Rest Haven-York

In the surveyor’s words

From the most serious findings on record at Rest Haven-York, in the surveyor’s own words.

• Actual harm, isolatedF760Mar 9, 2023

  Based on facility policy review, clinical record review, hospital record review, facility incident report, and staff interviews, it was determined that the facility failed to ensure the prevention of a significant medication error, which caused actual harm by compromising the resident's clinical condition and resulted in the resident's transfer to the hospital for medication overdose following the medication error for one of 28 residents reviewed (Resident 359). Findings Include: Review of facility policy, titled Medication Administration- Preparation, Review, Safety, Administration last reviewed in May of 2022, revealed the following: Policy: It is the policy of this facility to prepare, review and safely administer medications. Measures identified in the policy included: 2. […]

• No harm, potential for more than minimal, patternF880Feb 5, 2026

  Based 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. Findings include: Review of facility policy, titled Care of Enteral Feeding Tube-Position, Cleansing, Observation, Notification, Storage, last reviewed December 16, 2025, line 9 stated, All feeding tube syringes should be stored in a clean area. […]

• No harm, potential for more than minimal, patternF583Jan 30, 2025

  Based 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). Findings include: Review of facility policy, titled Resident Rights, not dated, revealed it stated: 1. The Resident has the right to be informed of their rights and of all rules and regulations governing resident conduct and responsibilities both orally and in writing prior to or upon their admission or as appropriate during their stay. 2. […]

• No harm, potential for more than minimal, patternF812Jan 30, 2025

  Based 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. Findings include: Review of facility policy, titled Machine Warewashing, last revised December 1, 2007, read, in part, Purpose: To ensure that the dishwashing machine is operating in accordance with facility guidelines, department policy, manufacturers specifications and regulatory guidelines. Policy: The dish washing machine is serviced on a regular basis. Wash and rinse temperatures of the dish machine are monitored during each major use (3 times daily). Acceptable temperature ranges are: wash- minimum 150 degrees. […]

• No harm, potential for more than minimal, patternF880Jan 30, 2025

  Based 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: Review of facility policy with the subject of, PRECAUTIONS, CONTACT - Notification, Initiation, Communication, Prevention, Discontinuation, last revised March 30, 2021, revealed the policy's purpose stated, To provide a uniform process through which facility is notified of potentially harmful microorganisms, contact… […]