Aventura at Creekside: Medical Decisions Without Authority - PA
Federal inspectors found the facility allowed residents to sign forms for resuscitation preferences, psychotropic drugs, and vaccinations despite documented evidence the residents lacked the mental capacity to make such decisions independently.
Resident 27 scored just 7 out of 15 on a cognitive assessment, indicating severe impairment from schizophrenia and malnutrition. Yet the facility let him complete a Physician Orders for Life-Sustaining Treatment form in November 2025, choosing full medical treatment, antibiotics, and refusing artificial feeding.
The form lacked a physician's signature. Only the cognitively impaired resident and the Social Services Director had signed it.
"The facility informs Resident 27 of medical decisions despite documentation of cognitive impairment," the Nursing Home Administrator told inspectors on April 2.
Resident 51 performed even worse on cognitive testing, scoring just 4 out of 15 points. The resident has intellectual disabilities and depression but was signing vaccination consents and authorizations for psychiatric medications.
His life-sustaining treatment form, uploaded to his medical record in April 2023, showed similar problems. The resident had printed his name and signed the document choosing attempted resuscitation, full treatment, antibiotics, and artificial hydration. But no physician signed or dated the form, and it contained no documentation about who had reviewed the treatment decisions with him.
The form included a designated section for identifying who treatment decisions were reviewed with. It remained blank.
Resident 13 presented the most complex situation. The facility had no documented advance directive or medical power of attorney identifying anyone authorized to make healthcare decisions for him. Yet he required ongoing medical decisions due to his inability to make them independently.
The Assistant Director of Nursing explained during an April 2 interview that when Resident 13 needs medical decisions, "the physician or administrator is involved in decision making due to the resident's inability to make decisions independently."
But the Nursing Home Administrator denied making medical decisions for the resident when questioned 25 minutes later.
The facility's dietician offered a third version. She said she only speaks with the physician about medical decisions related to Resident 13's condition, and "the physician is the one who makes the medical decisions for the resident since he is unable to make decisions himself."
The Social Services Director acknowledged the facility had not initiated court appointment of a representative for Resident 13 despite his ongoing medical issues and need for decision making.
None of the three residents had legally authorized representatives for medical decision making in their clinical records. Federal regulations require nursing homes to ensure residents receive appropriate care and that medical decisions are made by people legally authorized to make them.
The facility's handling of these cases violated multiple requirements. Residents must have the right to make informed decisions about their care, but only when they have the cognitive capacity to understand the consequences. When residents cannot make decisions independently, facilities must ensure proper legal representatives are appointed.
The inspection revealed a pattern of confusion about who held decision-making authority. Staff members gave conflicting accounts about their roles in medical decisions for cognitively impaired residents.
For Resident 27, the administrator claimed to inform him of medical decisions despite his severe cognitive impairment from schizophrenia. His BIMS cognitive assessment score of 7 indicates significant limitations in recall, temporal orientation, and ability to make decisions.
Resident 51's intellectual disabilities and depression, combined with his BIMS score of 4, suggested even more severe cognitive limitations. Yet the facility continued allowing him to consent to medical treatments including psychotropic medications that require careful consideration of benefits and risks.
The documentation problems extended beyond missing signatures. The life-sustaining treatment forms lacked essential information about how decisions were explained to residents or whether they demonstrated understanding of their choices.
Psychotropic medications carry particular risks for residents with cognitive impairment and require informed consent from someone capable of understanding potential side effects and benefits. The inspection found these medications were being authorized by residents who lacked the capacity to provide meaningful consent.
Only after inspectors arrived did the facility begin addressing the problems. Documentation provided on April 3 showed the facility had initiated the process of obtaining court-appointed representatives for all three residents on April 2, the same day inspectors conducted their interviews.
The timing suggested the facility recognized the violations only when confronted by federal inspectors. The residents had been making their own medical decisions for months or years without proper legal authority.
The deficiencies affected residents' fundamental rights to appropriate medical decision making. When cognitively impaired residents cannot understand the consequences of medical choices, facilities must ensure proper guardians or representatives are appointed through legal processes.
The inspection found the facility had failed to follow Pennsylvania regulations requiring proper management of resident rights and medical decision making. The violations were classified as causing minimal harm or potential for actual harm to some residents.
For the three residents involved, the consequences of inadequate decision making could affect their medical care for months or years. Treatment preferences documented by people unable to understand them may not reflect their actual wishes or best interests.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aventura At Creekside from 2026-04-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 14, 2026 · Our methodology
AVENTURA AT CREEKSIDE in CARBONDALE, PA was cited for violations during a health inspection on April 3, 2026.
Resident 27 scored just 7 out of 15 on a cognitive assessment, indicating severe impairment from schizophrenia and malnutrition.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at AVENTURA AT CREEKSIDE?
- Resident 27 scored just 7 out of 15 on a cognitive assessment, indicating severe impairment from schizophrenia and malnutrition.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in CARBONDALE, PA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from AVENTURA AT CREEKSIDE or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 395984.
- Has this facility had violations before?
- To check AVENTURA AT CREEKSIDE's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.