Inspection·August 28, 2025

F 0812 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many appropriate and necessary, in providing pest control services. A tour of the kitchen on August 25, 2025, at 8:20 AM revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness. The exit door in the kitchen leading to the outside was propped open with a rock. An interview with Employee 1, a dietary aide, confirmed this observation and stated the door should not be propped open. Observation of the janitor's closet located next to the exit door revealed a mop directly on the floor and a cracked light shield containing debris. The perimeter area of the floors throughout the kitchen had a buildup of dirt and debris. The floor area under the dishwasher was soiled, and a three-foot length of stainless-steel plating located behind the dishwasher was pulling away from the wall, leaving a gap along the top edge of the dishwasher area located behind the garbage disposal. Further interview with Employee 1 at this time revealed that he does sometimes see water bugs in the dishwasher area. Observation of the floor in the food preparation and tray line service area revealed a dead cockroach on the floor. Interview with the Food Service Director (FSD) on August 25, 2025, at 9:00 a.m. confirmed that cockroaches were identified in the kitchen one month ago and that the nursing home administrator (NHA) was made aware. Further observation of the kitchen with the FSD on August 25, 2025, at 9:15 a.m. revealed several live cockroaches under the dishwasher. Interview with the NHA on August 25, 2025, at 9:30 a.m. confirmed the facility did have a contract with a pest management company and that on July 21, 2025, in response to seeing cockroaches in the kitchen, the facility requested pest control services increase from monthly visits to every two weeks. However, other than increasing visits with the pest management company, there was no documented evidence the facility addressed the concern of cockroaches in the kitchen between visits, increased sanitation, or evaluated food storage and distribution practices. The NHA confirmed that food and nutrition services were to be maintained in a sanitary manner and free of pests. Review of the Commercial Services Agreement for pest management dated July 21, 2025, revealed the facility requested to increase pest control services from monthly to every two weeks and signed a new contract on that date. Review of the Pest Control Report dated July 21, 2025, indicated heavy treatment was placed in the kitchen for roaches. Review of the next Pest Control Report dated August 18, 2025, 28 days after the previous treatment, indicated that roach gel (slow-acting poison-laced bait placed in areas where roaches hide that attracts and kills cockroaches), and growth regulators (substances that prevent immature cockroaches from reaching their full pest potential) were placed in the kitchen for roach activity.Further interview with the Administrator on August 25, 2025, at 9:45 AM confirmed the pest control company did not provide a service the week of August 4, 2025, as per the facility contract for service every two weeks. When questioned if there had been any reports made to him about cockroaches being present on residents' meal trays, the Administrator confirmed that staff had reported an incident to him on August 19, 2025, that a dead cockroach was on Resident 1's refused breakfast tray. Review of the clinical record confirmed that the resident did refuse breakfast on that day as he often does refuse breakfast per personal preference. The facility failed to provide any documented evidence the facility staff was monitoring for the presence of roaches in the kitchen or had put any increased sanitation measures or environmental measures (identifying gaps, repairing wall cracks, ensuring doors are closed) in place to ensure food was stored, prepared, distributed, and served under sanitary conditions and free of pest infestation. Immediate Jeopardy was identified and called on August 25, 2025, at 10:50 AM and the Immediate Jeopardy template was provided to the Nursing Home Administrator regarding the facilities failure to maintain the kitchen so that food was stored, prepared, distributed and served under sanitary conditions. The presence of live and dead cockroaches in food preparation and storage areas created a high risk of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395984 If continuation sheet Page 2 of 4 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 08/28/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete contamination of food, utensils, and food-contact surfaces with disease-causing organisms and resulted in failure to maintain proper sanitary conditions in the kitchen thereby placing all residents at risk for foodborne illness. Evaluation of the facility's records determined that Immediate Jeopardy was initially identified on July 21, 2025, when the pest control company documented the need for heavy pest control treatment in the kitchen. In response, the facility submitted an immediate corrective action plan at 2:45 PM on August 25, 2025. The plan directed the kitchen to begin using paper supply and disposable products for all meal service. Staff were assigned to monitor each meal while the tray line was active to ensure that no insects or cockroaches were observed. Facility leadership notified all residents, families, and the medical director regarding the situation and the actions being taken. Pest control services were activated for immediate treatment of the source areas. Full sanitation of the kitchen, including all equipment and floors, was completed, and all exposed food and single-use items were discarded. The three-compartment sink was designated for use as needed, and staff were instructed to complete sanitation treatments in the kitchen after each meal. The kitchen was placed under continuous monitoring throughout the day and night by the Food Service Director or the registered nurse supervisor. Audits were scheduled to be completed hourly for three days, then daily for seven days, and weekly for