Aventura at Creekside

Inspectors wroteBased on a review of clinical records and staff interviews, it was determined the facility failed to ensure residents who lacked the ability to make medical decisions had an identified authorized representative and failed to ensure documentation of advance directives or evidence the resident was offered information regarding the right to formulate an advance directive. The facility failed to ensure medical treatment decisions were made by an appropriate legally authorized decision maker for three of 19 residents reviewed (Residents 13, 27, and 51).

Inspectors wroteBased on review of facility policy, Resident Council meeting minutes, grievance documentation provided by the facility, and resident and staff interviews, it was determined the facility failed to make reasonable efforts to address concerns raised by the Resident Council and failed to keep residents informed regarding the status and outcome of identified concerns. The facility failed to ensure ongoing communication and timely follow-up regarding issues presented by eight of eight residents attending a Resident Council group meeting (Residents 8, 14, 22, 33, 35, 54, 55, and 68).

Inspectors wroteBased on observations and staff interview, it was determined the facility failed to provide housekeeping services necessary to maintain a clean and sanitary environment, including resident care equipment, for two of 19 residents reviewed (Residents 9 and 28).

Inspectors wroteBased on clinical record review, policy review, resident observation, and staff interviews, it was determined the facility failed to identify the use of a physical restraint and failed to implement facility policy regarding the use of restraints for one of 19 residents reviewed (Resident 10).

Inspectors wroteBased on a review of the facility's abuse prohibition policy, employee personnel files and staff interviews, it was determined the facility failed to implement procedures to fully screen three employees out of five to ensure they were eligible for employment in a long term nursing care facility. (Employees 1, 2, and 3).

Inspectors wroteBased on review of the Resident Assessment Instrument (RAI) Manual, clinical records, and staff interviews, it was determined the facility failed to complete an accurate Minimum Data Set (MDS) for three of 19 residents reviewed (Resident 10, Resident 11, and Resident 23).

Inspectors wroteBased on a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to ensure the comprehensive person-centered care plan was implemented consistently and accurately reflected resident-centered measures to meet each resident's assessed needs for two of 19 residents reviewed (Residents 10 and 11).

Inspectors wroteBased on clinical record review, review of personnel records, and staff interviews, it was determined the facility failed to ensure nursing services met professional standards of quality as required by the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to verify Licensed Practical Nurses possessed the required education, training, and demonstrated competency for the administration of an intravenous (IV) medication via peripheral inserted central venous catheter (PICC) for one of 19 residents reviewed (Resident 5).

Inspectors wroteBased on a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure licensed nurses accurately administered medication in accordance with physician orders for one of 19 residents reviewed (Resident 20).

Inspectors wroteBased on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure pain management was provided according to physician orders, including implementation of ordered parameters and nonpharmacological interventions, for one of 19 residents reviewed (Resident 1).

Inspectors wroteBased on a review of clinical records and staff interviews, it was determined the facility failed to ensure the attending physician acted upon and documented a clinical rationale regarding consultant pharmacist identified medication regimen irregularities for one of 19 residents reviewed (Resident 4).

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure a resident's drug regimen was free from the use of an unnecessary antibiotic for one of 19 residents reviewed (Resident 8). Findings Include:A review of Resident 8's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia (a progressive condition involving decline in memory, thinking ability, and reasoning beyond normal aging) and muscle weakness. A review of the facility policy titled Antibiotic Stewardship, last reviewed by the facility on September 25, 2025, indicated antibiotics are prescribed only when there is sufficient clinical evidence of an active infection. [...]

Inspectors wroteBased on observation, a review of select facility policy, and staff interviews it was determined that the facility failed to ensure the kitchen was maintained in a manner to ensure food was stored, prepared, distributed, and served under sanitary conditions and free of pest infestation. The presence of live and dead cockroaches in food preparation and storage areas created a high risk of contamination of food, utensils, and food-contact surfaces with disease-causing organisms. This failure created an increased potential for foodborne illness and placed 80 out of 80 residents in a situation of Immediate Jeopardy to their health and safety.

Inspectors wroteBased on a review of facility policy, observations of the food and nutrition services department, interviews with facility staff, and review of pest control records, it was determined that the facility failed to maintain an effective pest control program to ensure the facility was free of insects/pests, specifically cockroaches.

