Inspection visit
Inspection
31 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 31 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based 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).
Findings include:
During a resident group interview with alert and oriented residents on October 2, 2024, at 10:00 AM, the
residents in attendance expressed concerns regarding the long wait times for staff to provide assistance
with their care when requested/needed. All five residents (Residents 4, 16, 14, 2, and 70) in attendance
stated that it often takes longer than 30 minutes for staff to answer their call lights. The residents stated that
often when they have to wait longer than 30 minutes they end up soiling themselves and having to sit in a
soiled brief waiting for staff to come take care of them.
The residents in attendance stated that they have brought this concern up to the facility staff many times
during resident council without any real resolution to their concerns. Review of grievances and resident
council minutes for the last three months showed that these concerns were not captured through resident
council meeting minutes or grievances.
During an interview on October 6, 2024, at approximately 11:00 AM, the Nursing Home Administrator
(NHA) and Director of Nursing (DON) verified that all residents at the facility should be treated with dignity
and respect. The NHA and DON were unable to explain why residents are reporting untimely staff
responses to residents' requests for assistance.
28 Pa. Code 201.18 (e)(1) Management
28 Pa. Code 201.29 (a) Resident Rights
28 Pa. Code 211.12 (c)(d)(4)(5) Nursing Services.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
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Facility ID:
If continuation sheet
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Event ID:
395984
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No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
An observation on October 1, 2024, at approximately 10:52 AM of the main dinning room revealed debris
and food particles on the floor. The floor was noted to be sticky. Dirty place setting were still on the table
from the breakfast meal service. A resident breakfast tray was still sitting on a table in the dining room.
An observation on October 1, 2024, at 2:02 PM in room [ROOM NUMBER], revealed a hole in the wall in
the residents' bathroom covered with plaster. The floor in the resident's bathroom was also noted to have
debris and dirt near the hole.
Observations on October 3, 2024, at approximately 8:40 AM revealed the main dining room had debris and
food particles on the floor. Further dried sticky spills were noted on the floor.
Interview with the Nursing Home Administrator on October 4, 2024, at approximately 1:30 PM confirmed
that the facility failed to maintain a clean and sanitary environment for the residents.
28 Pa. Code 201.18 (e)(2.1) Management
FORM CMS-2567 (02/99)
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Event ID:
Facility ID:
395984
If continuation sheet
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Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0622
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Not transfer or discharge a resident without an adequate reason; and must provide documentation and
convey specific information when a resident is transferred or discharged.
Based 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).
The findings include:
A review of Resident 30's clinical record revealed that the resident was transferred to the hospital on June
5, 2024, and returned to the facility on June 12, 2024.
There was no documented evidence that the facility had communicated specific information to the receiving
health care provider for the residents transferred and expected to return, including advance directive
information, special instructions, or precautions for ongoing care, as appropriate, or comprehensive care
plan goals to ensure a safe and effective transition of care.
During an interview on October 4, 2024, at approximately 1:30 PM, the Director of Nursing (DON) and
Nursing Home Administrator (NHA) confirmed that there was no evidence that the necessary information
was communicated to the receiving health care institution or provider upon transfer or discharge.
28 Pa. Code 201.14(a): Responsibility of Licensee
28 Pa. Code 201.29 (a) Resident rights
28 Pa. Code 211.12 (c)(d)(3) Nursing Services
FORM CMS-2567 (02/99)
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Event ID:
Facility ID:
395984
If continuation sheet
Page 3 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
Based 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)
Findings include:
A review of Resident 30's clinical record revealed that the resident was transferred to the hospital on June
5, 2024, and returned to the facility on June 12, 2024.
Clinical record review revealed no documented evidence written notices had been provided to this resident
and their responsible parties regarding each transfer that included the required contents: reason for the
transfer, effective date of the transfer, location to which the resident was transferred to, contact and address
information for the Office of the State Long-Term Care Ombudsman, and, if applicable, information for the
agency responsible for the protection and advocacy of individuals with developmental disabilities.
Interview with the Nursing Home Administrator on October 4, 2024 at approximately 1:30 PM, confirmed
that there was no evidence that written notifications of transfer were provided to the resident and the
resident's responsible party.
28 Pa. Code 201.29(h) Resident rights
28 Pa. Code 201.14(a) Responsibility of Licensee
FORM CMS-2567 (02/99)
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Event ID:
Facility ID:
395984
If continuation sheet
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Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0625
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
Based 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).
Findings include:
A review of Resident 30's clinical record revealed that the resident was transferred to the hospital on June
5, 2024, and returned to the facility on June 12, 2024.
There was no documented evidence that the resident and/or their responsible parties or legal
representatives were provided written information about the facility's bed-hold policy (an agreement for the
facility to hold a bed for an agreed upon rate during a hospitalization) at the time of transfer.
Interview with the Director of Nursing (DON) on October 4, 2024, at approximately 1:30 PM confirmed the
facility is unable to provide documented evidence of the provision of written notice of the facility's bed hold
policy upon hospital transfer.
28 Pa Code 201.18 (e)(1) Management
28 Pa Code 201.29 (b) Resident rights
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 5 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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).
Findings include:
A review of the clinical record revealed Resident 56 was admitted to the facility on [DATE], with diagnoses
to include depression.
A review of nursing progress notes beginning in September 2024 revealed Resident 56 was exhibiting an
increase in behaviors, particularly after his wife, who is also a resident in the facility, would be early in the
evening pushing resident back to his room and asking staff to put Resident 56 to bed. Resident 56 does not
like to go to bed early and becomes frustrated and agitated. These incidents and Resident 56's personal
preferences for bedtimes were not addressed on the resident's care plan reviewed during the survey ending
October 5, 2024.