four weeks. On August 26, 2025, at 11:00 a.m., the licensed pest control inspector conducted a thorough inspection of the kitchen and identified cockroach activity around walls and behind appliances, including the entire kitchen area. Recommendations included fogging treatment, four-foot door sweep installation to the kitchen exit door and sealing around the floor pipe opening under the sink. Dietary staff were educated on the facility's Pest Control and Kitchen Sanitation Policies and Protocols. All residents were to be assessed for any gastrointestinal symptoms related to food. An Ad Hoc QAPI (meeting within a nursing home to address a specific quality issue) was held to address the issue and develop ongoing preventive measures. The facility initiated daily audits and weekly inspections and treatments by both the maintenance director and the licensed pest control vendor. A fogging treatment was recommended by the pest control company and scheduled for August 27, 2025, at 7:00 PM. Staff in-service training on food safety and pest prevention was scheduled for completion by the staff educator on August 27, 2025. Final environmental measures, including sealing cracks, installing a door sweep, and repairing baseboards, were assigned a completion deadline of August 30, 2025. The Immediate Jeopardy was lifted on August 28, 2025, at 10:00 a.m. after verification the facility had implemented a comprehensive corrective action plan that immediately addressed the risk of serious harm to residents. Cross Refer F92528 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18 (e)(1)(2.1)(3) Management. 28 Pa. Code 211.6 (f) Dietary Services. 28 Pa Code 211.10 (a)(b)(c)(d) Resident care policies Event ID: Facility ID: 395984 If continuation sheet Page 3 of 4 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 08/28/2025 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 a review of facility policy, observations of the food and nutrition services department, interviews with facility staff, and review of pest control records, it was determined that the facility failed to maintain an effective pest control program to ensure the facility was free of insects/pests, specifically cockroaches.Findings include: A review of the facility's Pest Control Policy last updated July 18, 2025, indicated the facility shall maintain an effective pest control program. The facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents. Contracted outside pest control services are provided. Windows are always screened. Only approved FDA and EPA' insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas. Garbage and trash are not permitted to accumulate and are removed from the facility daily. Maintenance services assist, when appropriate and necessary, in providing pest control services. During observation of the kitchen on August 25, 2025, at 8:20 AM interview with Employee 1 (dietary aide) revealed that at times he does see water bugs in the dishwasher area. At that same time, a dead cockroach was observed on the floor in the food preparation/tray line area. Interview with the food service director (FSD) on August 25, 2025, at approximately 9:00 AM confirmed cockroaches had been seen in the kitchen and that the administrator was informed approximately one month ago. Despite this increase in pest control, further observation with the FSD on August 25, 2025, at 9:15 AM revealed several live cockroaches under the dishwasher. Review of the facility's Commercial Services Agreement dated July 21, 2025, confirmed the increased service schedule, and the pest control report for that date documented heavy treatment for roaches. However, the next pest control report was dated August 18, 2025 which was 28 days later, rather than every two weeks as requested indicated that roach gel (slow-acting poison-laced bait placed in areas where roaches hide that attracts and kills cockroaches) and growth regulators (prevent immature cockroaches from reaching their full pest potential) were placed in the kitchen for roach activity. Interview with the nursing home administrator (NHA) on August 25, 2025, at approximately 9:30 AM confirmed that the facility did have a contract with a pest management company. The administrator confirmed that on July 21, 2025, in response to seeing cockroaches in the kitchen the facility requested the pest control services increase from monthly visits to every two weeks. During an interview with the nursing home administrator (NHA) on August 25, 2025, at approximately 9:45 AM confirmed the pest control company did not provide a service the week of August 4, 2025, as per the facility contract for service every two weeks. Interview with the maintenance director on August 25, 2025, at approximately 10:00 AM failed to provide any documented evidence the facility was monitoring for cockroaches, documenting finding, and identifying possible areas where the cockroaches could be entering and hiding (dark, warm, and moist areas near food sources such as under appliances, under the dishwasher, and within cracks and crevices) as per facility policy. On August 26, 2025, at 11:00 AM a licensed pest control inspector visited the facility for a thorough inspection of the kitchen. The inspection revealed cockroach activity around walls and behind appliances and under the dishwasher. The problem areas included the walls around the kitchen and the entire kitchen. Recommendations included a fogging treatment, four foot door sweep installation to the kitchen exit door, and to seal around the opening of pipe in floor under the sink. Interview with the nursing home administrator (NHA) on August 26, 2025, at approximately 12:30 PM confirmed that the facility failed to show evidence of an effective pest control program. The NHA confirmed it is the facility's responsibility to maintain an effective pest control program to ensure the facility is free of pests including cockroaches.Cross Refer F812 28 Pa. Code 201.18 (e)(1)(2.1) Management 28 Pa Code 211.20 (a)(b)(c)(d) Resident care policies Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395984 If continuation sheet Page 4 of 4