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 38 of 51 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 39 of 51 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 40 of 51 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 41 of 51 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 42 of 51 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 43 of 51 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 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43944

Residents Affected - Few Based on observations, review of the facility's planned written menus, menu extensions, and select facility policy, and staff interviews, it was determined that the facility failed to adhere to planned written menus for two residents out of 33 residents sampled (Residents 7 and 72).

Findings included:

A review of a facility policy entitled Double Portion Diet Policy last reviewed by the facility February 2024 indicated that all residents ordered/requested double entree unless requested otherwise. Special requested double portion would include but not limited to, double portion vegetable, double portion fruit, double portion starch, etc. Example: two pieces of lasagna, two slices of pizza, two 4-ounce portions of chicken, and two 8-ounce scoops of macaroni and cheese.

A review of Resident 7's clinical record revealed that he was admitted to the facility on [DATE REDACTED], with a diagnosis of a traumatic brain injury [A head injury causing damage to the brain by external force or mechanism and can result with long term complications or death.

A review of Resident 7's plan of care initiated on December 6, 2019, and revised on April 19, 2021, identified that the resident was nutritionally at risk due to hypertension. Planned interventions included: diet as per physician order - regular/ ground / thin, double portions per resident request, and to honor food preferences within prescribed diet.

A review of the facility's menu extension dated June 13, 2024, revealed that the standard/regular portion for

the ground hot turkey was a #10 scoop (equivalent to 3.25 fluid ounces or 3/8 cup) ground meat. A double portion should consist of two #10 scoops of ground hot turkey as indicated in the facility's double portions policy.

An observation of meal service on the C1 Unit on June 13, 2024, at 12:25 p.m., revealed Resident 7's tray card/ticket menu dated June 13, 2024, lunch meal, revealed that the resident's daily items were to include 4-ounces of super pudding (higher calorie and protein pudding), 8-ounces Ensure Clear (a clear-liquid high protein nutrition supplement), 1/2 cup fortified mashed potatoes (enhanced recipe to offer increased calories and protein), double portion entree, salt packet (1-each), pepper packet (1-each), 2 sugar packets, and the main menu included one #10 scoop (equivalent to 3.25 fluid ounces or 3/8 cup) ground meat - hot turkey with gravy (1-ounce), bread stuffing (4-ounces), chopped #8 scoop (1/2 cup) green beans, chilled pears (4-ounces), coffee/cream (6-ounces), and apple juice cup (4-ounces).

Further observation of Resident 7's lunch tray revealed that the resident's plate consisted of a single portion of ground hot turkey and side accompaniments and the not double portions as care planned.

An interview with Employee 6, a nurse aide, on June 13, 2024, at 12:25 p.m., confirmed that the resident did not receive a double portion of ground hot turkey as indicated on his tray card.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 51 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 0803 A review of Resident 72's clinical record revealed that the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included Alzheimer's dementia. Level of Harm - Minimal harm or potential for actual harm A review of a physician order dated December 4, 2021, at 3:30 a.m., revealed that the resident was prescribed a no added salt (NAS - no salt packet) double portion diet regular texture with thin liquids. Residents Affected - Few

A review of the facility's menu extension date June 13, 2024, revealed that the standard/regular portion for

the hot turkey was 3-ounces EP (edible portion - is the amount of usable food/ingredients that can be used in food preparation after removing trimmings or waste from the original AP form). A double portion should consist of 6-ounces EP as indicated in the facility's double portions policy.

An observation of meal service on the C1 Unit on June 13, 2024, at 12:30 p.m., revealed Resident 72's tray card/ticket [is a printed document for resident meal trays to help dietary departments and their staff organize and serve foods to their residents according to their prescribed diets] menu dated June 13, 2024, lunch meal, revealed that the resident's daily items were to include 4-ounces of yogurt, double portion entree, pepper packet (1-each), 2 sugar packets, and the main menu included hot turkey with gravy (3-ounces), bread stuffing (4-ounces), green beans (4-ounces), chilled pears (4-ounces), coffee/cream (6-ounces), and apple juice cup (4-ounces).

Observation of Resident 72's lunch tray revealed that the resident's plate consisted of a single portion of hot turkey and side accompaniments and not the double portions as ordered. Resident 72 stated during

interview at that time that he was still hungry after consuming one hundred percent of the meal and requested another meal.

Interview with Employee 6 confirmed that Resident 72 was served only a single portion and that his tray card indicated that he should receive a double portion.

Interview with the dietary manager on June 13, 2024, at 12:45 p.m., confirmed that residents were to receive double portions as ordered by the physician or per their preference/care plan and that the facility failed to provide double portions to Residents 7 and 72.

28 Pa. Code 211.6 (a) Dietary services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 51 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 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43944

Residents Affected - Few Based on observations, and review of clinical records, select facility policy and select reports and staff interview, it was determined that the facility failed to ensure that food was served in a form to meet the individual needs of one resident out of 33 sampled residents (Resident 28).

Findings include:

A review of the facility's Chopped Diet Policy that was last reviewed February 2024, indicated that a chopped diet consisted of foods cut into small, bite-sized pieces (approximately 1/4 inch to 1/2 inch) and was intended for patients with difficulty chewing and swallowing. When serving, clearly label all trays and meal components for patients on a chopped diet, verify the correct diet order before serving meals to ensure accuracy, and serve meals attractively to enhance the dining experience.

