Health inspection·March 9, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with activities of daily living for one of 28 residents reviewed (Resident 96). Residents Affected - Few Findings include: Review of Resident 96's clinical record revealed diagnoses that included: arthritis (inflammation of one or more joints, causing pain and stiffness that can worsen with age), anxiety (a feeling of worry, nervousness, or unease), and macular degeneration (a degenerative condition affecting the central part of the retina, resulting in distortion or loss of central vision). Observations on March 6, 2023, at 12:15 PM and March 7, 2023, at 9:15 AM, revealed Resident 96's finger nails were long and had a brown substance underneath them. Interview with Resident 96 on March 6, 2023, at 12:15AM, revealed she receives a bed bath once a week. Review of Resident 96's care plan included a problem for decreased activity of daily living function secondary to polyneuropathy, hypertensive chronic kidney disease, congestive heart failure (CHF), and gout, with a start date of December 30, 2022. Approaches included: Resident will wash face, hands, and perform upper body washing and dressing with set-up of items, verbal cues, and supervision from staff, with a start date of December 30, 2022; and Resident requires staff to provide verbal and tactile cues as needed, with a start date of December 30, 2022. Review of Resident 96's admission MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated December 15, 2022, Resident 96 was documented as requiring extensive assistance of one for personal hygiene, and physical help with assistance of one with bathing. Review of Point of care documentation for showers revealed Resident 96 was provided a shower weekly and was provided physical assistance. Interview with Nursing Home Administrator on March 8, 2023, at 10:46 AM, revealed the Resident 96's nails need to be cleaned. Interview with the Director of Nursing on March 9, 2023, at 10:30 AM, it was revealed that Resident 96 usually doesn't refuse care and would expect her nails to be clean. 28 Pa code 211.12.(a)(c)(1)(3)(4)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 2 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven-York 1050 South George Street York, PA 17403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, facility policy review, and record review, it was determined that the facility failed to ensure that a resident with a pressure ulcer received care consistent with professional standards of practice for one of two Residents observed for wound care (Resident 102). Residents Affected - Few Findings include: A review of the facility policy, titled Treatment Application-Preparation, Application, Documentation, last reviewed June 3, 2022, states, after removing the soiled dressing, discard, then remove gloves and wash hands or use alcohol sanitizer. A review of the clinical record for Resident 102 on March 9, 2023, revealed clinical diagnoses that included hypertension (high/elevated blood pressure) and stage IV pressure ulcer (ulcer involving loss of skin layers, exposing muscle and bone) of the right gluteus/buttock region. A review of Resident 102's physician orders dated March 2023, included an order for wound care to the right gluteus (buttock) to be completed daily and as needed. The wound care order specifies to cleanse area on right gluteus with normal saline solution, pack with silver alginate, and cover with a border foam dressing. Observation of wound care on Resident 102 on March 9, 2023, beginning at 9:15 AM, revealed Employee 4 (Licensed Practical Nurse) failed to perform hand hygiene between glove changes that included: after bowel continence care; after removing the soiled dressing; before application of treatment; and before application of the clean dressing. During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on March 9, 2023, at 11:36 AM, the DON and NHA stated they would expect hand hygiene between glove changes per policy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 3 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven-York 1050 South George Street York, PA 17403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on clinical record review and staff interview, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of two resident records reviewed (Resident 12). Findings include: Review of Resident 12's clinical record revealed diagnoses that included: unspecified protein-calorie malnutrition (malnutrition caused when not enough proteins and calories are consumed) and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). Review of Resident 12's physician orders revealed the following orders: 1) Diet: Regular Diet Consistency (regular with tough, roasted meats ground and puree shelled