Aventura At Prospect

F-F880.

28 Pa. Code 201.20(a)(b) Staff development

28 Pa. Code 211.12(d)(1) Nursing services

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 39 395203 Department of Health & Human Services Printed: 08/27/2025 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 395203 B. Wing 05/08/2025

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

Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 39344

Residents Affected - Few Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for four of four medication carts reviewed (2 North upper medication, 2 North low medication cart, 2 South back medication cart ) and maintain a system that allows for timely identification of narcotic diversion.

Findings include:

Review of facility policy, Pharmacy Services Policy and Procedure dated 2025, revealed, The Facility shall have a system to account for controlled medications' receipt and disposition in sufficient detail to enable an accurate reconciliation.

Observation on May 5, 2025, at 10:03 a.m. of the 2 North upper medication cart, with Employee E3, agency licensed nurse, revealed that the number of blister pack medication cards was not documented during the shift-to-shift narcotic medication reconciliation process. Interview, at the time of the observation, Employee E3, agency licensed nurse, confirmed the above finding.

Observation on May 5, 2025, at 10:11 a.m. of the 2 North low medication cart, with Employee E4, licensed nurse, revealed that the number of blister pack medication cards was not documented during the shift-to-shift narcotic medication reconciliation process. Interview, at the time of the observation, Employee E4, licensed nurse, confirmed the above finding.

Observation on May 5, 2025, at 10:24 a.m. of the 2 South back medication cart, with Employee E5, licensed nurse, revealed that the number of blister pack medication cards was not documented during the shift-to-shift narcotic medication reconciliation process. Interview, at the time of the observation, Employee E5, licensed nurse, confirmed the above finding.

Review of Narcotic book conducted on May 6, 2025, at 9:26 a.m. with Licensed nurse, Employee E20 during mediction observation on the first floor unit, revealed that individual narcotic accountability sheets were in a loose binder. Further observation revealed that each individual sheet did not have page number or any identifying marking that allows for immediate identification of missing page and there was no system in place to identify missing narcotic accountability sheets.

Interview with Licensed nurse, Employee E20 at the time of the observation noted above confirmed that if the narcotic accountability page is removed from the binder, the incoming nurse will not know that it was missing, further if the page narcotic accountability sheet is removed together with the corresponding blister pack of narcotics, the incoming nurse will not know that the narcotic has been removed from the bin.

28 Pa Code 211.12(d)(1) Nursing services

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 39 395203 Department of Health & Human Services Printed: 08/27/2025 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 395203 B. Wing 05/08/2025

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

Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm 39344

Residents Affected - Some Based on clinical record reviews, review of facility policies and documentation and interviews with staff, it was determined that the facility failed to ensure that pharmacist recommendations were reviewed by the physician in a timely manner for four of five residents reviewed related to medication regime reviews (Residents Resident R48, Resident R86, Resident R85 and Resident R125).

Findings include:

Review of facility policy, Pharmacy Services Policy and Procedure dated 2025, revealed, The drug regimen of each resident shall be reviewed at least once a month by a licensed pharmacist . The pharmacist shall report any irregularities to the attending physician and the Facility's medical director and director of nursing, who shall act upon these reports . The attending physician shall document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician shall document his or her rationale in the resident's medical record.

Review of Resident Resident R85's Medication Regimen Review Report, dated January 20, 2025, revealed that the pharmacist made recommendations regarding the resident's medications and that the recommendations were reviewed by the physician. Continued review revealed that there was no date to indicate when the pharmacist's recommendations were reviewed by the physician.

Review of Resident Resident R125's Medication Regimen Review Report, dated November 25, 2024, revealed that

the pharmacist made recommendations regarding the resident's medications and that the recommendations were reviewed by the physician. Continued review revealed that there was no date to indicate when the pharmacist's recommendations were reviewed by the physician.

Review of Resident Resident R125's Medication Regimen Review Report, dated January 21, 2025, revealed that the pharmacist made recommendations regarding the resident's medications and that the recommendations were reviewed by the physician. Continued review revealed that there was no date to indicate when the pharmacist's recommendations were reviewed by the physician.

Review of Resident Resident R48's clinical record revealed a physician's orders for: Risperdal Oral Tablet 0.5 MG (Risperidone) Give 0.5 mg by mouth in the morning for psychosis -Start Date 06/19/2024 and (Risperidone) Give 1 mg by mouth at bedtime for psychosis-Start Date 06/18/2024

Review of November 2024 Pharmacy Review dated November 25, 2024, revealed that under Pharmacy a Recommendation: Risperdal 0.5 mg every morning and at bedtime is due to assessment.