Inspectors wroteBased on review of clinical records, the facility's abuse prohibition policy, and select investigative reports and interviews with staff and residents it was determined the facility failed to ensure that one resident (Resident 49) out of 19 residents sampled was free from physical abuse perpetrated by a facility staff member This failure to prevent, identify, and respond appropriately to physical abuse placed Resident 49 and all other residents in the facility at risk for further harm, resulting in Immediate Jeopardy.

Inspectors wroteBased on observation, review of select facility policies, and staff interviews, it was determined that the facility failed to store, prepare, and serve food under sanitary conditions to prevent potential contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department.

Inspectors wroteBased on clinical record review, staff interviews, and review of the facility's abuse prohibition policy, it was determined that the facility failed to ensure allegations of abuse were reported to the State Survey Agency within 24 hours of the incident and failed to submit completed investigation findings within five (5) working days, for two of four abuse allegations reviewed (Residents 8 and 9).

Inspectors wroteBased on a review of clinical records, the facility's abuse prohibition policy and information provided by the facility it was determined the facility failed to promptly conduct a thorough investigation to rule out abuse and implement corrective action and submit the results of the completed investigation to the State Survey Agency within five working days of the incident as evidenced by two of 4 residents reviewed (Resident 9 and 8).

Inspectors wroteBased on a review of clinical records, select facility policy, observations, and resident and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered in accordance with physician's orders for three of 20 residents reviewed (Residents 13, 79, and 85).

Inspectors wroteBased on observation, review of select facility policy, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of two medication carts observed (Lilac Hall).

Inspectors wroteBased on a review of clinical records, select investigative reports, and employee job descriptions and staff interview it was determined the facility's administration failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental functioning of residents in the facility by failing to prevent the physical abuse of one resident (Resident 49) out of 5 sampled residents.

Inspectors wroteBased on a review of clinical records and interviews with staff, it was determined the facility the facility did not identify and respond to significant unplanned weight loss for one of 20 sampled residents . (Resident 9).

Inspectors wroteBased on a review of facility policies, medication count records, and staff interviews, it was determined that the facility failed to ensure nursing staff consistently follow established procedures for verifying and documenting the count of controlled substances at shift change on two of two medication carts observed.

Inspectors wroteBased on resident billing record review, clinical record review, facility document review, and staff interview, it was determined the facility failed to provide advance written of a private pay rate increase for 1 of 2 residents reviewed for billing notification of charges (Resident 18).

Inspectors wroteBased on review of clinical records, facility policy, observation, and resident and staff interviews, it was determined that the facility failed to implement its established smoking policy to ensure resident safety and regulatory compliance. Specifically, the facility failed to post smoking policies in a conspicuous and legible manner, ensure required smoking safety equipment was available in the designated smoking area for 12 residents who smoke, and assess one cognitively intact resident (Resident 1) who requested to smoke for safe smoking practices out of 6 residents sampled. These failures created a potential for fire hazards and compromised resident safety.

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to ensure that the discharge process honored the resident's preferences and goals and failed to demonstrate that the discharge was appropriate and necessary, for one of six sampled residents (Resident 1).

Inspectors wroteBased on a review of clinical records, investigative reports, staff interviews, and facility documentation, it was determined the facility failed to consistently ensure adequate supervision, staff training, and implementation of appropriate individualized interventions to prevent accidents for three residents (Residents 1, 2, and 3) out of 10 sampled resulting in harm including skin ters, lacerations and a head injury requiring staples.

Inspectors wroteBased on resident billing record review, clinical record review, facility document review, and staff interview, it was determined the facility failed to provide advance written notice of a per diem (daily) room rate increase for 1 of 2 residents reviewed for billing notification of charges (Resident 1).

Inspectors wroteBased on observation of the main kitchen and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness for 78 of 78 residents residing in the facility.

Inspectors wroteBased on observations, review of clinical records and staff interview it was determined that the facility failed to ensure therapeutic devices to provide support and maintain proper positioning were applied for one two of 19 residents reviewed (Resident 48).

Inspectors wroteBased on a review of select facility policy, clinical records, and staff interview, it was determined that the facility failed to thoroughly assess and evaluate bowel and bladder function and implement individualized approaches to restore normal bowel and bladder function to the extent possible for four out of 19 sampled residents (Resident 20, 48, 3 and 22).

Inspectors wroteBased on a review of clinical records and staff interview it was determined that the facility failed to ensure that the pharmacist conducted medication regimen reviews at least monthly for two residents out of five sampled (Resident 42 and 54 ).

