 on February 26, 2024, at 10:51 AM, revealed she was up in her chair and her nebulizer mask was lying out on her bedside table.

During an interview with Resident 65 on February 26, 2024, at 10:52 AM, she revealed "That is for my breathing treatments. I have a cold."

Observation of Resident 65 on February 26, 2024, at 12:14 PM, revealed she was up in her chair and her nebulizer mask was lying out on her bedside table.

Review of Resident 65's clinical record revealed a physician order for "ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg(2.5 mg base)/3 mL (units of measure); Amount to Administer: 1 vial; inhalation Every 4 Hours PRN (as needed) ...After each use mask is to be cleaned with soap and water, wrapped in a paper towel, and stored in a colander."

Review of Resident 65's MAR (Medication Administration Record - documentation for treatments/medication administered or monitored), revealed Employee 6 (General Practice Nurse) administered the ipratropium-albuterol solution via nebulizer mask to Resident 65 on February 26, 2024, at 7:51 AM.

During an interview with the Director of Nursing on February 29, 2024, at 11:26 AM, she confirmed she would expect Resident 65's nebulizer mask to be stored per physician's order and facility policy.

28 Pa code 211.12(c)(d)(1)(2)(5) Nursing Services

Plan of Correction - To be completed: 04/30/2024

F0695

Resident 65's nebulizer mask was cleansed and stored according to physician's order and facility policy prior to the end of survey.

All residents receiving respiratory care have been assessed to ensure respiratory masks are cared for and stored per physician orders and facility policy.

All licensed nursing staff have been educated on the facility policy for care and storage of respiratory supplies.

A QA tool has been developed to review 10% residents receiving respiratory care weekly to ensure nebulizer mask was cleansed and stored according to physician's order and facility policy. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.

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