Under Physician's Rationale to support continued use revealed a notion of History psychosis from PD (psychotic Disorder). Further, there was no date anywhere in the form, indicating when the pharmacy recommendation was reviewed by the physician

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 39 395203 Department of Health & Human Services Printed: 08/27/2025 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 395203 B. Wing 05/08/2025

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

Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

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 0756 Review of Resident Resident R86's Medication Regimen Review Report, dated December 26, 2024, revealed that the pharmacist made recommendations regarding the resident's medications and that the recommendations Level of Harm - Minimal harm or were reviewed by the physician. Continued review revealed that there was no date to indicate when the potential for actual harm pharmacist's recommendations were reviewed by the physician.

Residents Affected - Some Interview on May 7, 2025, at 10:18 a.m. the Director of Nursing confirmed that the pharmacy recommendations for Residents Resident R48, Resident R86, Resident R85 and Resident R125 were not dated by the physician.

28 Pa Code 211.5(f)(x) Medical records

28 Pa Code 211.9(k) Pharmacy services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 39 395203 Department of Health & Human Services Printed: 08/27/2025 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 395203 B. Wing 05/08/2025

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

Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39344 potential for actual harm Based on observations, review of facility policies, clinical record review and interviews with staff, it was Residents Affected - Few determined that the facility failed to ensure that the medication error rate was less than five percent for two of four residents observed during medication administration (Residents Resident R83 and Resident R88).

Findings include:

The facility's medication error rate was 5.88% based on observation of 34 medication administration opportunities with two errors observed.

Review of facility policy, Medication Administration Policy dated December 4, 2023, revealed, Medications must be administered in accordance with orders, including any required time frame.

Review of Medication Administration Records (MARs) for Resident Resident R83 revealed a physician's order, dated March 14, 2025, for aspart (rapid acting) insulin (medication used to lower blood sugar levels), inject 24 units subcutaneously (under the skin) before meals. Continued review revealed another order, dated April 4, 2025, for aspart insulin sliding scale (variable dosage based on blood sugar level), inject subcutaneously before meals. Both orders for aspart insulin were scheduled to be administered at 8:00 a.m.

Observation of morning medication pass on May 5, 2025, at 9:45 a.m. revealed that Employee E3, agency licensed nurse, stated that Resident Resident R83's blood sugar level was 323. Employee E3, agency licensed nurse, verified the physician orders for Resident Resident R83; the sliding scale indicated that eight units of insulin should be administered. Employee E3, agency licensed nurse, drew up a total of 32 units of insulin (standing dose of 24 units plus 8 units of the sliding scale dose) and administered them to Resident Resident R83 at 10:00 a.m. Both Resident Resident R83 and Employee E3, agency licensed nurse, confirmed that the resident had already finished eating breakfast. Employee E3, agency licensed nurse, confirmed that Resident Resident R83's insulin should have been administered before the breakfast meal.

Review of Resident Resident R88's clinical record revealed that Resident Resident R88 was admitted to the facility on [DATE REDACTED], with diagnoses of but not limited to Type 2 Diabetes Mellitus.

Review of resident Resident R88'd physician orders revealed an order for Novolog Injection Solution 100 UNIT/ML (Insulin Aspart) Inject 8 unit subcutaneously two times a day for DM (diabetes mellitus) Give before Breakfast and Dinner. Hold for BS <150-Start Date-01/17/2025

Medication administration observation on Resident Resident R88 conducted on May 6, 2025, at 9:06AM with Employee E20 revealed that Licensed nurse, Employee E20 administered 8 units of Insulin Aspart to Resident Resident R88.

Interview with Licensed nurse, Employee E20 conducted at the time of the observation revealed that Resident Resident R88 had already eaten her breakfast.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 39 395203 Department of Health & Human Services Printed: 08/27/2025 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 395203 B. Wing 05/08/2025

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

Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

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 0759 Further interview with Licensed nurse, Employee E20 confirmed that the order for the Insulin Aspart was to administer the Insulin Aspart before breakfast. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.9(a)(1) Pharmacy services

Residents Affected - Few 28 Pa. Code 211.12 (d)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 39 395203 Department of Health & Human Services Printed: 08/27/2025 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 395203 B. Wing 05/08/2025

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

Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 39344 Residents Affected - Few Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that medications were stored and labeled in accordance with professional practice standards and failed to ensure that compartments for storage of controlled medications were permanently affixed within storage areas, for thee of five medication storage areas reviewed (2 North upper medication, 2 North low medication cart, 1 North low medication cart, first floor medication room.).