A review of the clinical record revealed Resident 58 was admitted to the facility on [DATE] with a diagnosis
of Bipolar disorder (a mental illness characterized by mood swings) and muscle weakness (lack of muscle
strength).
A review of the documentation provided by the facility listed Resident 58 as a smoker. A review of Resident
58's care plan, last updated on May 24, 2024, determined that this was not addressed on the resident's
care plan.
A review of the clinical record revealed Resident 60 was admitted to the facility on [DATE]. Resident 60 was
admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (a lung condition that is caused by
damage and inflammation that limits airflow), and End Stage Renal Disease (an advanced stage of chronic
kidney disease).
A review of documentation by the facility listed Resident 60 as a smoker. A review of the resident's care
plan revealed smoking was not addressed on the resident's care plan.
Interview with the Nursing Home Administrator and Director of Nursing on October 7, 2024, at
approximately 1:30 PM confirmed the facility failed to ensure that comprehensive care plans were
developed.
28 Pa. Code 211.12 (d)(5) Nursing services
FORM CMS-2567 (02/99)
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Event ID:
Facility ID:
395984
If continuation sheet
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Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0660
Plan the resident's discharge to meet the resident's goals and needs.
Level of Harm - Minimal harm
or potential for actual harm
Based 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).
Residents Affected - Few
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.
An annual Minimum Data Set Assessment (MDS- standardized assessment process conducted at periodic
intervals to plan resident care) dated July 3, 2024, revealed the resident had a BIMS (brief interview to aid
in detecting cognitive impairment) score of 15, indicating that his cognition was intact.
Review of Resident 47's comprehensive care plan revealed a focus area dated December 26, 2023,
indicating the resident has been identified as a long-term placement. This discharge plan was not revised or
updated as of the time of the survey on September 20, 2024.
A review of social service notes between Resident 47's September 2023, and end of survey October 5,
2024, revealed no documented evidence that social services had discussed the residents discharge plans
and desires.
There was no documented evidence the resident's discharge care plan was assessed and updated as
needed.
Interview with the Nursing Home Administrator on October 4, 2024, at approximately 1:30 PM confirmed
the facility failed to revise and implement a discharge plan based on the resident's desire.
28 Pa. Code 201.25 Discharge policy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 7 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Few
Findings included:
According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State
Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans,
implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In
carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care
actions which promote, maintain, and restore the well-being of individuals (6)(b) The registered nurse is
fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care
delivered and Subsection 21.18. (a)(5) document and maintain accurate records.
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, understandings
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: (5) Document and maintain accurate records.
A review of Resident 8's clinical record revealed that the resident was admitted to the facility on [DATE],
with diagnoses that included diabetes and muscle weakness.
A progress note dated September 3, 2024, at 6:57 AM revealed the resident was found lying on his back on
the floor by his bed. Employee 5, (LPN) was called to his room by Resident 8's roommate. Employee 5's
nursing progress note indicated she assessed for injury and no apparent injury was noted. Neuro checks
and 15-minute checks were started per nursing note.
Further review of the resident's clinical record, conducted during the survey ending October 4, 2024,
revealed no documented evidence that an RN conducted an assessment of the resident after the
unwitnessed fall.
During an interview on October 3, 2024, at approximately 1:45 PM, the Nursing Home Administrator
verified that a licensed registered nurse had not completed an assessment after an unwitnessed fall
consistent with professional standards of practice.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 8 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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).
Findings include:
A review of Resident 48's clinical record revealed the resident was admitted to the facility on [DATE], with
diagnoses which included contracture (a permanent stiffening of the muscles, tendons, ligaments, skin, and
other tissues surrounding a joint that limits its range of motion) to the right and left ankle and contracture to
the right and left elbow.
Further review of the resident's clinical record revealed the resident was receiving restorative nursing and
was to have right and left ankle plantar flexion contracture boots (a type of boot that can help with
contractures, a condition that limits the ability to bend the foot and ankle downward) on in the morning and
off at night. Also, the resident was to have [NAME] elbow splints (soft splints that restricts painful
movement) to both elbows on in the morning and off at night.
Review of Resident 48's August 2024 Documentation Survey Report revealed the resident's contracture
boots were not placed on in the morning and/or removed at night 29 times for the month of August. Further
the resident's elbow splints were not placed on in the morning and/or removed at night 31 times for the
month of August.
Review of Resident 48's September 2024 Documentation Survey Report revealed the resident's
contracture boots were not placed on in the morning and/or removed at night 31 times for the month of
September. Further the resident's elbow splints were not placed on in the morning and/or removed at night
30 times for the month of September.
An observation of Resident 48 on October 1, 2024, at 12:59 PM revealed the resident's contracture boots
and elbow splints were not in place.
An observation of Resident 48 on October 2, 2024, at 10:02 AM revealed the resident's contracture boots
and elbow splints were not in place.
An interview with Employee 4 NA on October 2, 2024, at approximately 1:10 PM, confirmed the boots and
elbow splints were not on the resident. She looked in his room at that time and found the boots in the
resident's closet but could not locate his elbow splints. The employee stated she normally does not work on
that hall and was not familiar with the resident.
An observation on October 3, 2024, at approximately 9:15 AM revealed the resident's contracture boots
and elbow splints were not in place.
