Health inspection·August 14, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical record review, the nurse practice act, and resident and staff interviews, it was determined that the facility failed to provide care and services according to accepted standards of clinical practice in the medication procurement and administration for residents with a noted allergy which resulted in harm as evidenced by a rash for one of 11 residents reviewed (Resident 9). Residents Affected - Few Findings Include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (1) undertake a specific practice only if the licensed practical nurse has the necessary knowledge, preparation, experience, and competency to properly execute the practice. Clinical record review revealed that Resident 9 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus. A review of a quarterly Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 2, 2024, revealed her to be cognitively intact with a BIMS (Brief Interview for Mental Status - a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 14 indicating that the resident is cognitively intact. A review of nurse's note dated August 9, 2024, at 2:26 PM, revealed Resident 9 complained of burning/itching to the vaginal area, and that the nurse practioner was made aware. A Physician's order dated August 9, 2024, included an order for Diflucan (an oral antifungal medicine that treats and prevents fungal infections in various parts of the body) 200 mg one time dose by mouth. A review of Resident 9's August 2024 medication administration record (MAR) revealed that Diflucan 200 mg by mouth was administered to Resident 9 on August 9, 2024, at 5:55 PM. A review of nurse's note dated August 11, 2024, at 6:31 AM, revealed Resident 9 received Diflucan on August 9, 2024, at 6 PM. The Resident was allergic to Diflucan as listed in her chart. The Page 1 of 6 395414 395414 08/14/2024 Aventura at Terrace View 260 Terrace Drive Peckville, PA 18452

F 0658 Level of Harm - Actual harm Residents Affected - Few Resident approached the writer with signs and symptoms of an allergic reaction, including pruritic circular rash areas located on left upper extremity, posterior trunk (back side of the body), anterior (front side of the body) trunk, bilateral legs. Resident stated she first noticed the areas on August 10, 2024, shortly after waking, and was told that nursing staff would look into getting an order for hydrocortisone cream due to pruritus (itchy rash). It was noted that the Supervisor assessed the Resident as well, multiple failed attempts were made to reach the attending Physician, and noted to notify oncoming staff (7 AM to 3 PM) and encourage staff to contact attending Physician for appropriate orders for allergic reaction. A review of a nurse's note dated August 11, 2024 at 11:20 AM, revealed that the licensed nurse called the Attending Physician regarding the Resident's reaction to Diflucan given the prior night at 6:00 PM. The Physician ordered Benadryl (antihistamine medication) 50 mg three times a day for one day and Hydrocortisone (steroid cream) 1% for three days. Review of the MAR revealed that Benadryl 25 mg, give two tabs (50 mg) was administered to Resident 9 on August 11, 2024, at 4:00 PM. There was no evidence at the time of the survey that the Resident was given the additional two doses of the Benadryl that was Physician ordered. A review of a facility investigation dated August 9, 2024, at 5:00 PM, revealed Resident 9 had a documented allergy to the medication Diflucan. The medication was ordered by the Nurse Practioner on August 9, 2024. The Resident's care plan and the electronic face sheet indicated that the Resident had the noted allergy, however, when a medication is entered into the electronic clinical record as a verbal Physician order, the expected warning from the system did not appear. Employee 3 (LPN) entered the Physicians order for the diflucan into the electronic physician's ordering system without checking for an allergy. The medication was scheduled to be given Friday August 9, 2024, at 5:00 PM. The medication needed to be accessed from the electronic emergency system (PYXIS) located on the B2 resident unit. Employee 5 ( LPN) accessed the Diflucan 200 mg tablet from the PYXIS system and brought it to the floor. She did not check for allergies as the PYXIS system did not alert the nurse of the noted allergy prior to removing the medication from the machine. Employee 4 (LPN) administered the medication to the Resident August 9, 2024, at 5:55 PM. This Employee failed to check the Resident's allergies prior to administering the medication. A review of a witness statement dated August 9, 2024 at 12:30 PM, Employee 3 (LPN) stated, I received the order for Diflucan and entered it into the system. I asked another LPN to pull the med for me (from the PYXIS). I didn't verify the resident's allergies upon receiving the order was entered. I passed the medication on to the next shift (3 PM to 11 PM). A review of a witness statement dated August 9, 2024, (no time indicated) Employee 5 (LPN) stated, [Employee 3] asked me to pull the medication (Diflucan) from the PYXIS and bring it over to him. I pulled the med, no warning/alert was given in the PYXIS. Took the med over to [Employee 2 (LPN)]. I did not look at the allergies prior to pulling the med out of the machine. During an interview August 14, 2024, at 1:00 PM, Resident 9 stated that when she received the 395414 Page 2 of 6 395414 08/14/2024 Aventura at Terrace View 260 Terrace Drive Peckville, PA 18452