vegetables) Liquid Consistency Thin, dated October 27, 2022; and 2) Isosource 1.5 (a nutritionally complete, high calorie tube feeding formula designed for individuals with increased calorie needs) give 360 milliliters via peg (percutaneous endoscopic gastrostomy-a flexible feeding tube placed through the abdominal wall and into the stomach which allows nutrition to be placed directly into the stomach) following lunch and dinner if po (by mouth/ oral) intake is <51%, dated December 28, 2022. Review of Resident 12's Medication Administration Records from December 28, 2022, through March 6, 2023, for the administration of the ordered Isosource revealed the following documentation: December 2022: 30th: 50% of lunch meal consumed and fluid intake indicated 240 milliliters. January 2023: 9th: 6:00 PM 25% of supper meal consumed and fluid intake indicated 240 milliliters; 10th: 6:00 PM 25% of supper meal consumed and fluid intake indicated 240 milliliters; 12th: 1:00 PM 10% of lunch meal consumed and fluid intake indicated 120 milliliters; 13th: 1:00 PM 20% of lunch meal consumed and fluid intake indicated 240 milliliters; 17th: 1:00 PM 50% of lunch meal consumed and fluid intake indicated 240 milliliters; 19th: 6:00 PM 25% of supper meal consumed and fluid intake indicated 120 milliliters; 20th: 1:00 PM 50% of lunch meal consumed and fluid intake indicated 240 milliliters; and 6:00 PM 50% of supper meal consumed and fluid intake indicated 240 milliliters; 22nd: 6:00 PM 0% of supper meal consumed and fluid intake indicated 240 milliliters; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 4 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven-York 1050 South George Street York, PA 17403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 23rd: 1:00 PM 0% of lunch meal consumed and fluid intake indicated 180 milliliters; Level of Harm - Minimal harm or potential for actual harm 24th: 1:00 PM 50% of lunch meal consumed and fluid intake indicated 240 milliliters; 25th: 1:00 PM 50% of lunch meal consumed and fluid intake indicated 240 milliliters; and the Residents Affected - Some 26th: 1:00 PM 50% of lunch meal consumed and fluid intake indicated 240 milliliters. February 2023: 1st: 6:00 PM 50% of supper meal consumed and fluid intake indicated 0 milliliters; 3rd: 1:00 PM 10% of lunch meal consumed and fluid intake indicated 120 milliliters and 6:00 PM 50% of supper meal consumed and fluid intake indicated 0 milliliters; 9th: 6:00 PM 50% of supper meal consumed and fluid intake indicated 0 milliliters; 13th: 6:00 PM 50% of supper meal consumed and fluid intake indicated 0 milliliters; 16th: 6:00 PM 50% of supper meal consumed and fluid intake indicated 0 milliliters; 20th: 6:00 PM 50% of supper meal consumed and fluid intake indicated 0 milliliters; and 22nd: 6:00 PM 50% of supper meal consumed and fluid intake indicated 0 milliliters. March 2023: 1st: 6:00 PM 50% of supper meal consumed and fluid intake indicated 0 milliliters; and 2nd: 6:00 PM 50% of supper meal consumed and fluid intake indicated 0 milliliters. Review of clinical record progress notes revealed the following dietician notes: 1) A note dated January 18, 2023, at 11:31 AM, indicated that Resident continued to have soreness from a dental procedure on January 11, 2023. The note also indicated that Resident 12 was agreeable to some applesauce and some jello at this time as well as a butter pecan ensure. Noted meal intakes have been more down since dental work. She is getting bolus of tube feeding after lunch and supper if she does not eat at least 50%. Resident did note to writer that she has been getting them more often at this time. Resident refused weight on January 13, 2023. Last weight was obtained on January 6, 2023, and was 171.87 pounds- stable. 2) A note dated February 21, 2023, at 10:57 AM, indicate that Resident 12's current body weight was 163.4 pounds, down 5 pounds (3%) in 30 days and 6 pounds (3.6%) in four months. The note further indicated that Resident 12 had remained on regular diet with tough, roasted meats ground and puree shell vegetables; has peg tube and receives bolus of Isosource 1.5 360 milliliters if leaves more than 50% of lunch and or dinner; had remained on oral supplements, which Resident takes fairly well; had remained on weekly weights and will follow-up at the end of the month to determine if they should continue. The note further revealed that the Resident 12 did receive the bolus feedings nine times this month. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 5 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven-York 1050 South George Street York, PA 17403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3) A note dated March 2, 2023, at 5:15 AM, indicated that Resident 12's weight on March 1, 2023, was stable at 167.2 pounds and that their oral intake overall remained improved from admission. Resident 12 to continue with tube feeding bolus after lunch and dinner if po intake is not 50% or more. Dietician noted that a recommendation would be made to discontinue weekly weights and change to monthly weights. Email communication received from the Director of Nursing (DON) on March 8, 2023, at 1:14 PM, indicated that there were occasions when the nurse should have given enteral feeding and did not for intake of 50%. The DON further indicated that these instances all involved the same nurse which she described as very thorough. The DON indicated that the nurse probably thought it was <50% and that 51% was a weird percentage. The DON stated, so yes, technically she messed up by 1%. As far as the fluids, staff were marking the amount of fluids Resident 12 had with the meal on some occasions instead of marking the amount of Isosource administered. During an interview on March 9, 2023, at 10:16 AM, with the Nursing Home Administrator and the DON, the DON indicated that she would expect nurses to follow the physician's orders and that the order should not have been entered the way it was because it was confusing. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 6 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven-York 1050 South George Street York, PA 17403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to ensure one of 28 residents reviewed were free of unnecessary medications (Resident 51). Residents Affected - Some Findings include: Review of Resident 51's clinical record documented diagnoses that included: vascular dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), and psychotic disorder with delusions (a thought or mood disorder; a belief or altered reality that is persistently held despite evidence or agreement to the contrary). Review of Resident 51's March 2023 physician orders included: Humalog (medication used to treat diabetes mellitus, fast acting insulin) 10 units before meals (7:30AM, 11:30AM, 4:00PM), hold blood sugar (BS - the level of glucose in the blood) less than 150 milligrams/deciliter (mg/dl - unit of measure), with a start date of November 7, 2022; Levemir (medication used to treat diabetes mellitus, long acting insulin) 46 units once a day (between 7:00 AM and 9:00 AM), hold BS less than 90 mg/dl, with a start date of October 3, 2022; Levemir 46 units once a day (between 6:00 PM and 10:00 PM), hold BS less than 110 mg/dl, with a start date of October 3, 2022; and Trulicity 0.5 ml (medication used to treat diabetes mellitus) once a day, once a week on Friday, with a start date of March 10, 2023. Review of Resident 51's February 2023 and March 2023 MAR documented that Humalog was administered when blood sugars were below 150 mg/dl: February 25, 2023, at 4:00 PM with BS 144; February 26, 2023, at 4:00 PM with BS 146; March 3, 2023, at 4:00 PM with BS 147; March 4, 2023, at 7:30 AM with BS 132 and at 11:30 AM with BS 101; and March 5, 2023, at 7:30 AM with BS 114 and at 11:30 AM with BS 149. The facility failed to follow physician orders regarding holding Humalog when BS were below 150 mg/dl, and administered the medication without adequate indications for its use. Interview with Director of Nursing on March 9, 2023, at 10:30 AM, reveled that the aforementioned medication was administered outside of parameters and physician orders weren't followed. It was also revealed the expectation is that physician orders would be followed. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 7 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven-York 1050 South George Street York, PA 17403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm 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). Residents Affected - Few 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. Read EMAR and medication label 3 times before administering medication. Review of Resident 359's clinical record revealed diagnoses that included Alzheimer's Disease, anxiety disorder, and dementia with behavioral disturbances. Review of Resident 359's physician's orders revealed an order for lorazepam gel (a topical medication that is applied to the skin to reduce anxiety) 5 milligrams/milliliter give 0.5 milligrams topical every six hours as needed (prn), for combativeness, restlessness, and inability to relax, dated February 18, 2023. Review of Resident 359's Medication Administration Records revealed that a prn (given as needed) dose of lorazepam (ativan) gel was administered on February 24, 2023, at 6:34 PM, for restlessness and anxiety. It further indicated that the medication was effective. Review of Resident 359's clinical record progress notes revealed a nurse's note dated February 24, 2023, at 12:57 PM, that