An interview with the Director of Nursing and Nursing Home Administrator on October 4, 2024, at
approximately 1:30 PM confirmed the facility failed to ensure therapeutic devices to provide support and
maintain proper positioning was applied to Resident 48.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 9 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0688
28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing Services.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 10 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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).
Findings include:
A review of facility policy titled Falls and Fall Risks, managing last reviewed by the facility on July8, 2024,
indicated that the facility will identify interventions related to the residents' specific risks and causes to
prevent the resident from falling and to try to minimize complications from falling.
Review of clinical records for Resident 10 was admitted to the facility on [DATE], with diagnoses that
included Schizophrenia (a mental illness that affects how a person thinks, feels and behaves) Anxiety (a
mental condition that causes a felling of worry, nervousness or unease) and hypertension (High blood
pressure).
Resident 10 has a documented history of falls, as noted in facility investigations and a clinical record review,
occurring on the following dates: July 4,2024, July 7, 2024, July 9,2024, July 11, 2024, July 12, 2024, July
29, 2024, August 2, 2024, August 17, 2024, August 22, 2024, August 23, 2024, August 31, 2024
September 14, 2024 September 20, 2024.
Resident 10's care plan-initiated July 3, 2024, indicated she is limited to extensive assistance with dressing,
personal hygiene, walking, transferring, toileting, change of position in bed and eating related to change in
mental status, decrease in functional ability. Her care plan, also indicated she has a progressive decline in
intellectual functioning characterized by deficit in memory, judgment and decision making and thought
process related to Dementia and Schizophrenia. Additionally, it indicated she has a potential for falls related
to her impulsivity and poor safety awareness.
Interventions implemented to mitigate Resident 10's risk of falling and protect her from injury included
ensuring her bed is in the lowest position, bilateral floor mats, a bed alarm, and ensuring the call bell is
within reach, and monitoring toilet needs initiated July 3, 2024.
A fall risk assessment dated [DATE], identified that Resident 10 is at a high risk for falling.
A review of Resident 10's care plan revealed that after falling on July 29th, 2024 there were no new
interventions put into place until September 21, 2024. A review of Incident Reports and progress notes
showed that Resident 10 had seven documented falls during this time.
An observation on October 3, 2024 at 9:35 AM revealed Resident 10 was in her wheelchair in her room,
attempting to get out of wheelchair with chair alarm sounding, the resident's call bell was attached to bed,
but unable to be reached.
During an interview on [DATE] at 10:50 AM, Employee 1, RN, confirmed that Resident 10's call bell was not
within reach, and her bed alarm was sounding.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 11 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0689
Level of Harm - Minimal harm
or potential for actual harm
During an interview on [DATE] at approximately 10:50 AM, the Nursing Home Administrator (NHA) and the
Director of Nursing confirmed it is the facility's responsibility to implement each resident's person-centered
care plan. The NHA confirmed that it is the facility's responsibility to ensure that all interventions identified
in Resident 10's care plan are implemented to mitigate Resident 10's risk for falls and injury.
Residents Affected - Few
28 Pa. Code 211.10(d) Resident care policies.
28 Pa. Code 211.12(c)(d)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 12 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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).
Findings include:
A review of facility policy entitled Urinary Incontinence last reviewed July 8, 2024, revealed it is the policy of
the facility to identify, assess, and provide the appropriate treatment and services to achieve or maintain as
much normal urinary function as possible. A three day bladder diary will be completed for every resident
upon admission, readmission, and as needed to determine if the resident requires a toileting plan or a
every two hour check and change program.
A review of the clinical record revealed that Resident 20 was admitted to the facility on [DATE], with
diagnoses which included cerebral palsy (a group of neurological disorders that affect a person's ability to
move, balance, and maintain posture.
A review of Resident 20's quarterly Minimum Data Set assessment (MDS- a federally mandated
standardized assessment process conducted periodically to plan resident care) dated June 5, 2024,
revealed that the resident was always continent of bowel.
A review of Resident 20's quarterly Minimum Data Set assessment dated [DATE], revealed that the resident
was now frequently incontinent of bowel.
The facility failed to assess the resident's new bowel incontinence after the decline was noted. Further the
facility failed to identify the resident's patterns of incontinence to develop and specific toileting plan to
restore bowel function to the extent possible for the resident.
A review of the resident's current plan of care revealed the plan of care failed to identify the resident's
incontinence status and specific interventions to address the resident's incontinence.
A review of Resident 48's clinical record revealed the resident was admitted to the facility on [DATE], with
diagnoses which included Parkinson's disease (a disorder of the central nervous system that affects
movement, often including tremors).
A review of Resident 48's quarterly Minimum Data Set assessment dated [DATE], revealed that the resident
was always incontinent of bowel and bladder.
A review of the resident's continence evaluation revealed the facility had not assessed the resident bowel
and bladder function since February 5, 2024. Further the assessment identify the resident is incontinent of
bowel and bladder. Under treatment options there was no documentation how often the facility would
provide maintenance care to the resident.
A review of the resident's current plan of care revealed the plan of care failed to identify the resident's
incontinence status and specific interventions to address the resident's incontinence.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 13 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0690
Level of Harm - Minimal harm
or potential for actual harm
An interview with the Director of Nursing on October 3, 2024, at approximately 11:00 AM revealed residents
that are always incontinent should be placed on a two hour check and change program to ensure the
resident is dry.
The facility failed to initiate a two hour check and change program for Resident 48.