Inspectors wroteBased on a review of the facility's planned cycle menus, observations, and staff interview it was determined that the facility failed to follow planned menus for 4 of 4residents requiring a pureed diet.

Inspectors wroteBased on observations, review of test tray results and staff interview, it was determined that the facility failed to serve foods at safe and palatable temperatures for 1 out of 5 residents.

Inspectors wroteBased on observations and resident and staff interviews, it was determined the facility failed to provide food that accommodated residents' preferences for four residents of 9 residents reviewed (Resident 8, 60, 58, and 49).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to demonstrate systematically organized, readily accessible and secured resident medical records.

Inspectors wroteBased on review of select facility policies and the facility's infection control tracking log, and staff interview, it was determined that the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility, including protocols and provisions for Enhanced barrier precautions and their implementation for 5 of five residents observed (Residents 42, 22, 48, 15, and 24).

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure that essential equipment was in safe operating condition in the facility's storage area.

Inspectors wroteBased on select facility policy, observations of the food and nutrition services department, and staff interview, it was determined that the facility failed to maintain an effective pest control program.

Inspectors wroteBased on resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life and assures that each resident is treated with dignity by failing to respond timely to residents' requests for assistance, as evidenced by experiences reported by five of five residents sampled (Residents 4, 16, 14, 2, and 70).

Inspectors wroteBased on observation staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment.

Inspectors wroteBased on clinical record review and staff interviews, it was determined the facility failed to develop person-centered care plans that included individual behavioral management for one resident and smoking for two residents out of 18 sampled (Residents 56, 58 and 60).

Inspectors wroteBased on clinical record review and resident and staff interview it was determined the facility failed to develop and implement an individualized discharge plan for one of 18 residents sampled (Resident 47). Findings Include: A review of facility policy titled Discharge Summary and Plan last reviewed July 2024 revealed that every resident will be evaluated for his or her discharge needs, the discharge plan will be reevaluated based on changes in the residents needs or condition, and residents will be asked about their interest in returning to the community. A review of the clinical record of Resident 47 revealed admission to the facility on July 14, 2020, with diagnoses including bipolar disorder. [...]

Inspectors wroteBased on review of select facility policy and clinical records, and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to demonstrate that licensed nurses fully evaluated a resident's status after an unwitnessed fall for one resident (Resident 8) out of 19 residents reviewed.

Inspectors wroteBased on a review of clinical and select facility policy, information submitted by the facility, it was determined that the facility failed to provide a resident who sustained repeated falls effective fall interventions to prevent the resident from falling for one of the 19 sampled residents (Resident 10).

Inspectors wroteBased on a review of select facility policy, observation, and staff interview, it was determined that the facility failed to maintain respiratory equipment in a manner to promote optimal functioning for one resident out of 19 sampled residents (Resident 48).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for one resident (Resident 24) of 19 residents reviewed.

Inspectors wroteBased on facility documentation review, policy review, clinical record review, and staff interview, it was determined that the facility failed to provide pharmaceutical services to ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate accounting of controlled drugs when acquiring, receiving, dispensing, and or administering to identify possible diversion for one of three residents reviewed (Resident 76).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to show adequate monitoring of behaviors and potential adverse consequences of psychoactive drug use and failed to consistently attempt non-pharmacological interventions prior to the administration of psychoactive drugs for one resident out of 19 residents reviewed (Resident 24).

Inspectors wroteBased on observation, select facility policy review and staff interview, it was determined the facility failed to implement and adhere to procedures to ensure acceptable storage and use by dates for multi-dose medications in the medication storage room.

Inspectors wroteBased on a review of the facility's plan of correction from the survey ending October 4, 2024, the outcome of the activities of the facility's quality assurance committee, a review of clinical records, and staff interview it was determined the facility failed to effectively identify ongoing deficient practices related to unnecessary psychotropic medication.

Inspectors wroteBased on a clinical record review and staff interview, it was determined that the facility failed to ensure that the necessary resident information was communicated to the receiving health care provider for one out of the 19 residents sampled with facility-initiated transfers (Residents 30).

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a written notice regarding emergency transfer to the hospital was provided to the resident and resident's responsible party for one resident out of 19 residents sampled (Resident 30)

Inspectors wroteBased on a review of clinical records and staff interview it was determined that the facility failed to provide evidence of written information of the facility's bed hold policy was provided upon transfer to the hospital of one resident out of 19 residents sampled (Resident 30).

