Pennsylvania Department of Health
AVENTURA AT PROSPECT
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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 one complaint and one facility reported incident, completed on August 26, 2026, 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 Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition:

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.

§483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Observations:

Based on review of facility policy, review of facility investigation/documentation, review of clinical records, and staff interviews it was determined that the facility failed to ensure that resident essential equipment was maintained in a safe operating condition for one of eight resident wheelchairs observed (Resident R1).

Findings include:

Review of facility policy on Assistive Devices and Equipment dated February 2021, revealed that under section POLICY STATEMENT: Our facility maintains and supervises the use of assisted devices and equipment for residents. under section policy interpretation and implementation #4 the following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment. #C. Devise condition - devices and equipment are maintained on schedule and according to manufacturer's instructions. Defective or worn devices are discarded or repaired.

Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on May 11, 2026, with diagnoses of but not limited to bipolar disorder (also known as manic depression, is a mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior), and sleep disorder.

Review of Resident R1's Minimum Data Set (MDS - federally required resident assessment completed at a specific interval) dated May 17, 2026, revealed that C0500. BIMS (Brief Interview for Mental Status Score) Summary Score was coded as 15, suggesting that Resident R1 was cognitively intact.

Review of Resident R1's progress note dated August 12, 2026, revealed Resident R1 rolled oob (out of bed) to right side onto floor while sleeping and sustained a laceration to L (left) lower extremity. Per the progress note, Resident R1 may have banged leg on wheelchair that was at bedside.

Review of the facility investigation regarding Resident R1's fall revealed that the incident occurred on August 12, 2026, at 1:00 a.m.

Review of statement by licensed nurse, Employee E4, dated August 12, 2026, revealed that prior to the event (fall), Resident R1's "wheelchair was on the right side of the bed near the bottom of bed". Further review of statement by Employee E4 revealed, "Resident R1 stated he/she was sleeping and fell out of bed".

Review of statement by licensed nurse, Employee E3, dated August 12, 2026, under section Environmental factors that may have contributed to the event- revealed that after fall, Resident R1's leg came in contact with wheelchair.

Review of "Post Event Staff Interview" completed by Licensed nurse, Employee E3 dated August 12, 2026, revealed that under question: "Were there any other environmental factors (et floor, faulty equipment, etc.) that may have contributed to the event?", was answered Resident R1 "wheelchair at bed side". Under question "In your own words, what do you think caused this event, was answered "wheelchair at bedside contribute tolaceration on LLE (left lower extremity)".

Observation on August 26, 2026, at 8:48AM revealed that Resident R1 was in bed, awake, and dressing to Resident R1's right lower extremity. Further, a wheelchair was observed to the right of Resident R1's bed, facing towards the head of the bed. Further observation revealed that the right metal brake handle of the wheelchair did not have a rubber covering leaving the metal handle exposed.

Interview on August 26, 2026, at 8:48AM with Resident R1 revealed that he/she was sleeping and did not remember rolling out of bed. Resident R1 woke up when face hit the floor. Further Resident R1 revealed that his/her wheelchair was on the right side of her bed facing towards the head of the bed. Further Resident R1 revealed that she/he must have rolled towards the right side of the bed and hit his/her left leg on the wheelchair.Further interview with Resident R1 revealed that at the time of the incident, the handle of her wheelchair did not have a rubber cover.

Follow-up observation of Resident R1's wheelchair conducted on August 26, 2026, at 9:33AM with the Director of Rehab Employee E5 revealed that the right break handle of Resident R1's wheelchair did not have a protective rubber cap exposing the metal brake. Interview with Employee E5 conducted at the time of the observation confirmed that resident R1's brake handles did not have a protective rubber cap. Employee E5 stated it should have a protective rubber cap and that she will immediately replace the missing rubber cap.

28 Pa. Code 201.14 (a) Responsibility of licensee

Plan of Correction - To be completed: 09/30/2026

1. Resident R1 wheelchair was checked for safety. Rubber cap on wheelchair brake was replaced
2. All residents have the potential to be affected.
Audit completed by maintenance director/designee of wheelchairs for risk of harm.
3. Education was initiated by NHA/designee for maintenance department on preventative maintenance checks for resident essential equipment.
4. NHA/designee will complete random audits of wheelchairs for safety concerns. The audits will be weekly for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly Quality Assurance and Performance Improvement meeting. Based on the results of these audits a decision will be made regarding the need for continued submissions and reporting.

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program:

§483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

Observations:
Based on observation and interview with residents, it was determined that the facility failed to maintain an effective pest control management program for one of three units observed (first floor unit).

Findings include:

Review of facility policy on Pest Control dated April 1, 2026, revealed that Under section POLICY STATEMENT: the facility shall maintain an effective pest control program. Under section POLICY IMPLEMENTATION AND IMPLEMENTATION: 1 the facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents.

Observations on August 26, 2026, at 8:28AM in floor-floor pantry, in the cabinet under the pantry counter, revealed clutter which included a mix of personal items such as an insulated bag, a cup, a thermos, and an open plastic bag. Further observations revealed a live roach running inside the cabinet.

Interviews with several residents revealed they observed cockroaches in their rooms.

Interview with the Nursing Home Administrator, Employee E1, revealed that she will have the pantry cabinets cleaned out.

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

Plan of Correction - To be completed: 09/30/2026

1. Unit pantries were deep cleaned on the day of survey.
2. All residents have the potential to be affected.
Audit completed of all resident rooms and pantries my Maintenance director/designee for cleanliness and pest entry locations.
3. Education was initiated by NHA/designee for maintenance and housekeeping to ensure cleanliness and pest entryways addressed.
4. NHA/designee will complete random audits of resident rooms/pantries for pest concerns. The audits will be weekly for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly Quality Assurance and Performance Improvement meeting. Based on the results of these audits a decision will be made regarding the need for continued submissions and reporting.

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