Residents Affected - Some
A review of Resident 3's clinical record revealed the resident was admitted to the facility on [DATE], with
diagnoses which included Cerebral Palsy (a neurological disorder that affects muscle movement and
development)
A review of the resident's bladder and bowel evaluation dated January 4, 2024, revealed the resident was
always incontinent of bowel and bladder, has poor a potential for a toileting schedule, and was placed on an
incontinence care and comfort plan.
A review of the resident's current plan of care failed to identify the resident's urinary incontinence and
interventions to provide care and services.
A review of the resident's clinical record revealed the facility failed to document the resident's incontinence
care and comfort care plan was being implemented and completed each shift.
A review of Resident 22's clinical record revealed the resident was admitted to the facility on [DATE], with
diagnoses which included Acute Cystitis (inflammation of the bladder caused by bacterial infection), Urine
retention (a condition where a person is unable to empty their bladder) chronic kidney disease (a gradual
loss of kidney function).
An interview with Resident 22 on October 2,2024 at 10:45 AM revealed that many times the resident's
catheter bag is not emptied at the end of every shift, resulting in the resident's catheter bag having up to
1500 ml of urine in the bag. An interview on October 2,2024 at 1:20 PM stated that Resident 22's catheter
bag had 1500 ml of urine in it that morning when she was rendered AM care.
A review of report Documentation Survey Report revealed that the facility failed maintain routine catheter
care to Resident 22 each shift.
Interview with the Nursing Home Administrator on October 4, 2024, at approximately 1:30 PM confirmed
that the facility failed to thoroughly assess bowl and bladder function to properly identify the resident's
toileting needs.
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 14 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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).
Residents Affected - Few
Findings include:
A review of facility policy entitled Nebulizer Therapy last reviewed on July 8, 2024, revealed to care for the
nebulizer equipment the staff will clean the equipment after each use, disassemble parts after each
treatment, rinse the nebulizer cup and mouthpiece with water, shake off excessive water, and air dry on an
absorbent towel.
A review of Resident 48's clinical record revealed the resident was admitted to the facility on [DATE], with
diagnoses which included Parkinson's disease (a disorder of the central nervous system that affects
movement, often including tremors).
Further review of the resident's clinical record revealed a physician's order dated January 29, 2024 and
discontinued on August 19, 2024, a nebulizer (a small machine that turns liquid medication into a mist that
can be inhaled through a mouthpiece or mask) treatment of Ipratropium-Albuterol solution 0.5-2.5MG
(milligrams) per 3ML (milliliters) inhale 3ML orally via nebulizer every six hours as needed for shortness of
breath or coughing.
An observation on October 1, 2024, at 12:59 PM, revealed Resident 48 was lying in bed. A nebulizer
machine was noted on the resident's nightstand. The nebulizer machine had dried brown substance on top
on the machine. Black spots were also noted on the machine. The tubing and mask was sitting in a bag.
The tubing nor the bag was dated as to when the tubing went into use. The bag was noted to be visibly
dirty. There was a dried brown substance on the bag. The mask inside the bag was also visibly dirty with
dried spots noted on the mask.
An observation on October 2, 2024, at 10:02 AM, revealed the nebulizer machine was still sitting on the
resident's nightstand in the same condition as noted during the prior observation on October 1, 2024.
An observation on October 3, 2024, at 9:05 AM, revealed the nebulizer machine still had dried brown
substance and black spots on top on the machine. The tubing and the bag remained not dated. The bag
was still contained a dried brown substance on it and the mask inside the bag continued to be visibly dirty
with dried spots noted on the mask.
Interview with the Director of Nursing on October 3, 2024, at approximately 10:00 AM confirmed the facility
failed to maintain the residents' nebulizer equipment.
28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 15 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Few
Findings include:
A review of the clinical record revealed that Resident 24 was admitted to the facility on [DATE], with
diagnoses to include neuropathy ( a nerve condition that can cause a range of symptoms, including pain,
numbness, tingling, swelling, or muscle weakness) and hypertension (high blood pressure).
The resident had a current physician order initially dated September 10, 2024, for oxycodone ( a narcotic
pain medication) 15 mg (milligram) tablet give one tablet by mouth, every eight hours as needed for
moderate to severe pain.
A review of the resident's September 2024 Medication Administration Record (MAR) revealed that staff
administered the pain medication 29 times for the month of September. Of the 29 doses given, 24 doses
were administered with no non-pharmacological interventions attempted prior to giving the pain medication.
A review of the resident's October 2024 MAR revealed that staff administered the pain medication eight
times for the month of October. Of the eight doses given, six doses were administered with no
non-pharmacological interventions attempted prior to giving the pain medication.
A review of the resident's July 2024 MAR revealed that staff administered the pain medication July 3, 2024,
July 4, 2024, July 5, 2024, and July 12, 2024. Of the four doses given, two were administered with no
non-pharmacological interventions attempted prior to giving the pain medication.
Interview with the Nursing Home Administrator and Director of Nursing on October 4, 2024, at
approximately 1:30 PM confirmed that there was no evidence that non-pharmacological interventions were
consistently attempted and proved ineffective prior to administration of a as needed pain medication.
28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 16 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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).
Findings include:
Review of facility policy, titled Discharge Medications, last reviewed July 2024, revealed The nursing staff
shall forward completed drug disposition records to medical records. The complete list of the resident's
medications shall also be provided to the resident upon discharge.
Review of Resident 76's clinical record revealed the resident was admitted on [DATE] with diagnoses that
included diabetes.
Review of Resident 76's clinical record revealed they were discharged home from the facility on July 25,
2024.