Findings include:

Review of facility policy, Medication Administration Policy dated December 4, 2023, revealed, The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method of administration before giving the medication. Check the expiration date on the medication label. When opening a multi-dose container, place the date on the container. Continued review revealed,

During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering the medications, and all outward sides must be inaccessible to residents or others passing by.

Observation on May 5, 2025, at 10:03 a.m. of the 2 North upper medication cart, with Employee E3, agency licensed nurse, revealed an opened Humalog lispro kwikpen (a multi-dose device designed to administer insulin [medication that treats diabetes by lowering blood sugar levels] for single resident use) that had no resident name label on it. Continued review revealed a Lantus insulin pen for Resident Resident R83 that was opened and undated. Employee E3, agency licensed nurse, confirmed the above findings.

Observation on May 5, 2025, at 10:11 a.m. of the 2 North low medication cart, with Employee E4, licensed nurse, revealed an opened Novolog insulin pen that had no resident name label on it. Interview, at the time of the observation, Employee E4, licensed nurse, confirmed the above finding.

Continued observation of morning medication pass on May 5, 2025, of the 1 North low medication cart, revealed that Employee E15, agency licensed nurse, left the medication cart unlocked and unattended, next to the resident dining area, from 10:36 a.m. through 10:42 a.m. Interview, at the time of the observation, Employee E15, agency licensed nurse, confirmed the above finding.

Observation of the first-floor medication room medication refrigerator conducted on May 6, 2025 at 9:52 AM with Unit Manager Employee E21 revealed a transparent plastic box containing an opened vial of Lorazepam Intensol 2mg/ml with 5.5ml left in the vial labelled with Resident Resident R110's name on it. Further, an unopened vial of Lorazepam oral concentrate 2mg/ml, three vials of unopened lorazepam injection 2mg/ml and 10 tablets of Marinol 2.5 mg labelled with Resident Resident R140's name on it was also observed inside the plastic box.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 39 395203 Department of Health & Human Services Printed: 08/27/2025 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 395203 B. Wing 05/08/2025

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

Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

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 0761 Further observation revealed that the plastic box was not permanently affixed to the refrigerator.

Level of Harm - Minimal harm or Interview with Employee E21 conducted at the time of the observation confirmed that the box containing an potential for actual harm opened vial of Lorazepam Intensol 2mg/ml with 5.5ml left in the vial labelled with Resident Resident R110's name on it. Further, an unopened vial of Lorazepam oral concentrate 2mg/ml, three vials of unopened lorazepam Residents Affected - Few injection 2mg/ml and 10 tablets of Marinol 2.5 mg labelled with Resident Resident R140's name on it was not permanently affixed to the refrigerator.

Review of facility policy, Pharmacy Services Policy and Procedure dated 2025, revealed, The Facility shall provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the Facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

28 Pa Code 211.12(d)(1) Nursing services

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 39 395203 Department of Health & Human Services Printed: 08/27/2025 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 395203 B. Wing 05/08/2025

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

Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 43277

Residents Affected - Many Based on review of facility policy, observations, and interviews with staff and residents, it was determined that the facility did not ensure that food was stored, prepared, and served in accordance with professional standards for food service safety.

Findings Include:

Review of facility policy Dishwashing Machine Use revised March 2010 revealed dishwashing machine chemical sanitizer for use of chlorine solution, the minimum concentration should be 50-100 ppm (parts-per-million) for a contact time of 10 seconds.

A tour of the main kitchen conducted on May 5, 2025, 9:30 a.m. with Food Service Director, Employee E29, revealed the following:

Observations of the walk-in refrigerator revealed an open large sleeve of ground beef, poorly resealed, and not labeled with received or open date.

The opened sleeve of ground beef was placed on top of a new, unopened box (delivered earlier in morning of 5/5/2025) of ground beef. The opened sleeve of ground beef was observed with raw meat drippings on the new box.

Observations and interview revealed the main kitchen utilizes a low water temperature, chemical (chlorine - minimum concentration should be 50-100 ppm) sanitizer for the cleaning of dishes. When the Food Service Director, Employee E29, tested the concentration of sanitizing solution, the test strip indicated a PPM of < 10.

