Gardens at York Terrace, The

In the surveyor’s words

From the most serious findings on record at Gardens at York Terrace, The, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 5, 2024

  Based on observation and staff interview it was determined that the facility failed to store food under sanitary conditions in the kitchen. Findings include: Observation of the kitchen during a tour on January 3, 2024, at 10:00 a.m. revealed an opened container of thickener that was not labeled or dated, an opened bag of spaghetti that was undated, and a grilled cheese sandwich on the bottom shelf in the dry storage area. There was trash and food debris on the floor in the freezer. In an interview on January 3, 2024, at 10:20 a.m., Employee 1 confirmed that the opened items should have been dated and that the grilled cheese sandwich should have been discarded. 28 Pa. Code 201.18(b)(3) Management.

• No harm, potential for more than minimal, isolatedF692Dec 5, 2024

  Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to adequately monitor and assess weight loss for one of three sampled residents at risk for weight loss. (Resident 5) Findings include: Review of the facility policy entitled, Weight Assessment and Intervention, last reviewed January 18, 2024, revealed that any weight change of five pounds (lbs.) or more from the last weight assessment would be retaken for confirmation. If the weight was verified, nursing staff would notify the dietitian. The dietitian or Certified Dietary Manager would review the individual weight records and make recommendations as appropriate. Clinical record review revealed that Resident 5 had diagnoses that included osteoporosis and dementia. […]

• No harm, potential for more than minimal, isolatedF684Jan 5, 2024

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 16 sampled residents. (Resident 10) Findings include: Clinical record review revealed that Resident 10 had diagnoses that included congestive heart failure, diabetes mellitus, dementia, and peripheral vascular disease. On November 20, 2023, the physician ordered that staff administer a medication (Lasix) if the resident gained more than three pounds in one day to treat the resident's swelling in her legs. Review of Resident 10's weights revealed that on December 7, 2023, Resident 10 weighed 134 pounds (lbs). On December 8, 2023, the resident weighed 145 lbs, indicating a nine pound weight gain. […]

• No harm, potential for more than minimal, isolatedF690Jan 20, 2023

  Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that proper catheter care was provided for one of two sampled residents who used an indwelling urinary catheter (a flexible tube that a clinician passes through the urethra and into the bladder to drain urine). (Resident 8) Findings include: Clinical record review revealed that Resident 8 had a physician's order dated January 7, 2023, for the use of an indwelling catheter for the diagnosis of urinary retention. Observations on January 19, 2023, from 12:15 p.m. through 1:33 p.m., revealed the resident was seated in a wheelchair with the Foley bag and tubing directly on the floor. […]

• No harm, potential for more than minimal, isolatedF558Feb 24, 2022

  Based on clinical record review and observation, it was determined that the facility failed to ensure that a call bell was accessible for one of 14 sampled residents. (Resident 6) Findings include: Clinical record review revealed that Resident 6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE], revealed the resident required extensive assistance from staff for activities of daily living, including bed mobility, personal hygeine, and toileting. Review of the current care plan revealed Resident 6 was at risk for falls and that he was to be encouraged to use the call bell which was to be kept within reach. […]