Aventura At Creekside

During an interview on April 2, 2026, at 2:20 PM, the Social Services Director indicated the facility had not initiated court appointment of a representative for Resident 13 despite his ongoing medical issues, and need for decision making.

Interview with the Nursing Home Administrator (NHA) on April 2, 2026, at 1:25PM, denied that the NHA was making medical decisions for the resident.

Interview with the facility appointment Dietician on April 2, 2026, at 2:00PM revealed she only speaks with the physician regarding 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.

Documentation provided by the facility on April 3, 2026, at 9:00 AM revealed the facility initiated the process of obtaining a court-appointed representative for Resident 13 on April 2, 2026. A review of Resident 27's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including malnutrition (deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients), and schizophrenia (a chronic, severe brain disorder that causes psychosis, hallucinations, and delusions. A review of Resident 27's quarterly MDS dated [DATE], revealed Resident 27 was severely cognitively impaired with a BIMS score of 7. A review of the clinical record revealed no documentation identifying a legally authorized representative for medical decision making. A review of the clinical record revealed ongoing medical treatment decisions, including use of psychotropic medications and completion of a POLST dated November 5, 2025, signed by the resident despite documentation of severe cognitive impairment.

The POLST indicated preferences for attempted resuscitation, full treatment, use of antibiotics, and refusal of artificial tube feeding.

The POLST lacked physician signature and reflected signatures of the incapable resident and Social Services Director.

During an interview on April 2, 2026, at 2:00 PM, the Nursing Home Administrator indicated the facility informs Resident 27 of medical decisions despite documentation of cognitive impairment.

Documentation provided April 3, 2026, at 9:00 AM revealed the facility initiated the process of obtaining a court-appointed representative for Resident 27 on April 2, 2026. A review of Resident 51's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included intellectual disabilities (a developmental condition characterized by significant limitations in intellectual functioning (learning, reasoning, problem-solving), and depression(a serious, common mood disorder causing persistent sadness, loss of interest, and functional impairment, affecting how one thinks, feels, and act). A review of the quarterly MDS dated [DATE], revealed a BIMS score of 4, indicating severe cognitive impairment. A review of resident 51's clinical record revealed ongoing medical decision making, including vaccination consents and psychotropic medication authorizations, completed by the resident despite documented inability to make medical decisions independently. A review of a POLST uploaded to Resident 51's clinical record on April 17, 2023, revealed the form was signed by the resident (printed name) but not signed or dated by the physician.

The POLST indicated preferences for attempted resuscitation, full treatment, use of antibiotics, and artificial hydration if life prolonging.

The form lacked documentation identifying who the treatment decisions were reviewed with, despite the presence of a designated section for this information.

During an interview on April 3, 2026, at 9:00 AM, the Nursing Home Administrator indicated the facility had not identified an individual authorized to make medical decisions for Resident 51.

Documentation provided revealed the facility initiated the process of obtaining a court-appointed representative April 2, 2026. 28 Pa.

Code 201.18 (b)(1) Management. 28 Pa.

Code 201.29 (a)(b) Resident rights.

395984 04/03/2026

Aventura at Creekside 45 North Scott Street Carbondale, PA 18407

During an interview conducted on April 2, 2026, at 2:20 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) reviewed the above findings that the facility failed to ensure housekeeping services were provided to maintain a clean and sanitary environment and resident care equipment, consistent with maintaining a safe, comfortable, and homelike environment for residents. 28 Pa code 201.18 (b)(1) Management.

395984 04/03/2026

Aventura at Creekside 45 North Scott Street Carbondale, PA 18407

During an interview conducted on April 1, 2026, at 2:20 PM, the Assistant Director of Nursing (ADON) and Nursing Home Administrator (NHA) stated the buckle belt was used to reduce the risk of falls and to maintain Resident 10's safety while seated in the wheelchair.

The ADON and NHA acknowledged Resident 10 was unable to remove the device independently and confirmed the buckle belt restricted Resident 10's movement. A device the resident cannot remove that restricts freedom of movement meets the definition of a physical restraint.

The stated purpose of fall prevention does not represent a medical symptom that justifies restraint use without evidence that less restrictive interventions were attempted and determined ineffective.

The clinical record lacked documentation demonstrating the interdisciplinary team evaluated whether the buckle belt was necessary for positioning, whether less restrictive positioning interventions were attempted, or whether the use of the buckle belt was clinically justified based on an assessed medical symptom.

The clinical record failed to demonstrate interdisciplinary team and resident or resident representative involvement in the decision-making process regarding the use of the buckle belt.