Review of facility documentation revealed a log in the dish room to monitor the chlorine concentration of the dish machine. Per a review of the log, dietary staff were inaccurately documenting the chlorine concentration.

Continued observations during a tour of the main kitchen revealed a black metal rack with multiple shelves that holds the boxes of juice used to dispense juice into the juice machine. The metal racks were sticky to touch. Observations revealed two tubes not in use, however were filled with stagnant old juice laying directly

on the floor.

Observations throughout the main kitchen revealed the floors had a significant amount of food and debris embedded into the grout and perimeter of the kitchen.

Observations were confirmed by the Food Service Director, Employee E29, throughout the duration of the tour.

Review of facility documentation revealed the contractor came out to assess the dish machine on May 5, 2025, which confirmed it was not dispensing sufficient sanitizing solution due to a hole in the tubing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 39 395203 Department of Health & Human Services Printed: 08/27/2025 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 395203 B. Wing 05/08/2025

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

Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

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 0812 28 Pa. Code 201.14 (a) Responsibility of licensee.

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 32 of 39 395203 Department of Health & Human Services Printed: 08/27/2025 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 395203 B. Wing 05/08/2025

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

Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or 39344 potential for actual harm Based on observations, review of facility policies and interviews with staff, it was determined that the facility Residents Affected - Few failed to ensure that personal foods were stored and labeled in accordance with food safety standards for one of two nursing units reviewed (2 North medication room).

Findings include:

Review of facility policy, Medication Storage Policy dated December 4, 2023, revealed, Employee or resident food should not be stored in the medication refrigerator.

Review of facility policy, Outside Food undated, revealed, Resident and or person bringing in the food will be notified that perishable food will only be kept for 72 hours. Continued review revealed, Staff will monitor resident's room, unit pantry, and refrigeration units for food and beverage disposal.

Observation on May 5, 2025, at 9:58 a.m. of the 2 North medication room, with Employee E3, agency licensed nurse, revealed that the refrigerator contained both resident medications as well as foods brought into the facility. Continued observation revealed several opened containers of foods; none of the containers had dates to indicate when the foods were brought in or opened. Further observation revealed that some of

the containers had writing to indicate a name or room number, however, the writing was illegible. Interview, at the time of the observations, Employee E3, agency licensed nurse, stated that she did not know if the foods belonged to staff or residents and confirmed that the opened containers of food did not have any legible names or dates on them.

28 Pa Code 205.25(b) Kitchen

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 39 395203 Department of Health & Human Services Printed: 08/27/2025 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 395203 B. Wing 05/08/2025

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

Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

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 39344 potential for actual harm Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was Residents Affected - Few determined that the facility failed to maintain an effective infection control program related to insulin administration and hand hygiene during medication administration for two of three licensed nurses observed (Employee E3 and E20).

Findings include:

Review of facility policy, Medication Administration Policy dated December 4, 2023, revealed, The individual administering medications must verify the resident's identity before giving the resident his/her medications .

The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method of administration before giving the medication. Check the expiration date on the medication label. When opening a multi-dose container, place the date on the container. Continued review revealed, Staff shall follow established facility infection control procedures (e.g., hand washing, antiseptic technique, gloves, isolation precautions, etc.) when these apply to the administration of medications.

Review of Medication Administration Records (MARs) for Resident Resident R83 revealed a physician's order, dated March 14, 2025, for aspart (rapid acting) insulin (medication used to lower blood sugar levels), inject 24 units subcutaneously (under the skin) before meals. Continued review revealed another order, dated April 4, 2025, for aspart insulin sliding scale (variable dosage based on blood sugar level), inject subcutaneously before meals.

Observation of morning medication pass on May 5, 2025, at 9:45 a.m. revealed Employee E3, agency licensed nurse, prepare aspart insulin for Resident Resident R83. Employee E3, agency licensed nurse, removed a Novolog (aspart insulin) Flexpen from the medication cart. Inspection of the Novolog Flexpen revealed that

the pen was opened, however, there was no resident name label or date that the pen was opened. Employee E3, agency licensed nurse, stated that Resident Resident R83's blood sugar level was 323. Employee E3, agency licensed nurse, verified the physician orders for Resident Resident R83; the sliding scale indicated that eight units of insulin should be administered. Employee E3, agency licensed nurse, drew up a total of 32 units of insulin (standing dose of 24 units plus 8 units of the sliding scale dose). Employee E3, agency licensed nurse, then administered the insulin to Resident Resident R83.