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to provide care consistent with a resident's advanced directive and honor the resident's requests for future treatment for one resident out of four sampled (Resident 1).

Inspectors wroteBased on a review of clinical records and grievances lodged with the facility and staff interview it was determined that the facility failed to ensure that residents receive services to maintain hearing ability for one of four residents sampled (Resident 1).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness, in the dietary department and the resident unit food storage area.

Inspectors wroteBased on staff interviews and a review of documentation provided by the facility, it was determined that the facility failed to conduct a facility wide assessment that accurately reflected the personnel and specific resources presently available and to identify those that are necessary to care for its current resident population.

Inspectors wroteBased on a review of grievances filed with the facility and the minutes from Residents' Council meetings and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by three out of the 10 residents sampled (Residents 11, 17, and 50).

Inspectors wroteBased on observations, review of clinical records and staff interviews, it was determined that the facility failed to conduct meal service in a manner respectful of each resident's personal dignity for two residents observed during meals (Residents 61 and 68), failed to maintain a respectful environment as evidenced by observation of staff conduct and behaviors and as reported by two residents (Resident 50 and 17) and failed to ensure that resident maintained a dignified personal appearance for two of the 10 residents sampled (Residents 29 and 66).

Inspectors wroteBased on observation and resident and staff interviews it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment in three of the three nursing halls.

Inspectors wroteBased on a review clinical record, the facility's plan of correction from the survey ending May 16, 2024, observations and the outcome of the activities of the facility's quality assurance committee it was determined that the facility failed to develop and implement a quality assurance plan, which was able to identify, and correct ongoing quality deficiencies related to providing a safe, clean and homelike environment.

Inspectors wroteBased on a review of clinical records and select incident reports, and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to demonstrate that a registered nurse promptly assessed a resident displaying possible signs and symptoms of a potential change in condition for one resident (Resident 38) out of 15 sampled residents sampled.

Inspectors wroteBased on a review of clinical records and select facility policy and staff interviews it was determined that the facility failed to consistently and accurately monitor resident weights to timely identify changes in nutritional parameters for two residents out of 15 sampled (Residents 51 and 47).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice, by failing to ensure that a resident's clinical record included details related to injuries sustained post incidents with changes in medical status for one out of 15 sampled residents (Resident 38).

Inspectors wroteBased on observation, staff interviews and a review of employee credentials and current staffing of the facility's food and nutrition services department it was determined that the facility failed to consistently provide qualified staff to provide oversight of the food and nutrition services department.

Inspectors wroteBased on observations, review of the facility's planned written menus, menu extensions, and select facility policy, and staff interviews, it was determined that the facility failed to follow planned menus, failed to ensure that the facility's dietitian periodically updated the planned menus to reflect variety, the preferences of the current resident population and nutritional adequacy and failed to assure consistent availability of food to serve the emergency menu in the event of an emergency.

Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to provide adaptive dining equipment as required by one of seven residents reviewed (Resident 1).

Inspectors wroteBased on a review clinical records, the facility's plan of correction from the survey ending March 13, 2024, and the outcome of the activities of the facility's quality assurance committee it was determined that the facility failed to develop and implement a quality assurance plan, which was able to identify and correct ongoing quality deficiencies related to adherence to written menus and menu planning to meet the needs and preferences of residents

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and the resident pantry.

Inspectors wroteBased on observation and staff interview it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment and resident care equipment in one resident room out of 34 (room [ROOM NUMBER]) and as observed for one resident on the one resident unit in the facility.

Inspectors wroteBased on observations and staff and resident interview it was determined that the facility failed to maintain an environment free of potential accident hazards on one of one nursing unit

Inspectors wroteBased on observations and staff interview it was determined that the facility failed to provide each resident with a clean mattress on one bed out of 81 available in the facility (Resident room [ROOM NUMBER]). Findings revealed: Observations of resident room [ROOM NUMBER] on January 24, 2024, at 11:25 AM revealed that the resident bed located by the door was stripped of its bottom fitted sheet. Further observation of the exposed mattress on the bed revealed that there were distinct dirty shoe footprints visible on top of the mattress. Interview with the Nursing Home Administrator on January 24, 2024, at approximately 2:30 PM confirmed the facility is to provide a clean and sanitary mattress for each resident. 28 Pa.