Pennsylvania Department of Health
AVENTURA AT PROSPECT
Patient Care Inspection Results

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AVENTURA AT PROSPECT
Inspection Results For:

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AVENTURA AT PROSPECT - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to three complaints completed on June 6, 2024, it was determined that Aventura at Prospect was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.





 Plan of Correction:


483.10(j)(1)-(4) REQUIREMENT Grievances:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:


Based on interviews with facility staff and review of facility documentation, it was determined that the facility did not initiate the grievance process for one of three residents reviewed (Resident R2).

Findings include:

Review of facility documents revealed that resident R2 reported an incident of alleged verbal abuse to administration. The incident occurred on May 9, 2024. The nature of the allegation was that the resident asked to change the TV channel and a nursing aide yelled at the resident.

An interview was conducted with Nursing Home Administrator, Employee E1 on June 6, 2024, at 1:00 p.m. Employee E1 confirmed that he and the director of nursing met with the resident regarding her concern. The allegation of verbal abuse was reported to the State Survey Agency and that an investigation was initiated. Employee E1 acknowledged that the resident's complaint was not processed as a grievance.

28 Pa. Code 201.29(a)(d)(k) Resident rights





 Plan of Correction - To be completed: 07/11/2024

- Corrective action: All reported allegations of abuse will be recorded and processed as a grievance by 07/11/2024

- Identified Others: No like residents identified

- Measures implements: NHA and DON were educated on grievance policy and recording complaints of abuse as a grievance in addition to reporting to DOH ERS by 07/11/2024

- Monitoring: To monitor and maintain ongoing compliance, the Administrator/Designee will audit DOH ERS weekly x4, then monthly x2 to ensure all complaints of abuse are recorded and processed as a grievance.


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