Lackawanna Health And Rehab Center

F-F755,809

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 201.18(e)(1) Management

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 395414

F-F809, a review of the facility's audit for

the provision of bedtime snacks was conducted. The audit indicated that a Resident Council Meeting was held on March 18, 2025, during which residents expressed ongoing concerns about not consistently receiving evening snacks. Further review of the facility's audit showed that 40 out of 111 residents reported not consistently receiving a bedtime snack.

During an interview on March 21, 2025, at approximately 12:00 PM, the Nursing Home Administrator confirmed that residents continued to express concerns about the lack of consistency in receiving evening snacks, acknowledging that the issue remained unresolved despite prior corrective actions.

The facility's failure to provide a nourishing snack when more than 14 hours elapsed between the evening meal and breakfast did not align with its own policy having the potential to negatively impact residents' nutritional status.

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 4 of 6 395414 Department of Health & Human Services Printed: 09/04/2025 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 03/21/2025

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 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 39929

Residents Affected - Some Based on a review of the facility's plan of correction from the survey ending January 23, 2025, the outcome of the activities of the facility's Quality Assurance and Performance Improvement (QAPI) committee, a review of clinical records, and staff interviews, it was determined the facility failed to ensure agency staff employed and working in March 2025 received the required training on the corrective measures outlined in the facility's plan of correction.

Findings include:

A review of the facility's plan of correction submitted following the survey ending January 23, 2025, revealed

the facility had developed a corrective plan as its allegation of compliance, which included a quality assurance monitoring component to ensure that all licensed staff received education on identified deficient practices. The plan indicated that this corrective action was to be completed and fully implemented by March 18, 2025.

As part of the plan of correction, the facility was to provide immediate re-education to staff on the following policies:

Resident's Right to Freedom from Abuse, Neglect, and Exploitation

Comprehensive Person-Centered Care Planning

Skin Care Policy

Administering Medications

Restorative Nursing Services

Medication Utilization and Prescribing - Clinical Protocol

Water Pass

Frequency of Meals

Infection Control

However, during the follow-up visit conducted on March 20, 2025, the facility provided documentation, including a list of agency employees, post-tests from the mandatory education, and staff education sign-in sheets. A review of these documents revealed that only 12 of the 75 agency staff members employed in March 2025 had received training on the policies outlined in the plan of correction.

The facility was unable to provide a plan to ensure that the remaining 63 agency staff members employed in March 2025 received the required education. Additionally, the facility failed to produce any documentation or tracking system related to the completion of training for agency personnel.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 395414 Department of Health & Human Services Printed: 09/04/2025 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 03/21/2025

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 0867 During an interview on March 21, 2025, at approximately 1:00 PM, the Director of Nursing (DON) confirmed

the facility failed to implement a monitoring system to ensure agency staff received training related to the Level of Harm - Minimal harm or deficiencies cited in the January 23, 2025, survey. The DON acknowledged that the facility failed to identify potential for actual harm gaps in training, failed to ensure agency staff were adequately educated before working shifts, and failed to prevent the recurrence of similar quality deficiencies in the identified areas of concern. Residents Affected - Some

This failure resulted in a breakdown in the facility's Quality Assurance and Performance Improvement (QAPI) program, as the facility did not ensure ongoing monitoring, implementation, and sustainability of corrective actions.

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