Lackawanna Health And Rehab Center

F-F679

28 Pa Code 211.12 (d)(3)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 25 395414 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395414 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aventura at Terrace View 260 Terrace Drive Peckville, PA 18452

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 - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26142 potential for actual harm Based on review of resident clinical records and select facility reports and staff interview it was revealed that Residents Affected - Few the facility failed to ensure that two of 26 residents reviewed were free of significant medication errors (Residents A3 and A1).

Findings include:

A review of the clinical record revealed that Resident A3 was admitted to the facility on [DATE REDACTED], with diagnoses of cerebral infarction (stroke), dementia and diabetes. Resident A3 resided on the D unit (locked dementia unit).

Resident A3 had a current physicians order at the time of the survey. initiated April 30, 2024, for Lantus Solostar solution (long acting insulin in a pen injector delivery system) 100 U/ml, inject 6 units subcutaneously twice a day.

A review of a facility medication incident dated July 8, 2024 at 7:50 AM revealed on that a medication incident occurred on that date and time, and actions taken in response, were to check the resident's blood glucose (fingersticks). The report included no further details or description of the incident or identification of

the cause.

An employee witness statement dated July 8, 2024, (no time indicated) from Employee 2, a licensed practical nurse employed by a staffing agency, revealed that During morning med pass, around 8 AM I had Lantus (insulin) prepared for 2 residents on my med cart. One was a pen containing 6 units for {Resident A3} and the other, a syringe containing 20 units of Lantus for {Resident A4}. I mistakenly grabbed the syringe (containing 20 units of Lantus insulin) and brought it to Resident A3's room. I administered 12 units of the 20 units into the right lower abdomen before I realized it was the wrong dose.

A review of Resident A3's blood glucose levels after the medication error on July 8, 2024 revealed:

- 8:03 A.M. 106 mg/dl

- 12:08 A.M. 97 mg/dl

- 3:52 P.M. 78 mg/dl

- 4:22 P.M. 83 mg/dl

- 7:09 P.M. 97 mg/dl

- 9:52 P.M. 118 mg/dl

- 10:39 P.M. 140 mg/dl

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 25 395414 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395414 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aventura at Terrace View 260 Terrace Drive Peckville, PA 18452

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 Employee 2, an agency LPN drew up insulin for Resident A3 and A4 at the same time and took both insulin pens with her into Resident A3's room. Employee 2 picked up the wrong insulin pen (intended for Resident Level of Harm - Minimal harm or 4) and administered the wrong dose of insulin to Resident 3. Resident 3 received 12 units of insulin instead potential for actual harm of the six prescribed. There was no evidence that Employee 2 attempted to identify Resident 3 to assure accurate medication administration. Residents Affected - Few

A review of the clinical record revealed that Resident A1 was admitted to the facility on [DATE REDACTED], with diagnoses to include Alzheimers disease, diabetes and anxiety. Resident A1 resided on the D unit, locked dementia unit.

A review of a facility medication incident report dated July 10, 2024, at 10 AM revealed that Employee 1, an agency LPN, administered Resident A1 the incorrect medications. The was no documentation of the medications that were administered in error.

A review of a witness statement dated July 10, 2024, Employee 1 (agency LPN) stated I was passing out medications and I gave medicine to the wrong resident.

Surveyor investigation on July 30, 2024, revealed that Employee 1, agency LPN, erroneously adminstered

the medications prescribed for Resident A2 to Resident A1 on July 10, 2024 at approximately 9 AM. These medications were Eliquis ( a blood thinning medication) 5 mg, Amlodipine ( a calcium channel blocker, used to treat high blood pressure, Donepezil HCL ( a medication to treat Alzheimers disease) 10 mg and Depakote delayed release oral tab ( an antiseizure medication, enteric coated tablet has a coating the prevents dissolution in the stomach and releases in the stomach), 125 mg tablet.

Employee 1 crushed all the above medications and placed them in chocolate milk, which was given to Resident A1. Resident A1 drank the chocolate milk. The facility's med report did not identify how much of the milk the resident had consumed.

An observation on July 31, 2024 of Resident A2' pharmacy card, containing the prescribed Depakote 10 mg delayed released medication, revealed a sticker placed by the pharmacy, indicating to take the medication whole, do not crush.

Employee 1, agency LPN, crushed a delayed release enteric coated medication and administered the incorrect medications to Resident A1.

During an interview July 31, 2024 at 1 P.M., the assistant Director of Nursing confirmed that Employees 1 and 2 administered the incorrect medications to the residents, resulting in significant medication errors.