indicated that Resident 359 was pleasant and cooperative with care; took medications crushed without difficulty; vital signs were stable; complained of abdominal pain/discomfort; and had normal bowel sounds. The note further indicated that the Registered Nurse was aware, and that nursing would continue to monitor. Further review of the progress notes revealed that there was no nurse's note corresponding to the ativan administration on February 24, 2023, at 6:34 PM. The next entry in the nurse's notes was dated for February 24, 2023, at 8:49 PM, which indicated, Writer found resident in unresponsive state at 20:05 [8:05 PM]. Resident was sitting at nursing station in wheelchair. Writer noticed resident had head hyperextended and pupils were not reactive to light. Resident did not respond to staff for about 15-20 minutes. Resident was trying to cough, but was unable to clear throat. Abdominal thrust attempted, unsuccessful, gag reflex was absent. Vital Signs: Temperature 98 degrees F, Pulse/ Heart Rate 54, Respirations 18, Blood Pressure 170/71, and Oxygen Saturation was 97% on Room Air. Initial Blood Pressure was 188/88 then came down to 170/71. Resident had no strength or grip to LUE [Left Upper Extremity] or RLE [Right Lower Extremity]. The note further indicated that Resident 359's Power of Attorney was contacted and updated on Resident's status and that the Power of Attorney wanted the Resident sent to the hospital to be evaluated. The physician was then notified of Resident's status and an order was obtained to send Resident 359 to the hospital due to unresponsive episode, loss of consciousness, high blood pressure, and possible aspiration (accidental breathing in of fluid or food into the lungs). A nurse's note dated February 24, 2023, at 11:42 PM, indicated that the emergency department at the hospital was called and was given information on the medications administered earlier in the evening. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 8 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven-York 1050 South George Street York, PA 17403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Review of Resident 359's Hospital History and Physical dated February 25, 2023, at 7:01 AM, indicated the following: Level of Harm - Actual harm 1. Principal problem: altered mental status, unspecified altered mental status type; Residents Affected - Few 2. Active problems: small bowel obstruction; incarcerated hernia; accidental overdose; dementia; and somnolence; 3. At some point was given topical ativan. Apparently, [Resident 359] were given a very large dose by mistake; 4. Was given 5mg on skin instead of half a milligram. This was for some agitation and quite possibly the agitation was probably from abdominal pain; 5. The patient [Resident 359] is protecting their airway, but is very sedated and obviously cannot be discharged at this time; 6. Consideration was given to administering a medication to reverse the sedation, but the physician determined for the sake of bringing [patient] out of this slowly, it is probably reasonable to let it fade off; 7. At this point, we think [patient's] mental status is most likely due to ativan induced somnolence. Patient still able to protect [their] airway; and 8. Suspect [their] mental status is most likely due to the ativan overdose. Plan for hospitalization for monitoring of his mental status. Review of the facility's event/incident report indicated that Resident 359 was given prn (as needed) ativan at 6:34 PM for agitation. The agency (supplemental nursing staff provided by a contracted company) nurse, [Employee 2] gave 1 milliliter of ativan which equaled 5 milligrams rather than the ordered dose of 0.1 milliliter which equaled 0.5 milligrams. Resident was found unresponsive at 8:05 PM, assessed by Registered Nurse immediately, physician notified, and Resident was sent to the ER for evaluation. Medication error was not found until the change of shift when the administering agency nurse was counting controlled medications with the next shift. The report also indicated that the agency that provided the nurse was notified and that this nurse would not return to the facility. During an interview with NHA and Director of Nursing (DON) on March 9, 2023, at approximately 10:36 AM, the DON indicated that she would have expected the agency nurse to properly administer the medication as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.9(a)(1) Pharmacy Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 9 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven-York 1050 South George Street York, PA 17403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, facility policy review, and staff interview, it was determined that the facility failed to store medication in