Review of the resident's closed record revealed that there was no record of the disposition of the resident's
remaining supply of Alprazolam 0.5 mg (antianxiety medication) upon the resident's discharge to home on
July 25, 2024.
During an interview with the NHA on October 3, 2024, at 1:10 PM, he revealed he did not have any further
information to provide and would expect Resident 76's medication disposition was completed per facility
policy.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 17 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 ).
Findings include:
A review of Resident 42's clinical record revealed that the resident was admitted to the facility on [DATE],
with diagnoses to include dementia (the impaired ability to remember, think, or make decisions that
interferes with doing everyday activities).
A review of Resident 42's clinical record conducted at the time of the survey ending October 4, 2024,
revealed no evidence that the pharmacist had conducted drug regimen reviews at least once a month
between December 2023 and March 2024.
A review Resident 54's clinical record revealed the resident was admitted to the facility on [DATE], and had
diagnoses that included Picks Disease (A specific type of dementia that affects a person's ability to speak
and be understood), and Alzheimer's disease (a brain disorder that causes memory loss, thinking problems
and behavior changes).
A review of Resident 54's clinical record at the time of survey ending October 4, 2024, revealed no
evidence the pharmacist had conducted drug regimen reviews at least once a month between December
2023 and March 2024
During an interview with the Director of Nursing on October 3, 2024, at approximately 11:35 AM, it was
confirmed that there was no evidence the pharmacist conducted monthly medication regimen reviews as
required for Residents 42 and 54.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 18 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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).
Findings include:
A review of the clinical record revealed that Resident 24 was admitted to the facility on [DATE], with
diagnoses to include neuropathy ( a nerve condition that can cause a range of symptoms, including pain,
numbness, tingling, swelling, or muscle weakness) and hypertension (high blood pressure).
A review of physician orders revealed an order initially dated September 9, 2024, the resident had an order
for Ativan 1mg (psychotropic medication) give one tablet by mouth every eight hours as needed for anxiety.
The physician failed to include a stop date for the as needed psychotropic drug.
A review of a medication administration note dated September 15, 2024, at 11:22 PM revealed the resident
received a dose of the as needed Ativan. The facility failed to document the specific behaviors the resident
was exhibiting for the Ativan to be administered. Further no non-pharmacological interventions were
attempted prior to the administration of the as needed antianxiety medication.
A review of a medication administration note dated September 29, 2024, at 8:08 PM revealed the resident
received a dose of the as needed Ativan. The facility failed to document the specific behaviors the resident
was exhibiting for the Ativan to be administered. Further no non-pharmacological interventions were
attempted prior to the administration of the as needed antianxiety medication.
A review of a medication administration note dated September 30, 2024, at 11:07 PM revealed the resident
received a dose of the as needed Ativan. The facility failed to document the specific behaviors the resident
was exhibiting for the Ativan to be administered. Further no non-pharmacological interventions were
attempted prior to the administration of the as needed antianxiety medication.
A review of a medication administration note dated October 1, 2024, at 9:36 PM revealed the resident
received a dose of the as needed Ativan. The facility failed to document the specific behaviors the resident
was exhibiting for the Ativan to be administered. Further no non-pharmacological interventions were
attempted prior to the administration of the as needed antianxiety medication.
Interview with the Director of Nursing on October 4, 2024, at approximately 1:30 PM confirmed that nursing
staff failed to record adequate monitoring for behaviors and confirmed that non-pharmacological
interventions were not consistently being attempted prior to the administration of the as needed antianxiety
drug.
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 19 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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
locked, compartments for controlled drugs.
Based 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.
Findings include:
A review of facility policy titled Expiration Dating of Multidose Vials last reviewed by the facility July 8, 2024,
revealed the expiration/beyond use date on the medication label must be checked prior to administering.
When opening a multi-use container, the nurse's initials, and the date opened shall be recorded on the
container.
Observation of the medication room on October 3, 2024, at 9:35 AM, in the presence of Employee 1
(registered nurse), of medication stored in the medication refrigerator, revealed a multi-dose vial of
Lidocaine Hydrochloride Injection USP (a local anesthetic agent) as well as a vial of Tuberculin Purified
Protein Derivative (a solution used for Tuberculosis skin test) that had been opened, and available for use,
but was not dated.
Interview with Employee 1 at the time of the observation on October 3,2024, at 9:35 AM confirmed the vial
of Lidocaine Hydrochloride Injection USP and a vial of Tuberculin Purified Protein Derivative were stored in
the medication refrigerator, were open but not dated or initialed.
Interview with the Nursing Home Administrator and Director of Nursing on October 4, 2024 at 8:45 AM,
confirmed that the facility failed to adhere to acceptable storage and use by dates for multi-dose
medications.
28 Pa. Code 211.9(a)(1)(k) Pharmacy services
28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 20 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 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 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.
Residents Affected - Some
Findings included:
A review of the planned menu for October 1, 2024, revealed the lunch meal consisted of a barbecue
cheeseburger, lettuce, tomato, a pickle spear, confetti coleslaw, french fries, and an oatmeal raisin cookie.
Further review of an extension menu for October 1, 2024, for pureed (a method for turning solid foods into a
smooth, creamy, or paste-like consistency) diets revealed residents on a pureed diet would receive a
pureed barbecue cheeseburger, pureed mixed vegetable salad, mashed potatoes, and a pureed sugar
cookie.