28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 25 395414 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395414 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aventura at Terrace View 260 Terrace Drive Peckville, PA 18452

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 0773 Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26142 Residents Affected - Few Based on a review of select facility policy and clinical records and staff interviews it was determined that the facility failed to promptly notify the physician of abnormal lab results, and timely notify the physician when orders to obtain clinically necessary lab studies were not followed, for one resident out of 26 sampled (Resident A5), which compromised the resident's clinical condition and delayed treatment.

Findings included:

A review of the clinical record revealed that Resident A5 was admitted to the facility on [DATE REDACTED], and had diagnoses to include dementia, basal cell carcinoma of the right ear, heart disease and chronic kidney disease.

The resident's responsible party was a court appointed legal guardian, a local county non-profit organization.

The resident's quarterly minimum data set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated [DATE REDACTED], revealed that the resident was severely cognitively impaired with a BIMS ( Brief Interview for Mental Status - a tool to screen and identify the cognitive condition of long-term care residents of 3 (a score of 1 to 7 indicates severe impairment) and the resident required maximum assistance with activities of daily living.

The resident's care plan, initiated [DATE REDACTED], revealed that the resident was non-compliant with care. His behaviors included refusing showers, bed baths, refusing care, refusing MD appointments, refusing medications, refusing meals, refusing to be seen by wound care MD. Planned interventions included to discuss with family (resident has a son) when appropriate, with resident's permission non-compliant behaviors; encourage resident to verbalize, if able, the reason for non-compliant behavior. Notify MD of recurrent non-compliance and possible alternatives to treatments, meds, recommendations etc; Notify Social Worker of non compliant behavior. Resident will be informed of risk vs. benefits of non-compliance. Resident will be offered appropriate alternatives when possible.

The resident's care plan was updated [DATE REDACTED], to include a cognitive Impairment/Dementia diagnosis, with interventions to include allowing the resident to ample time to absorb & respond to information. Allow and encourage the resident to make needs known, decisions and choices as able; establish and maintain eye contact; introduce self and role during interaction; needs will be anticipated and met by staff daily prn. Observe for changes in cognition. Orient to person, place and time prn. Provide cues and reminders prn. Provide reassurance during periods of confusion. Provide simple step by step directions prn. Speak slowly & clearly & repeat if needed.

A review of a nurses note dated [DATE REDACTED] at 11:49 AM. revealed that the resident's both lower legs had increased edema (swelling). A call was placed to the resident's physician. At 12:32 PM the physician returned the call and ordered to obtain a BMP (basic metabolic profile blood work to include electrolytes, including potassium).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 25 395414 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395414 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aventura at Terrace View 260 Terrace Drive Peckville, PA 18452

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 0773 Interview with the resident's attending physician on [DATE REDACTED] at 9:30 AM revealed after receiving information from the facility she asked for blood work to be completed a BMP (basic metabolic panel) due to a fear that Level of Harm - Actual harm he would have a blood clot due to his history of taking blood thinners.

Residents Affected - Few A review of blood work results dated [DATE REDACTED] revealed that the resident's potassium level was elevated at 5.6 mmol/L (normal level 3XXX,d+[DATE REDACTED].1)

This level was flagged on the lab report as high.

In response to receipt of these results, the physician gave an order to the facility on [DATE REDACTED], to obtain another potassium level.

A review of a nurses note dated [DATE REDACTED] at 06:00 AM revealed, Resident A5 refused to have the repeat bloodwork drawn to obtain the potassium level this AM. There was no documented evidence that the facility implemented the resident's care plan, and had reapproached the resident in an attempt to obtain the physician ordered lab test. There was no documented evidence that the facility informed the physician or the resident's guardian of the resident's refusal.

Interview with the physician on [DATE REDACTED] at 9:30 AM revealed she was not aware of the resident's refusal for

the repeat potassium level. She stated she had informed the facility to contact her with any resident refusals, but they never did regarding the failure to repeat the lab work and obtain a current potassium leve. She stated that she was concerned that the resident does not understand, and cannot make an informed decision, and that he must be reapproached after the initial refusal.

A review of electronic communication between the attending Physician and the nursing department at the facility dated [DATE REDACTED] at 3:56 P.M. revealed, potassium level 5.6 mmol/l, which was still elevated, recommend to repeat it if he is having heart palpitation, chest pain or lightheaded or dizziness then advised to go to the emergency room .

There was no physicians order directly related to the [DATE REDACTED] Potassium lab draw. The initial physicians order from [DATE REDACTED], was not completed until [DATE REDACTED].

Interview with the physician on [DATE REDACTED] at 9:30 AM revealed that the facility failed to inform her that the resident refused the labwork that she had wanted repeated on [DATE REDACTED]

During an interview [DATE REDACTED] at 10 A.M., the Assistant Director of Nursing could not state why the potassium level was not drawn timely.