locked compartments under proper temperature controls for one of three areas observed (Lily medication storage refrigerator). Findings Include: Review of facility provided policy, titled Medications- Controlled Drugs- Receiving, Tracking, Secure Storage, Destruction, Documentations, revised September 17, 2013, revealed, the medication is locked in the narcotic box in the medication cart. The facility failed to provide any further instruction for medications that require refrigeration. Observation of the Lily medication storage refrigerator on March 6, 2023, at 10:00 AM, revealed a pad lock hanging on a latch on the outside of the refrigerator, unsecured. Upon opening the refrigerator, revealed two syringes containing 1 ml of 5 mg/ml Lorazepam (schedule IV controlled substance) and 13 syringes containing 0.5 ml of 2 mg/ml Lorazepam. Interview with Director of Nursing on March 6, 2023, at 1:35 PM, revealed she would expect facility employees to keep the Lorazepam locked in the medication refrigerator. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1)(i) Pharmacy services 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 10 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven-York 1050 South George Street York, PA 17403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of manufacture product packaging, review of facility policy, and interview, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety for one of three food pantries observed (Glow food pantry). Findings include: Review of facility policy, titled Food from Outside Sources, reviewed August 23, 2018, revealed, 5. Food will be labeled and dated with the following: name of item, date received, and resident name. 6. Refrigerated items are kept no longer than 3 days from the date they are received. 7. Unopened items that have a manufacturer's expiration date i.e. yogurt, pudding or soda, etc. may be kept in pantry refrigerators until the specified manufacturer's expiration date. These items must also be labeled with resident name and date received. Review of [NAME] Readycare thickened lemon-flavored water product packaging on March 6, 2023, at 10:11 AM, revealed that this product should be disposed of seven days after opening. Observation of the refrigerator in the Glow food pantry on March 6, 2023, at 10:11 AM, revealed one container of [NAME] Readycare, thickened lemon-flavored water, mildly thick, without open date. Further observation revealed the following: one open container of whipped cream cheese spread, with no resident name or open date, and one sealed container of whipped cream cheese spread, with no resident name; a cob salad, not labeled with the date received or resident name; one half gallon container of chocolate milk, with no open date and a sell by date of March 5, 2023; one 16-ounce container of coffee creamer, without a resident name or date received or opened; one Devour brand buffalo chicken with mac and cheese frozen meal, with no resident name or date removed from freezer; and one chicken pot pie frozen meal, without resident name or date received or removed from refrigeration. During an interview with the Employee 6 (Food Service Director) on March 6, 2023, at 10:11 AM, revealed that she would expect the food in the refrigerator to be labeled in accordance with facility policy and disposed of after the time specified. Interview with the Nursing Home Administrator on March 9, 2021, at 12:00 PM, revealed the expectation is that the facility policy will be followed. 28 Pa code 211.6(b)(d) - Dietary Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 11 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven-York 1050 South George Street York, PA 17403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility records, and resident and staff interviews, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents and staff for six out of 85 resident rooms observed (Residents 23, 24, 25, 35, 51, and 84). Findings include: Observation of Resident 23's room revealed the following on March 6, 2023, at 12:08 PM: the bed control soiled with food debris. Observation of Resident 23's room on March 7, 2023, at 10:17 AM, revealed the bed control soiled with the same food debris as March 6, 2023. Observation of Resident 23's room on March 8, 2023, at 11:26 AM, revealed the bed control soiled with the same food debris. Observation of the soiled bed control was shown to Employee 3 (Licensed Practical Nurse) on March 8, 2023, at 11:26 AM, and Employee 3 agreed that the bed control had food debris and should be cleaned when soiled. During an interview with Resident 23 on March 9, 2023, at 11:00 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) agreed Resident 23's bed control should have been cleaned daily as needed. Observations of Resident 