A review of Resident 28's clinical record revealed that she was admitted to the facility on [DATE REDACTED] and was prescribed a mechanically altered, chopped diet.

A review of the facility's menu extension date June 13, 2024, revealed that the chopped diet was to consist of a #10 scoop (equivalent to 3.25 fluid ounces or 3/8 cup) ground meat on one piece of white bread.

A review of Resident 28's tray ticket/card [is a printed document for resident meal trays to help dietary departments and their staff organize and serve foods to their residents according to their prescribed diets] dated June 13, 2024, lunch meal, revealed that the resident's main menu was to consist of chopped #10 scoop (equivalent to 3.25 fluid ounces or 3/8 cup) hamburger on a bun (double portion).

An observation of Resident 28's served lunch on June 13, 2024, at 11:30 a.m., revealed that the resident received two hamburgers that were not chopped as indicated on her tray ticket/card and diet order.

During an interview with the Food Service Manager on June 13, 2024, at 11:33 a.m., confirmed that Resident 28's hamburger was served whole and not chopped. The manager stated, she always gets her hamburgers that way, her brother does not want her to have chopped food. The Food Service Manager was unable however to provide documented evidence that supported that the resident could safely consume the whole foods, and meats that were not chopped.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 51 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 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 43944 potential for actual harm Based on observation and staff interview, it was determined that the facility failed to properly contain and Residents Affected - Many dispose of garbage and provide a sanitary environment on the facility grounds.

Findings include:

Observation of the dietary department's receiving dock and cardboard receptacle on June 14, 2024, at 12:07 p.m., revealed one of two outside dumpsters, used for cardboard only, was overflowing with cardboard boxes.

The area surrounding the dietary dumpster was cluttered with a large broken cart and other maintenance equipment cluttering the refuse area.

Interview with the Nursing Home Administrator (NHA) on June 14, 2023, at 1:30 p.m., confirmed that the facility's dumpsters and surrounding areas should be maintained in a sanitary manner and garbage contained.

28 Pa. Code (e)(2.1) Management

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 51 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 26142 potential for actual harm Based on review of select facility policies, the facility's infection control tracking log and staff interview, it was Residents Affected - Many determined that the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility.

Findings include:

A review of the facility's current infection control policy dated as reviewed by the facility February 2024, revealed that it is the policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

A review of the facility's infection control data provided at the time of the survey ending June 14, 2024, revealed that the facility's infection control program failed to reflect an operational system to monitor and investigate causes of infection and manner of spread. There was no evidence of a functional system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection

in a timely manner.

A review of a facility form entitled Outbreak Case-Patient Line List dated March 2024 revealed 6 resident cases of influenza A and 2 cases of Influenza B; April 2024 revealed 2 cases of influenza B and 6 cases of RSV, and April 16, 2024 through May 2, 2024, 27 residents with GI symptoms. There was a notation on the April line listing of residents with respiratory symptoms which stated 3 cases of employee flu, confirmed and 1 symptomatic employee, not confirmed.

There was no documentation of any staff infections in the infection control logs.

A review of facility infection control logs for June 2024, as of June 14, 2024, revealed that the facility had not yet started tracking infections for the month of June as of the time of the survey.

Threw was no documentation of any staff or resident education provided after the upper respiratory or GI outbreaks in the facility noted on the line listings. There was no documentation of any evaluation or interventions designed to prevent the spread of the infections in response to the outbreaks of flu, RSV and GI illnesses that occurred.

There was also no documented evidence that the facility tracked and trended these infections to identify the potential need for intervention with staff and residents to deter similar infections.

There was no indication that the limited data that was compiled was then evaluated to determine what could be done to prevent the spread or recurrence of infection.

Interview with the Infection Preventionist on June 13, 2024, at 11 AM confirmed that the facility infection control tracking logs were incomplete and that the facility was unable to demonstrate a fully functioning comprehensive program to monitor and prevent infections.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 51 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 0880 28 Pa. Code 211.10(a)(d) Resident care policies

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 51 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 0920 Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. Level of Harm - Minimal harm or potential for actual harm 26142

Residents Affected - Few Based on observation and interview, it was determined that the facility failed to provide adequate dining/activity space one one of four occupied resident units (Resident unit, C1).

Findings include:

The current census for the C1 male only locked dementia unit at the time of the survey was 24 residents.

The resident capacity for the unit is 57.

There was one dining /activity room on the locked unit. The room measured 24 feet x 24 feet, 576 square feet.

An observation of the C1 dining/activity room, June 11, 2024 at 12 P.M. revealed 9 dining tables with 4 chairs, a video game machine, a poker machine placed on a dining table, an over the bed table, and 4 stationary high back chairs. There were 6 residents seated in wheelchairs at the time of the observation. Several residents were observed having difficulty passing each other and maneuvering about in the room due to space constraints.

There room did not provide adequate space to accommodate the number of residents currently residing on

this unit and the necessary dining and activity equipment/supplies.

During an interview June 12, 2024 at approximately 1 P.M. the interim Director of Nursing (DON) stated that there was only one seating for each meal and most of the residents eat in this dining room. She stated that it was a tight fit in the room during meals. She confirmed that this room is the only dining/activity on the male locked unit for residents use as these residents do not leave the unit for any meals or activities.

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 50 of 51 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 51 of 51 395414