Observation of the lunch meal service on October 1, 2024, at approximately 11:55 AM revealed there were
no pickles, pureed marinated mixed vegetables, or pureed sugar cookies on the tray line as indicated on
the menu.
Further observations of the lunch meal service on October 1, 2024, revealed Resident 15, 33, 34, and 53
meal tickets revealed they were to receive a pureed cheeseburger, pureed hamburger bun, mashed
potatoes, pureed marinated mixed vegetable salad, and pureed sugar cookie. The residents' meals were
plated and did not contain the pureed hamburger bun, mixed vegetables, or sugar cookie.
An interview with Employee 3 District Kitchen Manager on October 1, 2024, at approximately 1:15 PM
revealed all planned items should be prepped on the tray line prior to the meal service and confirmed the
facility failed to follow the planned menus.
28 Pa. Code 211.6 (a)(f) Dietary Services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 21 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Some
Findings include:
According to the federal regulation 483.60(i)-(2) Food safety requirements - the definition of Danger Zone,
found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135
degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness.
Review of the facility meal service time schedule revealed that the scheduled lunch time for dining room
cart one was 12:20 PM and dining room cart two was 12:25 PM.
Observation of the lunch meal tray line on October 1, 2024, at 11:55 AM, revealed dining room cart one left
the kitchen at 12:35 PM and dining room cart two left the kitchen at 12:48 PM.
Observations on the nursing unit at approximately 1:15 PM revealed the staff were pushing a cart of meal
trays out of the dining room and on to the nursing unit. The trays on that cart started to be delivered to
residents that did not go to the dining room for lunch.
An interview with Employee 3 District Kitchen Manager on October 1, 2024, at 1:15 PM indicated the trays
being delivered to the residents were trays made for the dining room, but the residents did not come to the
dining room to eat. The employee indicated the trays should have been remade since they have been sitting
in the dining room since 12:35 PM.
The residents' trays were being passed to the residents after sitting in the dining room for 40 minutes.
A test tray was completed with Employee 3 on October 1, 2024, at 1:20 PM and revealed the following:
Cheeseburger - 90 degrees Fahrenheit. The bun appeared soggy.
French fries - 82 degrees Fahrenheit. The fries appeared soggy and limp.
Coleslaw - 65 degrees Fahrenheit. The coleslaw appeared watery.
Coffee - 125 degrees Fahrenheit.
Interview with Employee 3 on October 1, 2024, at approximately 1:20 PM confirmed the facility failed to
ensure palatable temperatures for residents.
28 Pa. Code 211.6(a)(f) Dietary services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 22 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0806
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure each resident receives and the facility provides food that accommodates resident allergies,
intolerances, and preferences, as well as appealing options.
Based 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).
Findings include:
An observation of lunch meal tray line on October 1, 2024, at 11:55 AM revealed the following concerns
were identified:
Resident 8's meal ticket indicated the resident wanted pasta salad on his tray for lunch. The kitchen staff did
not have pasta salad available for the resident and he did not receive pasta salad as requested.
Resident 60's meal ticket indicated the resident wanted pasta salad on his tray for lunch. The kitchen staff
did not have pasta salad available for the resident and he did not receive pasta salad as requested.
Resident 58's meal ticket indicated the resident wanted fruit cocktail on his tray for lunch. The kitchen staff
did not have fruit cocktail available for the resident and he did not receive fruit cocktail as requested.
Resident 49's meal ticket indicated the resident wanted a barbecue cheeseburger on his tray for lunch. The
kitchen staff served him a plain cheeseburger and he did not receive barbecue cheeseburger as requested.
Interview with the Nursing Home Administrator on October 1, 2024, at approximately 1:30 PM confirmed
that the dietary staff failed to accommodate the residents' preferences.
28 Pa. Code 211.6(a) Dietary services
28 Pa. Code 201.29(a) Resident rights.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 23 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based 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.
Findings include:
Food safety and inspection standards for safe food handling indicate that everything that comes in contact
with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food
handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell,
or taste harmful bacteria that may cause illness according to the USDA (The United States Department of
Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible
for developing and executing federal laws related to food).
A tour of the kitchen was conducted with Employee 2 Dietary Manager, on October 1, 2024, at
approximately 8:15 AM, that revealed the following unsanitary practices with the potential to introduce
contaminants into food and increase the potential for food-borne illness:
The floor of the kitchen was sticky, and food, dirt and debris was noted throughout the floor.
The juice machine guns were noted to have a build up of juice in them.
The counter had dried sticky juice on it.
Multiple fruit flies were noted near the juice machine.
The juice that was open and tapped into was not dated when it was opened.
The dry storage room was propped open with 2 large cans of baked beans.
On the prep counter there was an uncovered container of biscuits not dated, a container of shredded
cheese not covered or dated, and one open quart of light cream not dated and felt warm to the touch.
Dried food particles were noted on the steam table and plate warmer.
The covers for the plates on the plate warmer were broken off.
The ice machine was not draining into the drain.
A small puddle of water was noted under the ice machine.
There was 5 containers of cereal noted under a counter. Two containers were dated to discard on
September 6, 2024, one container dated to discard on August 18, 2024, and one container not dated.
In the dry storage, room breadcrumbs were opened and not dated.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 24 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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
A janitor's closet in the kitchen was noted to have multiple boxes sitting on the floor.
Level of Harm - Minimal harm
or potential for actual harm
There was a mop sitting on the floor in the closet.
Residents Affected - Many
A mop bucket was sitting outside the closet in the kitchen due to the closet being full of boxes and the mop
bucket not being able to fit.