Review of Novolog prescribing information, available at https://www.novomedlink. com/diabetes/products/treatments/novolog/dosing-and-administration.html revealed, Never Share a NovoLog FlexPen . between patients, even if the needle is changed . Sharing poses a risk for transmission of blood-borne pathogens.

Interview, on May 5, 2025, at 10:03 a.m. Employee E3, agency licensed nurse, confirmed that there was no resident name or date on the Novolog Flexpen and that it had previously been opened. Employee E3, agency licensed nurse, stated that it was the only aspart insulin in the cart, that it was the only physician's order she could find on the cart for aspart insulin and assumed that the pen must have belonged to Resident Resident R83.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 39 395203 Department of Health & Human Services Printed: 08/27/2025 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 395203 B. Wing 05/08/2025

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

Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

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 Medication administration observation conducted on May 6, 2025, at 9:42 a.m., with Employee E20 from revealed that a hand sanitizer was on top of the medication cart. Further, during medication administration Level of Harm - Minimal harm or for Resident Resident R88, Employee E20 did not wash her hands and did not wash her hands or sanitized her hands potential for actual harm using the hand sanitizer on top of the cart prior to preparing the medications.

Residents Affected - Few Further observation revealed that during medication preparation, Employee E20 handle the inside of the medication cup containing medications for Resident Resident R88 and Employee E20 did not sanitize the Insulin Aspart before inserting the insulin needle into the vial.

Observation conducted during the administration of medications to Resident Resident R88 revealed that Employee E20 did not sanitize or wash her hands before and after administering the oral medications to Resident Resident R88. Further, Employee E20 donned gloves and proceeded to inject the insulin into Resident Resident R88. Employee E20 then proceeded to remove the gloves and disposed of it. Employee E20 did not sanitize or wash her hands

before donning and after doffing the gloves.

Further observation of the medication administration with Employee E20 revealed that, Employee E20 proceeded to prepare Resident Resident R121's medications. Employee E20 did not sanitize or wash her hands

before starting to prepare Resident Resident R121's medications. Further Employee Resident R20 handled the inside of the medication cup containing medications for Resident Resident R88. Further, Employee E20 proceeded to administer Resident Resident R121's medication without washing her hands before and after administering the medications to Resident Resident R121.

28 Pa. Code 211.9(a)(1) Pharmacy services

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 39 395203 Department of Health & Human Services Printed: 08/27/2025 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 395203 B. Wing 05/08/2025

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

Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 43277 potential for actual harm Based on observations and staff interviews, it was determined that the facility failed to ensure equipment was Residents Affected - Few maintained in safe and operating conditions related to the main kitchen and fire doors.

Findings Include:

An initial tour of the main kitchen was conducted on May 5, 2025, at 9:30 a.m. with Food Service Director, Employee E29.

Observations and interview with Food Service Director, Employee E29, revealed the main kitchen is equipped with two steamers, four ovens, and one tilt skillet. Further interview and observation revealed one steamer, three ovens, and the tilt skillet are broken.

Further observations during the initial tour of the main kitchen on May 5, 2025, at 9:30 a.m. revealed the stainless steel, industiral preparation table was noted to be on a slant. The table was observed to be holding other kitchen prep equipment such as cutting boards, food processor, and toaster oven. Food Service Director, Employee E29, confirmed the table was broken and needed to be replaced or fixed.

Follow-up observations on May 8, 2025, at 12:00 p.m. in the main kitchen with Food Service Director, Employee E29, revealed dietary staff were in the midst of tray line assembling resident lunches. Continued

observation and interview with the Food Service Director, Employee E29, confirmed the tilt skillet was still broken and was storing dirty pots and pans that were used to prepare lunch.

Observation conducted during the tour of the first-floor unit on May 5, 2025, at 9:47 a.m. revealed that the fire door on the first floor unit was propped open with a wooden wedge. Further observation revealed that the magnets that keeps the doors open when the fire alarm is not activated and releases the doors to close it when the fire alarm is activated did not work and the fire door cannot be kept open without the wooden wedge that kept the fire door from closing.

Observation of the second-floor unit revealed that two other fire doors on the second floor unit were also propped open with a wooden wedge. Further the magnets that keeps the two fire doors on the second-floor units open when the fire alarm is not activated and releases the doors to close it when the fire alarm is activated did not work and the two fire doors cannot be kept open without the wooden wedge that kept the fire doors from closing.