The clinical record lacked documentation demonstrating the buckle belt was assessed as the least restrictive intervention or that alternative interventions were attempted and determined ineffective prior to use.

The clinical record failed to include documentation of informed consent (permission granted by the resident or representative after receiving sufficient information to make a decision) for the use of the buckle belt as a restraint.

The clinical record also lacked documentation of ongoing monitoring of the resident's condition and safety while the restraint was in place, including documentation of routine observations, release of the device, provision of range of motion (movement of joints to maintain flexibility and prevent stiffness), or evidence the restraint was used for the least amount of time necessary.

During an interview on April 3, 2026, at 9:15 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) stated the facility had not identified the wheelchair buckle belt as a restraint.

The facility was unable to provide documentation demonstrating the restraint policy was implemented, including interdisciplinary team assessment, identification of a medical symptom, informed consent, care plan interventions to reduce or eliminate restraint use, or ongoing monitoring of Resident 10 while the buckle belt was in use.

The facility failed to demonstrate ongoing interdisciplinary team reassessment of a device that had been in place since at least 2013 and failed to ensure the use of the least restrictive intervention to meet Resident 10's assessed needs. 28 Pa.

Code 211.10 (c) Resident care policies. 28 Pa.

Code 211.12 (c)(d)(1)(3)(5) Nursing service. 28 Pa.

Code 211.8(c.1)(1)(2)(3)(i)(ii)(d)(e) Use of Restraints.

395984 04/03/2026

Aventura at Creekside 45 North Scott Street Carbondale, PA 18407

Review of employee personnel files revealed the following: Employee 1 (Licensed Practical Nurse): Hired on February 26,

• The application listed previous employers, but there was no documentation showing the facility

had contacted any former employer to fully screen the individual to ensure the individual was eligible for employment in a long term care nursing facility.

Employee 2 (Registered Nurse): Hired on February 20, 2026.

The application listed previous employers, but there was no documentation showing the facility had contacted any former employer to fully screen the individual to ensure the individual was eligible for employment in a long term care nursing facility.

Employee 3 (Licensed Practical Nurse): Hired on March 9, 2026.

The application listed previous employers, but there was no documentation showing the facility had contacted any former employer to fully screen the individual to ensure the individual was eligible for employment in a long term care nursing facility.

Interview with the Nursing Home Administrator (NHA) on April 2, 2026, at 1:15 PM was unable to provide evidence that previous employers were contacted for information regarding the employees past work history.

The facility failed to follow its own abuse prohibition policy by not verifying previous employment for three out of five new hires. 28 Pa.

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

Code 201.18 (e)(1) Management. 28 Pa.

Code 201.19 (1) Personnel records.

395984 04/03/2026

Aventura at Creekside 45 North Scott Street Carbondale, PA 18407

was determined the facility failed to complete an accurate Minimum Data Set (MDS) for three of 19

Facility RAI User's Manual, which provides instructions and guidelines for completing the MDS dated [DATE], requires the assessment accurately reflects the resident's status. A registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. A clinical record review revealed Resident 10 was admitted to the facility May 18, 2011, with diagnoses that included cerebral palsy (brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination).

The annual Minimum Data Assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 1, 2026, Section P (section addressing restraints and alarms) indicated Resident 10 does not use a restraint when in a chair, including a trunk restraint, or limb restraint. An observation on April 1, 2026, at 1:15 PM revealed Resident 10 was seated in his wheelchair, at the nurses' station. Resident 10 was observed to have a belt that was attached to the wheelchair; the belt included a buckle and was secured in the front of Resident 10's waistline. Resident 10 was not able to verbalize what the purpose of the belt with a buckle was and could not demonstrate any movement in his upper extremities (including arms, hands, wrists, or trunk) at the time of the observation. An interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on April 1, 2026, at 2:20 PM confirmed Resident 10 was not able to release the belt, and the intent of the belt was for Resident 10's safety.

The DON and NHA further elaborated that due to Resident 10's underlying medical condition and the potential for unexpected loss of control over muscle movement consistent with his admission diagnosis, the belt's purpose is for safety.

The DON and NHA acknowledged the belt is attached to the wheelchair, secured Resident 10 in the wheelchair, and limited Resident 10's movements.

The DON and NHA did not consider the use of the buckle belt as a restraint. A clinical record review revealed Resident 11 was admitted to the facility July 26, 2022, with diagnoses that included chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs which results in swelling and irritation, inside the airways that limit airflow into and out of the lungs).