Further there was a mop and broom just sitting on the floor in the kitchen.
Two dirty garbage cans were noted in the kitchen with lids that had a dry sticky substance on them.
A refrigerator was noted to have a container of marinated vegetables with no label or date on them.
There was a tray of cut potatoes with no label or date on them.
A container of tuna fish was not dated and a build up of liquid was noted on top of the tuna. One container
of mushrooms was dated to be discarded on September 30, 2024.
One container of lemons was dated discard on September 30, 2024.
One container of rice was not dated.
One open package of hotdogs was not dated when opened.
A second refrigerator was noted to have a jar of apple sauce not dated when opened.
A pan of cake that was in use not dated.
Five peanut butter and jelly sandwiches that were hard and dried out were not dated.
Interview with the Nursing Home Administrator on October 4, 2024, at approximately 1:30 PM, confirmed
that food should be stored, prepared, and served under sanitary conditions.
28 Pa. Code 211.6 (f) Dietary services.
28 Pa. Code 201.18(b)(1) Management
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 25 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Based 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.
Residents Affected - Some
Findings include:
Observations on October 1, 2024, at 10:00 AM and again at 2:00 PM revealed a copier room in the front
lobby with the door unlocked and open. The room contained multiple resident medical records. The records
were not secure and being stored in a location where non-medical staff can enter and access these
confidential medical records.
Observations on October 2, 2024, at 11:00 AM revealed a copier room in the front lobby with the door
unlocked and open. The room contained multiple resident medical records. The records were not secure
and being stored in a location where non-medical staff can enter and access these confidential medical
records.
Observations on October 3, 2024, at approximately 9:15 AM revealed an unlocked shed outside of the
facility. The shed had a box of papers that contained resident medical records sitting on the floor. The
records were not secure and being stored in a location where non-medical staff can enter and access these
confidential medical records.
An interview with the Nursing Home Administrator on October 4, 2024, at approximately 1:30 PM confirmed
the facility failed to demonstrate systematically organized, readily accessible and secured resident medical
records.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 201.14 (a) Responsibility of licensee
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 26 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0867
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop
corrective plans of action.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
As a result of the deficiencies cited under the requirements related to the unnecessary administration of
psychotropic anti-anxiety drugs during the survey of October 4, 2024, the facility developed a plan of
correction to serve as their allegation of compliance, which included a quality assurance monitoring
component to ensure that solutions were sustained. This corrective plan was to be completed and
functional by November 11, 2024.
However, during the survey ending November 26, 2024, continuing deficient facility practice was identified
with these same requirements.
According to the facility's plan of correction for the deficiency cited on October 4, 2024, relating to the
unnecessary administration of psychotropic anti-anxiety drugs, procedures implemented to ensure deficient
practice was corrected included (1) identifying other residents receiving anti-anxiety medication, (2)
reviewing administrations of anti-anxiety medications to determine the existence of a pattern, (3) ensuring
non-pharmacological interventions are attempted prior to administration of anti-anxiety medication, and (4)
educating staff as identified through the correction process.
Additionally, the facility implemented anti-anxiety medication reviews two times a week until compliance is
achieved. The Director of Nursing (DON) or designee will monitor Medication Administration Records
(MAR) to ensure that non-pharmacological interventions were attempted prior to antianxiety medication
administration.
A clinical record review revealed Resident 6 was admitted to the facility on [DATE].
A physician's order for Resident 6 to receive an oral tablet of Alprazolam 0.5 mg (a psychotropic
anti-anxiety medication) with instructions to give 1.5 mg every 12 hours as needed for anxiety was initiated
on November 15, 2024.
A review of the facility quality assurance and performance improvement activities failed to reveal
documented evidence that identified Resident 6 as at risk to be affected by noncompliance related to
receiving as-needed psychotropic anti-anxiety medication.
Further clinical record review revealed Resident 6's physician order for alprazolam 0.5 mg was
implemented without an option to implement non-pharmacological interventions prior to administration of
the as-needed psychotropic anti-anxiety medication.
During an interview on November 26, 2024, at approximately 1:00 PM, the Director of Nursing (DON)
confirmed that nursing staff failed to provide documented evidence that non-pharmacological interventions
were attempted for Resident 6 prior to the administration of 15 doses of psychotropic
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 27 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 0867
Level of Harm - Minimal harm
or potential for actual harm
anti-anxiety medication (Alprazolam 1.5 mg) between November 16, 2024, and November 25, 2024. The
DON confirmed the facility failed to identify that Resident 6 was receiving an as-needed psychotropic
anti-anxiety medication without the implementation of non-pharmacological interventions prior to the
administration of the drug. The DON confirmed the facility failed to prevent recurrence of similar quality
deficiencies in the areas of unnecessary psychotropic medication.
Residents Affected - Few
Refer F758
28 Pa. Code 211.5 (f)(xi) Medical records.
28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services
28 Pa. Code 201.18(e)(1) Management.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 28 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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).
Residents Affected - Some
Findings include:
A review of the facility's current enhanced barrier precautions policy dated as reviewed by the facility March
2024, revealed that it is the policy of this facility for PPE should be stored near residents' room and
accessible to staff. Near the exit or outside the room is acceptable. For residents for whom EBP are
indicated EBP is employed when performing high contact resident care activities
A review of MEMO FROM THE Center for Clinical Standards and Quality/Quality, Safety & Oversight
Group, Ref: QSO-24-08-NH, CDC, Centers for disease control, dated March 20, 2024 regarding, Enhanced
Barrier Precautions in Nursing Homes to Prevent Spread of disease revealed, CMS is issuing new
guidance for State Survey Agencies and long term care (LTC) facilities on the use of enhanced barrier
precautions (EBP) to align with nationally accepted standards. EBP recommendations now include use of
EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care
activities regardless of their multidrug-resistant organism status.
Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce
transmission of multidrug-resistant organisms that employs targeted gown and glove use during high
contact resident care activities.
EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and
gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff
hands and clothing.
Review of information provided by the facility indicated Residents 42, 22, 48, 15, and 24 required enhanced
barrier precautions.
Review of the clinical record revealed Resident 42 was admitted to the facility on [DATE], with diagnoses
including adult failure to thrive. The resident required enhanced barrier precautions due to a tube feeding.
Review of the clinical record revealed Resident 22 was admitted to the facility on [DATE] with diagnoses
including urinary retention. The resident required enhanced barrier precautions for a foley catheter.
Review of the clinical record revealed Resident 48 was admitted to the facility on [DATE] with diagnoses to
include other unspecified eating disorder. The resident required enhanced barrier precautions due to a tube
feeding.
Review of the clinical record revealed Resident 15 was admitted to the faiclity on July 23, 2023 with
diagnoses to include neuropathic bladder. The resident required enhanced barrier precautions due to a
foley catheter.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 29 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of the clinical record revealed Resident 24 was admitted to the faiclity on September 9, 2024 with
diagnoses to include pneumonia. The resident required enhanced barrier precautions due to an open
wound on her buttocks.
Observations during the initial environmental tour including the rooms of the above mentioned residents on
October 1, 2024, at 8:30 a.m., revealed there was no evidence of EBP for any of the above noted residents
in the facility.
Interview with the Director of nursing on October 1, 2024, at 1:00 p.m., confirmed that there were no EBP
implemented for any resident in the facility at the time of the survey despite meeting the above criteria.
28 Pa. Code 211.12 (c)(d)(5) Nursing services.
28 Pa. Code 211.10(a)(d) Resident care policies
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 30 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 potential for actual harm
Based 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.
Residents Affected - Some
Findings include:
A tour of the facility's storage area on October 3, 2024, at approximately 9:15 AM revealed two sheds that
stored resident equipment. Dirt and debris were observed on the floor of the sheds. Mattresses were noted
to be sitting directly on the shed floor. Dirt and dust were noted on the resident mattresses. There were
pails for bed side commodes sitting on the floor of the shed. One pail was noted to have a dried white and
brown substance inside it. Bed bolsters were uncovered and lying on the floor of the shed. There were
boxes of air mattresses sitting directly on the dirty floor. Wheelchairs were noted to have dirty wheel and
dust on them.
An interview with the Nursing Home Administrator (NHA) on October 3, 2024, at 9:20 AM revealed NHA
was unable to provide any information as to why the residents' items were stored in poor condition and
confirmed the facility failed to ensure that essential equipment was in safe operating condition.
28 Pa. Code 201.18(b)(1)(2)(3)(e)(2.1) Management
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 31 of 32
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395984
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Creekside
45 North Scott Street
Carbondale, PA 18407
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 potential for actual harm
Based 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.
Residents Affected - Some
Findings include:
A review of facility policy entitled Pest Control last reviewed July 8, 2024, indicated the facility shall maintain
an effective pest control program to ensure the building is kept free of insects and rodents.
Observation of the food and nutrition services department on October 1, 2024, at approximately 8:15 AM
revealed small flies (which resembled a fruit fly) flying around the juice machine.
A review of a pest control contract initiated on June 17, 2024, indicated the pest company will treat for
roaches, ants, mice and rats, and common spiders. Further it was indicated the company would provide
monthly services to the facility. It was not indicated in the contract that the company would provide services
for flies.
A review of pest control invoices dated June 18, 2024, July 25, 2024, August 28, 2024, September 12,
2024, and September 20, 2024, revealed the company had provided treatment to the facility on those
dates. Further review of the invoices revealed they pest company did not identify the flies in the kitchen or
provide treatment for them.
An interview with the Nursing Home Administrator (NHA) on October 4, 2024, at approximately 9:00 AM
revealed the facility had just recently sign a contract with the new pest management company and could
not provide any information as to who was providing pest management to the facility or when the facility
was treated for pest prior to June 2024.
An interview with the NHA on October 4, 2024, at approximately 1:30 PM confirmed the facility failed to
show evidence of an effective pest control program.
28 Pa. Code 201.18 (e)(1)(2.1) Management
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395984
If continuation sheet
Page 32 of 32
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Back to topCitations
31 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0161GeneralS&S Epotential for harm
Use approved construction type or materials.
- 0291GeneralS&S Cno actual harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0324GeneralS&S Cno actual harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Cno actual harm
Have approved installation, maintenance and testing program for fire alarm systems.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
F622 - Transfer and discharge-
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F660 - Quality of life
Plan the resident's discharge to meet the resident's goals and needs.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F761 - Labeling of Drugs and Biologicals
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 locked, compartments for controlled drugs.
F803 - Menus and nutritional adequacy
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.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
FAQ · About this visit
Common questions about this visit
What happened during the October 4, 2024 survey of AVENTURA AT CREEKSIDE?
This was a inspection survey of AVENTURA AT CREEKSIDE on October 4, 2024. The surveyor cited 31 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AVENTURA AT CREEKSIDE on October 4, 2024?
Yes, 31 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.