PECKVILLE, PA - Federal inspectors documented multiple serious care violations at Aventura at Terrace View, including staff physically restraining a dementia resident with a "chokehold" and failing to properly investigate the incident.
The January 2025 inspection report revealed that facility staff grabbed a cognitively impaired resident around the neck while attempting to remove him from behind the nurses' station. The incident involved multiple staff members and escalated into verbal threats in the presence of other residents.
Physical Restraint Incident Raises Safety Concerns
The most serious violation occurred on December 27, 2024, when a nurse aide physically restrained Resident A16, who had severe cognitive impairment. According to witness statements in the inspection report, the aide held the resident's arms above his head and placed his hands around the resident's neck in what staff described as a "chokehold."
The incident began when Resident A16, who required one-on-one supervision due to aggressive behaviors, was sitting behind the nurses' station. Employee A3, a nurse aide, attempted to remove the resident from the area using physical force. An agency licensed practical nurse intervened, telling the aide that his treatment of the resident was unacceptable.
The situation escalated when the nurse aide began cursing and making verbal threats. According to witness statements, the aide told the intervening nurse, "You're lucky you're a woman, I will beat you're a and I will kill you and your husband!" These threats were made in the presence of other residents and the nursing supervisor.
Federal regulations require nursing homes to protect residents from abuse and ensure their safety. Physical restraint of residents, particularly those with dementia, can cause serious injury and psychological trauma. Proper dementia care involves redirecting behaviors through non-physical interventions and environmental modifications.
Investigation Failures Compound Safety Risks
The facility's response to the incident violated multiple federal requirements for investigating potential abuse. Despite having written policies requiring immediate suspension of staff pending investigation, Employee A3 left the building immediately without speaking to anyone. Administrative staff attempted to contact the aide by phone but received no response.
The facility failed to conduct a thorough investigation as required by their own policies. Three days after the physical restraint incident, staff discovered a bruise on Resident A16's right hip during his shower. However, inspectors found no evidence the facility investigated the injury's potential connection to the earlier incident.
Federal regulations require nursing homes to investigate all injuries of unknown origin to rule out abuse, neglect, or mistreatment. The facility's investigation policy mandated interviewing all relevant parties, including the staff member who discovered the injury, other staff with resident contact, and witnesses. None of these requirements were met.
The inadequate investigation prevented the facility from determining whether the bruise resulted from the physical restraint incident or other causes. This failure compromises the facility's ability to protect residents and ensure staff accountability.
Medication Safety Breach Endangers Resident
A separate incident revealed dangerous medication administration errors that could have seriously harmed a resident. On December 1, 2024, licensed practical nurse Employee B16 administered three wrong medications to Resident B4, including antipsychotic medication Seroquel, anti-anxiety medication Xanax, and anticonvulsant Gabapentin.
Resident B4 had no physician orders for any of these medications. The error occurred because the nurse failed to verify the resident's identity before administering medications, relying only on names and photos posted on doorways. The mistake was discovered only when the intended recipient alerted staff that he had not received his morning medications.
The wrong medications caused increased fatigue in Resident B4, who was already severely cognitively impaired. Mixing antipsychotic and anti-anxiety medications without proper monitoring can cause dangerous sedation, especially in elderly residents with existing cognitive issues.
Federal standards require nurses to verify the "five rights" of medication administration: right patient, right medication, right dose, right time, and right route. The facility's own policy required checking medication labels three times before administration. These basic safety protocols were not followed.
Care Planning Deficiencies Leave Residents Vulnerable
Inspectors identified multiple failures in developing comprehensive care plans that address residents' individual needs. For Resident A17, the facility discontinued pressure sore prevention interventions in June 2024 despite the resident being at high risk for skin breakdown due to decreased mobility and cognitive impairment.
Six months later, staff discovered a 2.5 cm pressure sore on the resident's left heel along with unexplained bruising. Pressure sores develop when blood flow to skin areas is restricted, typically from prolonged pressure on bony prominences. For immobile residents, regular repositioning, pressure-relieving devices, and specialized mattresses are essential preventive measures.
The facility failed to implement any documented preventive interventions between June and December 2024, despite the resident's continued risk factors. Pressure sores can become serious medical complications, potentially leading to infection, hospitalization, or even death if left untreated.
Restorative Care Programs Not Implemented
Two residents were prescribed restorative nursing programs to maintain their mobility after completing physical therapy, but staff failed to provide the ordered services. Resident B1's program required ambulation 25-50 feet using a rolling walker with staff assistance, while Resident B2 needed ambulation 50-75 feet with similar support.
Documentation showed the programs were marked as "not applicable" on multiple days rather than being performed as ordered. For Resident B1, the program was skipped 5 out of 7 ordered days. Resident B2 missed his program 6 out of 7 days in January 2025.
Restorative nursing programs are crucial for preventing functional decline in nursing home residents. When residents don't maintain mobility through regular exercise and movement, they can experience rapid loss of strength, balance, and independence. This decline often leads to increased fall risk and need for higher levels of care.
Dementia Care Inadequacies Put Vulnerable Resident at Risk
The facility's specialized dementia program failed to provide appropriate interventions for Resident A16's documented aggressive and wandering behaviors. Despite requiring one-on-one supervision due to his condition, staff did not consistently implement this critical safety measure.
The resident's care plan lacked specific interventions to address his dementia-related behaviors. Just two days after admission, Resident A16 escaped from the facility through an open hallway window, demonstrating the inadequacy of safety measures for residents with elopement risks.
Nursing notes documented multiple instances of verbal and physical aggression by the resident toward staff and other residents, as well as continuous wandering. However, the facility failed to modify his care plan or implement evidence-based dementia care interventions to manage these behaviors safely.
Proper dementia care requires understanding that behavioral symptoms often indicate unmet needs or environmental stressors.** Rather than using physical restraints, trained staff should identify triggers for agitation and implement person-centered approaches such as redirection, environmental modifications, and therapeutic activities.
The violations at Aventura at Terrace View demonstrate systemic failures in protecting vulnerable residents and ensuring basic safety standards. The combination of physical restraint, investigation failures, medication errors, and inadequate care planning created multiple risks for residents who depend on the facility for their daily care and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lackawanna Health and Rehab Center from 2025-01-23 including all violations, facility responses, and corrective action plans.
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