Interview with Director of Maintenance, Employee E25 conducted on May 5, 2025, at 10:28 a.m. confirmed that three of the magnets of the fire doors did not work. Further, Employee E25 confirmed that the doors were propped open with wooden blocks.

Further, Director of Maintenance, Employee E25 revealed that when they were working on their wanderguard (security system) system, the alarm panel broke and needed to be changed, after it was changed the interior doors stopped working.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 39 395203 Department of Health & Human Services Printed: 08/27/2025 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 395203 B. Wing 05/08/2025

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

Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

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 0908 Interview with Licensed nurse, Employee E15 conducted on May 5, 2025, at 11:10 AM revealed that he did not know that's the fire doors were broken and that he did not know what to do with the fire doors when the Level of Harm - Minimal harm or alarm goes off. Further Employee E15 revealed that it was his first day of work. potential for actual harm

Interview with Unit Clerk, Employee E30 conducted on May 5, 2024, at 11:10 AM revealed that she was not Residents Affected - Few aware that the fire doors did not work.

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 37 of 39 395203 Department of Health & Human Services Printed: 08/27/2025 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 395203 B. Wing 05/08/2025

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

Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43277 potential for actual harm Based on review of facility policy, observations, and staff and resident interviews, it was determined that the Residents Affected - Some facility failed to maintain an effective pest control program for two of three nursing units and the main kitchen (2nd floor South nursing unit, 1-North Nursing Unit, and main kitchen ).

Findings include:

Review of facility policy Pest control dated April 1, 2022, revealed Aventura at Prospect shall maintain an effective pest control program. 1. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.2. Pest control services are provided a contracted vendor. 3. Only approved FDA and EPA insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas. 4. Garbage and trash are not permitted to accumulate and are removed from the facility daily. 5. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Interview during an initial tour of the main kitchen on May 5, 2025, at 9:30 a.m. with Food Service Director, Employee E29, confirmed sightings of pests in the main kitchen.

Observations during a tour of the main kitchen on May 5, 2025, at 9:30 a.m. revealed a hole, approximately 2 inches wide and 2 inches in height, in the wall (directly above the baseboard) located behind the door that exits the kitchen.

The floors of the kitchen had a significant amount food and debris embedded into the grout and perimeter of

the kitchen. The metal rack holding the containers of juice used for the juice machine was sticky to touch.

Review of pest control report dated May 1, 2025, revealed the pest control company Inspected and treated 1-North pantry for roach activity. Observed snacks from night before stored in cabinet area that's not put in sealed containers. Observed small, opened container of food substance opened upon floor behind vending machine. The pest control report indicated that the findings were reviewed with Nursing Home Administrator, Employee E1.

Observations on May 6, 2025, at 1:24 p.m. in the 1-North pantry revealed an open bag of chips in the cabinet, not in a sealed container. Further observations revealed a leftover breakfast tray on the counter, a trash can with no lid, a small plastic pudding cup, and a plastic lid with food substance on it (similar appearance to pudding) on the floor behind the ice machine.

Continued observations on May 6, 2025, at 1:24 p.m. in the 1-North pantry surveyors observed two roaches (1 dead and 1 alive) in the drawers of the cabinet.

On May 6, 2025, at 10:02 a.m., an interview was conducted with Resident Resident R127, who stated, Do you hear a mouse making a peep noise? There's a trapped mouse next to my bed by the window that a baby mouse has been caught in that mouse trap.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 39 395203 Department of Health & Human Services Printed: 08/27/2025 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 395203 B. Wing 05/08/2025

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

Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

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 At 10:15 a.m. the same day, the Maintenance Director, Employee E25 confirmed the observation in room [ROOM NUMBER], verifying that a live mouse was caught in a trap next to Resident Resident R127's bedside window. Level of Harm - Minimal harm or potential for actual harm A review of the pest control log for the second-floor south nursing unit revealed no recorded observations of mice after March 23, 2025, when sightings were noted in rooms [ROOM NUMBERS]. The previous entry Residents Affected - Some was dated February 18, 2025.

On May 6, 2025, at 10:23 p.m., an interview with Resident Resident R52 revealed that she/he had seen two mice running inside her room [ROOM NUMBER]-D yesterday. Resident Resident R52 reported to a staff. This was not recorded in the pest control logbook.

At 10:24 p.m., an interview was conducted with Licensed Nurse, Employee E27, who reported seeing a mouse in the medication room the previous week. However, she acknowledged that she did not document

the sighting in the pest control log.

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 39 of 39 395203