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 101 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 an Abbreviated Survey in response to complaints completed on May 9, 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 related to the health portion of the survey process.

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

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.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based 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."

Review of Resident 6's Medication Administration Record (MAR), during the month of March 2024, revealed staff did not administer the medication on March 12, 2024, March 22, 2024 and March 29, 2024.

The MAR revealed documentation of the reason the medication was not adminstered as "Drug/Item unavailable."

Review of Resident 6's MAR, during the month of April 2024, revealed staff did not administer the medication on April 5, 2024, with the reason documented as "Drug/Item unavailable."

An interview with the Nursing Home Administrator, on May 6, 2024, revealed the facility administrator had not been immediately informed of the medication being unavailable, however, once notified, management initiated an investigation, and a plan to address the missing medication.

After the administrator was made aware of the missing medication, the medication was re-ordered and the resident was administered the medication. Review of the April and May MAR revealed that Resident 6 was administered the medication per physcian order.

After the identification of the missing medication, the facility initiated a plan of correction. Review of the facility's corrective action information revealed all weight loss, injectable medication pens, will be kept in the Supervisor's office. The Supervisor will be notified and the Supervisor and Licensed Practical Nurse (LPN) will administer the medication together. The Supervisor will keep a log of dates the medication was adminstered and the Supervisor will initial the medication was administered and document the LPN administered the medication. The facility educated staff and performed audits to ensure compliance.

Prior to the abbreviated survey the facility failed to ensure Resident 6's medication was administered on four occasions, and inform facility administration and/or management of the medication not being available in order to administer to the resident. The facility immediately began an investigation when made aware, investigated the incident thoroughly, and initiated interventions in an effort to prevent a future incident.

During the abbreviated survey audits, staff education, and initiated procedures regarding the process of administering injectable medications were observed and reviewed. Staff interviews revealed that staff were educated, and knowledgeable regarding the implemented procedures.

28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services

Plan of Correction - To be completed: 05/16/2024

Past noncompliance: no plan of correction required.

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