A review of a laboratory report dated [DATE REDACTED], revealed that a potassium level was drawn and the results received indicating that resident's potassium remained elevated at 5.4 mmol/L (normal value 3XXX, d+[DATE REDACTED].1) and was again flagged as high.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 25 395414 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395414 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aventura at Terrace View 260 Terrace Drive Peckville, PA 18452

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 0773 A nurses note dated [DATE REDACTED], at 5:11 PM revealed, at 3:45 PM revealed that staff observed Resident A5 in a chair outside of room with blank stare. The resident's vital signs were obtained: temperature 94.1, pulse 5, Level of Harm - Actual harm respirations 16, blood pressure ,d+[DATE REDACTED], oxygen saturation level 90% on room air. Lung sounds were diminished. The resident was noted to have slight right sided weakness but not following commands well Residents Affected - Few related to lethargy. The physician was called and a new order was obtained to send resident to hospital for further evaluation and treatment. The resident was sent to the hospital at that time.

A review of hospital documentation revealed that upon arrival to the ER, the resident was hypotensive (low blood pressure)and bradycardic (low pulse rate) on arrival. Patient given 2.8 liters fluid. Labs with

hyperkalemia (high potassium level) 6.1 critical high level, AGMA(metabolic acidosis, Metabolic acidosis is a serious electrolyte disorder characterized by an imbalance in the body's acid-base balance.) , acute on chronic chronic kidney disease, leukocytosis. Started on Levophed. Patient tachypnea and when laid flat, became cyanotic. Decision to intubate in ED. ICU (intensive care unit) admission for septic shock likely. The resident was intubated ( a tube placed in his throat to keep his airway open ) he was then placed on a ventilator) and transferred to the ICU. He went into cardiac arrest in the ICU. CPR (cardio pulmonary resuscitation ) preformed for three minutes and the resident was revived.

During an interview with the assistant Director of Nursing (DON) on [DATE REDACTED], at approximately 1 PM the ADON stated that the laboratory results are sent to nursing and should be relayed to the physician when received at the facility. He stated that the resident refused the lab draw on [DATE REDACTED], and was not reapproached because the resident had the right to refuse treatment. The ADON was unable to explain the lab drawn and potassium level obtained on [DATE REDACTED], 7 days later. The ADON confirmed that the resident's refusal to have the blood drawn was not communicated to the resident's physician.

Interview with the physician on [DATE REDACTED] at 9:30 AM revealed that the facility failed to inform her that the resident's potassium lab work was not repeated on [DATE REDACTED], when ordered. The physician continued to state that the lab work was clinically necessary for the resident's care, and the resident did not have the mental capacity to under the implications of his refusing the blood draw and the risk to his health. The resident's physician stated that the delay in obtaining this labwork placed this resident in a medical crisis and subsequently he suffered a cardiac arrest with a critically high potassium level in the ER.

28 Pa. Code 211.12 (d)(3)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 395414 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395414 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aventura at Terrace View 260 Terrace Drive Peckville, PA 18452

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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or 43944 potential for actual harm Based on observation, a review of facility pest service records and staff interview, it was determined that the Residents Affected - Few facility failed to maintain an effective pest control program.

Findings include:

A review of the facility's contracted pest management company service inspection report dated June 11, 2024, at 3:22 p.m., revealed that staff made verbal reports that mice activity was observed in resident rooms D106, D115, and D-wing dining room. The logbooks (the facility's method of communicating pests with the pest management company) were checked and no written reports of pest activity were noted in the logbooks.

The pest management service inspection report revealed that RTU (ready-to-use) pesticide and glue boards [trays that are coated with a potent adhesive that prevents the escape of any animal that touches it] were placed throughout. Treated common areas, nurse's stations, lounge rooms, dinning rooms, employee breakrooms, restrooms, and lobby for general pest control.

Observation of the D-Unit dining room on June 13, 2024, at 8:29 a.m., revealed that inside a cabinet underneath the sink there was a dead decomposing mouse stuck to a glue trap. A yellow-colored substance was smeared on the floor of the cabinet, and small black/brown speckles, that appeared to be rodent droppings, were observed on the bottom floor of the cabinet along with debris and dead bugs.

Interview with the Nursing Home Administrator (NHA) on June 13, 2024, at 8:50 a.m., reported that that pest management company was just in on Tuesday to take care of the mice and that they {pest company} check

the traps.

The NHA confirmed that the facility failed to perform environmental maintenance and checks to remove dead rodents from pest traps and deter unsanitary dining conditions that increase the risk of infestation.

28 Pa. Code 201.18 (e)(2.1) Management

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 395414