24's room revealed the following: on March 6, 2023, at 10:36 AM, the floor at the foot of the bed and under the bed was noted to have dust and debris, and the fall mat located on the right side of the Resident's bed was noted to have dust and dried tan colored substance spilled on top; on March 7, 2023, at 10:19 AM, the floor and fall mats remained soiled as observed on March 6, 2023, at 10:23 AM; and on March 8, 2023, at 12:49 PM, the same observations were noted. Observations for Resident 24 were shown to the NHA and DON on March 8, 2023, at 12:49 PM. The NHA indicated that they have been short staffed in housekeeping, they have just hired four staff, and that the observed concerns would be addressed. Observation during initial tour on March 6, 2023, at 9:30 AM, revealed Resident 25 with a soiled wheelchair. The armrests, cushion, and chrome sections were soiled with food debris. The Resident was asked if her wheelchair is cleaned regularly and Resident 25 responded No. During an interview with the DON on March 7, 2023, she was asked if the facility has a wheelchair cleaning policy, and she stated that wheelchairs are cleaned on night shift when the staff have time. Observation in Resident 35's room on March 6, 2023, at 12:25 PM, revealed the black plastic fan on the bed-side table contained a grey fuzzy substance on the front and back of the fan, and the front panel on the baseboard heater was bent back, exposing the grates inside. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 12 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven-York 1050 South George Street York, PA 17403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation in Resident 35's room with the DON on March 6, 2023, at 2:30 PM, showing DON the front panel on the baseboard heater was bent back exposing the grates inside. The DON stated she would follow-up with maintenance. Observation in Resident 35's room on March 8, 2023, at 9:30 AM, the black plastic fan on the bed-side table contained a grey fuzzy substance on the front and back of the fan, and front panel on the baseboard heater was bent back exposing the grates inside. Review of the work order for Resident 35's baseboard heater documented the date submitted was March 6, 2023. Interview with the DON on March 9, 2023, at 10:30 AM, revealed that a work order regarding Resident 35's baseboard heater should've been submitted prior to March 6th, 2023. It was also revealed that the facility has ordered a [NAME] to complete the repair and is awaiting delivery of the needed part. Email communication with the NHA on March 9, 2023, at 2:30 PM, revealed that a work order could be submitted by any department, and that the work order for Resident 35's radiator should've been submitted prior to March 6, 2023. Observation in Resident 51's room on March 6, 2023, at 12:38 PM, the privacy curtain in the room was drawn between the two beds, and it had dried light brown liquid at the end of the curtain in the area staff would need to open and close the curtain. Observation in Resident 51's room on March 7, 2023, at 9:40 AM, the privacy curtain in the room was drawn between the two beds, and it had dried light brown liquid at the end of the curtain in the area staff would need to open and close the curtain. Interview on March 8, 2023, at 10:30 AM, the NHA was informed of the concern regarding the privacy curtain in Resident 51's room. The NHA stated that she would look into the concern. Interview with the NHA on March 8, 2023, at 10:50 AM revealed that the privacy curtain did need to be changed. Observation in Resident 84's room on March 6, 2023, at 11:29 AM, the privacy curtain in the room was drawn between the two beds and it had dried, light brown liquid and dried red spots at the end of the curtain in the area staff would need to open and close the curtain. Observation in Resident 84's room on March 7, 2023, at 9:30 AM, the privacy curtain in the room was drawn between the two beds and it had dried, light brown liquid and dried red spots at the end of the curtain in the area staff would need to open and close the curtain. Interview on March 8, 2023, at 10:30 AM the NHA was informed of the concern regarding the privacy curtain in Resident 84's room. The NHA stated that she would look into the concern. Interview with the NHA on March 8, 2023, at 10:50 AM, revealed that the privacy curtain did need to be changed. Pa code 205.61(b) Heating requirements for existing construction (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 13 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven-York 1050 South George Street York, PA 17403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Pa code 207.2 (a) Administrator's Responsibility Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 14 of 14