Lackawanna Health And Rehab Center

F-F607, F 838

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(e)(2) Management

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 43 395414

F-F679

28 Pa. Code 201.14(a) Responsibility of licensee

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 43 395414 Department of Health & Human Services Printed: 08/31/2025 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 03/28/2025

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 0838 28 Pa. Code 201.18(b)(1)(e)(2) Management

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 41 of 43 395414 Department of Health & Human Services Printed: 08/31/2025 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 03/28/2025

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 0946 Provide training in compliance and ethics.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26142 potential for actual harm Based on record review and staff interviews, the facility failed to implement an effective compliance and Residents Affected - Some ethics program, including providing required training to 6 of 6 employees reviewed (Employees 11, 12, 13, 14, 15, and 16), and failed to uphold standards of ethical conduct, as evidenced by the lack of staff training and an incident of theft involving Employee 11 and Resident 79.

Findings include:

A review of the facility's Corporate Compliance and Ethics Plan, last updated July 2024, revealed the facility had established written policies intended to promote compliance with legal and ethical standards. The plan specified that employees must receive training on the facility's Code of Conduct, including expectations related to ethical behavior and reporting of misconduct.

According to 42 CFR S483.85, the facility must develop, implement, and maintain an effective compliance and ethics program that includes:

Standards, policies, and procedures to prevent and detect criminal, civil, and administrative violations, a designated compliance officer, effective training and education for all staff, and a Code of Conduct made available to all staff.

However, during the survey the facility was unable to produce a copy of its Code of Conduct or policies related to the compliance and ethics program.

The facility assessment, last reviewed July 15, 2024, did not identify the Compliance and Ethics Program or related staff training as a component of risk or operations.

Employee files for Employees 12, 13, 14, 15, and 16, hired between February and March 2025, contained no evidence of ethics or compliance training.

The personnel file for Employee 11, who was rehired in February 2025, also lacked documentation of any such training.

Resident 79 was admitted on [DATE REDACTED], with a diagnosis of multiple sclerosis. An annual MDS assessment dated [DATE REDACTED], revealed the resident was cognitively intact (BIMS score of 15).

On March 26, 2025, Resident 79 reported to the Director of Social Services that approximately two years earlier, Employee 11, nurse aide (NA) took him to a bank to cash a $2,800 check and then offered to hold $2, 000 of the funds for him. The resident stated that Employee 11 NA never returned the money.

A police report dated March 26, 2025, confirmed the incident had been reported. On March 27, 2025, law enforcement confirmed with a local financial institution that Resident 79 cashed a check in the amount of $3, 925.77 on August 1, 2023. Employee 11 NA later admitted during police questioning that she took the money for safekeeping but did not return it, stating she was scared and made no effort to correct the issue even

after the resident confronted her.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 43 395414 Department of Health & Human Services Printed: 08/31/2025 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 03/28/2025

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 0946 Employee 11 NA was arrested and charged with theft.

Level of Harm - Minimal harm or The facility failed to prevent this ethical violation through the implementation of a functioning compliance potential for actual harm program and failed to detect or respond to unethical conduct in a timely manner. Interviews with facility leadership confirmed the compliance and ethics program was not part of orientation or ongoing training for Residents Affected - Some staff, and documentation to support its implementation could not be produced.

Refer