F 0658 Level of Harm - Actual harm Residents Affected - Few medication on Friday August 9, 2024, the nurse did not tell her what the medication was that she was receiving. She stated that she told nursing staff on August 10, 2024, that she had an itchy rash all over. She stated that nursing staff stated that they would get her something for it. She stated that she received benadryl one time and was still receiving the hydrocortisone cream, but some of the itchy rash was still there. An observation at the time of the interview revealed patchy red spots remained on the Resident's legs, arms, and torso. She stated that the areas were a little itchy. An interview August 14, 2024, at 2:00 PM, the Assistant Director of Nursing (ADON) stated that upon discovery of this event, it was noted that the allergy alerts in both the electronic clinical records and in the PYXIS system for all the Residents in the facility had been turned off by a previous Director of Nursing (DON) at the facility. It could not be determined at the time of the survey how long these alerts were not functioning. During an interview August 14, 2024, at 2:15 PM, the DON and the Nursing Home Administrator (NHA) stated that upon discovery of the event, the pharmacy was notified and made an immediate visit to the facility to rectify the issue. Interview with the DON and NHA failed to ensure that licensed nursing staff possessed the skills and competencies related medication procurement and administration. cross refer F755 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services 28 Pa. Code 211.10(a)(d) Staff development 395414 Page 3 of 6 395414 08/14/2024 Aventura at Terrace View 260 Terrace Drive Peckville, PA 18452

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on select policy review, clinical record review and staff interviews, it was determined that the facility failed to ensure current pharmacy policy and procedures were in the facility available to staff for use and failed to ensure safety features were functioning to ensure safe medication administration for one of 11 residents reviewed (Resident 9). Finding include: A review of a facility investigation dated August 9, 2024, at 5:00 PM, revealed Resident 9 had a documented allergy to the medication Diflucan. The medication was ordered by the Nurse Practioner on August 9, 2024. The Resident's care plan and the electronic face sheet indicated that the Resident had the noted allergy, however, when the medication was entered into the electronic clinical record as a verbal Physician order, the expected warning from the system did not appear. Employee 3 (Licensed Practical Nurse [LPN]) entered the Physician's order for the diflucan into the electronic physician's ordering system without checking for an allergy. The medication was scheduled to be given Friday August 9, 2024, at 5:00 PM. The medication needed to be accessed from the electronic emergency system (PYXIS) located on the B2 resident unit. Employee 5 ( LPN) accessed the Diflucan 200 mg tablet from the PYXIS system and brought it to the floor. She did not check for allergies as the PYXIS system did not alert the nurse of the noted allergy prior to removing the medication from the machine. Employee 4 (LPN) administered the medication to the Resident August 9, 2024, at 5:55 PM. This Employee failed to check the Resident's allergies prior to administering the medication. A review of a witness statement dated August 9, 2024, at 12:30 PM, Employee 3 (LPN) stated, I received the order for Diflucan and entered it into the system. I asked another LPN to pull the med for me (from the PYXIS). I didn't verify the resident's allergies upon receiving the order was entered. I passed the medication on to the next shift (3 PM to 11 PM). A review of a witness statement dated August 9, 2024, (no time indicated) Employee 5 stated, [Employee 3] asked me to pull the medication (Diflucan) from the PYXIS and bring it over to him. I pulled the med, no warning/alert was given in the PYXIS. Took the med over to [Employee 2 (LPN)]. I did not look at the allergies prior to pulling the med out of the machine. An interview August 14, 2024, at 3:00 PM, the Assistant Director of Nursing (ADON) stated that upon discovery of this event, it was noted that the allergy alerts in both the electronic clinical records and in the PYXIS system for all the Residents in the facility had been turned off by a previous Director of Nursing (DON) at the facility. It could not be determined at the time of the survey how long these alerts were not functioning. An interview August 14, 2024, at approximately 3:00 PM, the ADON confirmed that there were no current pharmacy policies and procedures in the facility at the time of the survey. When the surveyor asked for facility pharmacy policies, a binder with pharmacy policy dated 2018 was received. This policy and procedure manual did not include any information concerning the electronic medical system or the Pyxis system. 395414 Page 4 of 6 395414 08/14/2024 Aventura at Terrace View 260 Terrace Drive Peckville, PA 18452

F 0755 Level of Harm - Minimal harm or potential for actual harm The ADON stated that he inservices nursing staff to the PYXIS system by bringing them to the machine and verbally educating them. An interview August 14, 2024, at 3:15 PM, the DON confirmed that the most current issue of facility pharmacy's policies should be in the facility and available to staff. Residents Affected - Many cross refer F658 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services 28 Pa. Code 211.10(a)(d) Staff development 28 Pa Code 211.9(a)(1) Pharmacy services 395414 Page 5 of 6 395414 08/14/2024 Aventura at Terrace View 260 Terrace Drive Peckville, PA 18452

F 0803 Level of Harm - Minimal harm or potential for actual harm 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. Based on clinical record and document review, observations, and staff interviews, it was determined that the facility failed to ensure that planned food portions are served at meals for one meal observed. Residents Affected - Few Findings included: A review of resident clinical records indicated that there was 13 residents with Physician ordered puree diets in the facility at the time of survey. An observation of the lunch meal tray service line on August 14, 2024, at approximately from 11:45 AM to 12:30 PM, revealed that Employee 1 (Cook) was serving residents food behind the steam table. The puree vegetables were being served with a blue handled scoop. Employee 2 (Cook) stated that the blue handled scoop was a 3.5 oz portion. She confirmed that the puree vegetables should be served with grey handled scoop (4 ounces [oz]). A review of kitchen production sheets indicated for the lunch meal August 14, 2024, the puree vegetables portion size was noted as 4 oz. During an interview August 14, 2024, at 3:00 PM, the Certified Dietary Manager confirmed that the grey handled scoop (4 oz) should have been utilized for serving puree vegetables at lunch that day. 28 Pa Code 211.6(f) Dietary services 395414 Page 6 of 6