Health inspection·April 17, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior on five of six nursing units (Rosemont, A wing, B wing, C wing, Wedge [NAME] 1, and F wing west). Findings include: Observation in Resident 1's room on April 17, 2024, at 11:10 AM, revealed: there were crumbs on floor around the bed; a dried red liquid in a puddle in front of the closet and on the base board that encompassed an area of 18 inches by 6 inches; the over-bed table contained a dried liquid, and the wood was exposed due to the laminate missing; a section of the radiator cover was missing, and the inside of the unit was exposed; and there was a dried yellow liquid on the windowsill. Observation with Employee 1 (Licensed Practical Nurse) on April 17, 2024, at 11:15 AM, revealed Resident 1's room remained in the same condition as noted above. During an interview with Employee 1 on April 17, 2024, at 11:55 AM, it was revealed that the floor and windowsill needed cleaned, and a work order needed entered for the cover to the radiator. Observation in Resident 2's room on April 17, 2024, at 11:20 AM, revealed the over-bed table contained a dried white liquid and was missing the laminate with wood exposed in two areas; and the floor around the bed contained flake cereal, a used straw, and one empty packet of half and half. During an interview with Employee 2 (Licensed Practical Nurse) on April 17, 2024, at 11:20 AM, it was revealed that housekeeping tries to clean resident rooms daily and that, if an area needs to be cleaned, staff will let them know and they come to clean it. Observation in Resident 3's room on April 17, 2024, at 11:25 AM, revealed on the floor beside the bed, there were eight pieces of dried food. During an interview with Resident 4 on April 17, 2024, at 11:37 PM, it was revealed that her room isn't cleaned very often, maybe a few times a week. Observation in Resident 4's room on April 17, 2024, at 11:37 AM, revealed: the over-bed table stand contained dried white spots and red food; the floor contained white flecks and light brown crumbs between the bed and the bathroom door; the dresser and bookshelf were dusty; the bathroom floor was tacky when walked on; the tub was not in use, but contain brown specks and was dusty; and the bathroom smelled of stale urine. Page 1 of 6 395168 395168 04/17/2024 Yorkview Nursing and Rehabilitation 970 Colonial Avenue York, PA 17403

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation in Resident 4's room with Employee 4 (Registered Nurse) on April 17, 2024, at 11:45 AM, revealed the room remained as noted above. During an interview with Employee 4 on April 17, 2024 at 11:45 AM, it was revealed that housekeeping cleans the resident rooms only twice a week. It was noted that Resident 4's room needed to be cleaned, and that housekeeping would be notified. Observation in Resident 5's room on April 17, 2024, at 11:50 AM, revealed: the floor beside the bed contained a dried liquid; light brown crumbs were on the floor around the bed; and the over-bed table contained a dried on liquid, and a portion of the laminate was missing with wood exposed. During an interview with Employee 5 on April 17, 2024, at 11:50 AM, it was revealed that Resident 5 does eat in her room and can be messy. It was also noted that there is one housekeeper for the hall, and Employee 5 was not sure if resident rooms were cleaned daily. During an interview with the Nursing Home Administrator on April 17, 2024, at 1:21 PM, it was revealed that resident rooms should be cleaned daily and that, if an area needed to be cleaned, staff should notify housekeeping. It was also revealed the facility had two open housekeeping positions. 28 Pa. Code 201.18 (e)(1)(2.1)Management 395168 Page 2 of 6 395168 04/17/2024 Yorkview Nursing and Rehabilitation 970 Colonial Avenue York, PA 17403

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on a test tray and staff interviews, it was determined that the facility failed to provide food and beverage that are at a safe and appetizing temperature for one of one meal observed on the C Wing. Residents Affected - Some Findings include: A test tray was completed on April 17, 2024, at 12:50 PM, on C Wing. Test tray temperatures were taken by Employee 6 (Food Service Director 1) and revealed the following: Chicken Parmesan 103 degrees Fahrenheit (F), and the product was cold, hard, and dry Penne with marinara sauce 98 degrees F. Italian Blend Vegetables 103 degrees F. Mandarin Oranges 62, degrees F, product was served at room temperature Milk 47 degrees F, palatable During an interview with the Employee 6 on April 17, 2024, at 12:55 PM, it was revealed that the hot foods should've been warmer. During an interview with the Nursing Home Administrator on April 17, 2024, at 1:21 PM, the surveyor discussed concerns regarding the test tray pertaining to food temperature and food quality. No further information was provided. 28 Pa code 211.6 - Dietary Services 395168 Page 3 of 6 395168 04/17/2024 Yorkview Nursing and Rehabilitation 970 Colonial Avenue York, PA 17403

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations and staff interviews, it was determined that the facility failed to ensure a safe, functional, and sanitary environment for residents, staff, and the public in the dish room and boiler room. Residents Affected - Few Findings include: Observation in the dish room on April 17, 2024, at 9:26 AM, revealed there was a smell of rotting trash near the disposal. Observation on April 17, 2024, at 9:34 AM, revealed in the utility hallway outside of the kitchen, along the wall on the floor between the dish room and boiler room were dead bugs along the baseboard, in the corners, and at the base of the door frames. Observation on April 17, 2024, at 9:35 AM, with Employee 7 (Maintenance worker) in the boiler room, which is on the opposite side of the wall from the dish room, revealed the floor was noted to be damp and multiple live bugs were observed on the floor, on the wall, and coming from one of the two holes in the wall. One hole was noted to be 15 by 30 inches and was covered with a painted wood board, and the other hole was 24 by 30 inches and was covered with a painted board. There was a snow shovel leaning against the wall with a pile of silt/cement dust underneath it and, when moved, there were numerous bugs that ran from the pile. Observation inside the hole on the left revealed a pipe was visible and had water dripping from it. Observation of the floor in that area looked to be damp with a silt ring that spanned 4 feet. Observation on April 17, 2024, at 9:40 AM with the Nursing Home Administrator (NHA) in the boiler room, revealed the floor was noted to be wet; water was dripping down the wall at the hole on the left side, forming a puddle on the floor; and multiple live bugs were observed on the floor. It was observed that Employee 6 was spraying water on the walls and floor in the dish room. NHA asked Employee 7 to uncover both holes, clean the area, treat for pests, and to monitor for water and pest activity. Observation with Director of Nursing on April 17, 2024, at 10:50 AM, in the boiler room, revealed the hole in the wall on the left was uncovered and was 4 feet long by 2 1/2 feet at the widest point. Inside that hole, the pipe farthest left was moist and the cement wall in that area was wet, and the floor looked to be moist in an area of 5 feet. There were two pest traps inside the hole at the base of the wall. During an interview with NHA on April 17, 2024, at 1:10 PM, it was revealed that the facility's corporate office is aware of the concerns with the plumbing and pest concerns in the boiler room/dish room. 28 Pa. Code 201.18 (b)(3)(e)(2.1) Management 395168 Page 4 of 6 395168 04/17/2024 Yorkview Nursing and Rehabilitation 970 Colonial Avenue York, PA 17403

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interviews, and pests service report review, it was determined that the facility failed to maintain an effective pest control program so that the facility is free from pests in the kitchen and the boiler room. Residents Affected - Some Findings include: Observation in the dish room on April 17, 2024, at 9:26 AM, revealed there was a smell of rotting trash near the disposal. On the floor under the disposal was one plastic cup, a ball of used plastic wrap, one bowl lid, and one fork. Three cockroaches were observed on the pipe from the disposal into the wall, on the wall behind the disposal, and on the floor. Several gnats were observed flying around the dish room. Under the dish machine on the floor were two medicine cups, one plastic bowl, and several pieces of paper trash. It was noted that the dish room wasn't being utilized at that time. Observation on April 17, 2024, at 9:34 AM, in the utility hallway outside of the kitchen, along the wall on the floor between the dish room and boiler room, were dead bugs along the baseboard, in the corners, and at the base of the door frames. Observation on April 17, 2024, at 9:35 AM, with Employee 7 (Maintenance worker) in the boiler room, which is on the opposite side of the wall from the dish room, revealed the floor was noted to be damp and multiple live bugs were observed on the floor, on the wall, and coming from one of the two holes in the wall. Observation on April 17, 2024, at 9:40 AM, with the Nursing Home Administrator (NHA) in the boiler room, revealed the floor was noted to be wet and multiple live bugs were observed on the floor. It was observed that Employee 6 (Food Service Director) was spraying water on the walls and floor in the dish room. Review of pest control consultant reports revealed the following service dates, times, and findings: On March 6, 2024, service provided for 23 minutes at 12:19 PM in the kitchen and cafeteria, and no pest activity was noted. On March 12, 2024, service provided for 9 minutes at 11:08 AM in the kitchen and cafeteria, and no pest activity was noted. On March 27, 2024, service provided for 16 minutes at 11:01AM in the kitchen and cafeteria, and no pest activity was noted. On April 4, 2024, service was provided for 7 minutes at 10:19 AM in the kitchen, food prep areas, and offices, no activity was noted. On April 12, 2024, service was provided for 1 hour and 5 minutes at 7:18 PM in the kitchen, cafeteria to include the ceiling, and cockroaches and ants activity was observed. During an interview with NHA on April 17, 2024, at 1:10 PM, it was revealed that the facility does have routine pest control services and had received services to treat for cockroaches in the kitchen 395168 Page 5 of 6 395168 04/17/2024 Yorkview Nursing and Rehabilitation 970 Colonial Avenue York, PA 17403

F 0925 area previously; however, the concern with cockroaches has reappeared. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18 (b)(3)(e)(2.1)Management Residents Affected - Some 395168 Page 6 of 6