The quarterly MDS dated [DATE], Section J (section related to health conditions, including fall history) documented Resident 11 experienced no falls since admission/ readmission or prior assessment.

Upon clinical review, Resident 11 experienced falls on November 16, 2025, January 4, 2026, and January 14, 2026.

The three falls were not reflected on the quarterly MDS dated [DATE]. A clinical record review revealed Resident 23 was admitted to the facility on [DATE], with diagnoses that included dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (condition characterized by cognitive decline and affects memory, thinking, behavior, and the ability to perform activities of daily living such as bathing, dressing, walking, and eating).

The quarterly MDS dated [DATE], Section J (section related to health conditions, including fall history) documented Resident 23 experienced no falls since admission/ readmission or prior assessment.

Upon clinical record review, Resident 23 experienced a fall on November 24, 2026.

The fall on November 24, 2026, was not reflected on the quarterly MDS dated [DATE].

The above information reflecting the MDS coding for Resident 10, Resident 11, and Resident 23 was reviewed with Employee 4 Licensed Practical Nurse, MDS Coordinator on April 3, 2026 at 11:15 AM.

Employee 4 LPN acknowledged the MDS did not accurately reflect the health conditions for the three residents.

The information was communicated to the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 3, 2026, at 2:15 PM. 28 Pa.

Code 211.5(f)(ix) Medical records. 28 Pa.

Code: 211.12(d)(1)(2)(3)(5) Nursing Services.

395984 04/03/2026

Aventura at Creekside 45 North Scott Street Carbondale, PA 18407

services. 28 Pa.

Code 211.10(c)(d) Resident care policies.

395984 04/03/2026

Aventura at Creekside 45 North Scott Street Carbondale, PA 18407

Review of the electronic Medication Administration Record (eMAR, an electronic system used to document medication administration in the clinical record) revealed Employee 5, Licensed Practical Nurse (LPN), documented administration of Meropenem 1 gram intravenously via PICC line on March 21, 2026.

The eMAR further revealed Employee 6, Licensed Practical Nurse (LPN), documented administration of Meropenem 1 gram intravenously via PICC line on March 29, 2026.

The facility failed to produce evidence that Employee 5 or Employee 6 completed IV therapy education and training consistent with the requirements of Pennsylvania Code Title 49 S21.145(b).

The facility was unable to provide documentation of competency validation (process used to confirm staff have demonstrated the ability to safely perform a clinical skill), supervision documentation, or evidence of training specific to administration of IV medications through a PICC line.

During an interview conducted on April 2, 2026, at 11:50 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility was unable to provide documentation demonstrating Employees 5 and 6 completed the required IV therapy education or competency validation necessary to administer IV medications through a PICC line. 28 Pa.

Code 201.20(a) Staff Development. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

395984 04/03/2026

Aventura at Creekside 45 North Scott Street Carbondale, PA 18407

of Nursing acknowledged the medication was administered without obtaining required blood pressure

28 Pa.

Code 211.12 (c)(d)(1)(3)(5) Nursing services.

395984 04/03/2026

Aventura at Creekside 45 North Scott Street Carbondale, PA 18407

3.March 6, 2026, at 7:42PM, the medication was administered for a pain scale of 8.March 8, 2026,

administered for a pain scale of 8.March 20, 2026, 7:20PM, the medication was administered for a pain

21, 2026, at 8:45PM, the medication was administered for a pain scale of 8.March 23, 2026, at 05:58AM, the medication was administered for a pain scale of 8.March 26, 2026, at 7:52PM, the medication was administered for a pain scale of 8.March 27, 2026, at 7:40PM, the medication was administered for a pain scale of 8.March 29, 2026, at 1:19AM, the medication was administered for a pain scale of 8.March 29, 2026, at 7:46PM, the medication was administered for a pain scale of 8.Match 30, 2026, at 05:06AM, the medication was administered for a pain scale of 0. An interview with the Director of Nursing on April 3, 2026, at 11:00 AM included review of the above findings which revealed the facility failed to ensure staff administered opioid pain medication according to physician orders, including adherence to ordered pain scale parameters and implementation of ordered nonpharmacological interventions prior to medication administration. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa.

Code 211.5(f) Medical records. 28 Pa.

Code 211.12 (c)(d)(1)(5) Nursing Services.

395984 04/03/2026

Aventura at Creekside 45 North Scott Street Carbondale, PA 18407

Review of the November 2025 MRR revealed documentation from the facility's contracted psychiatric services Nurse Practitioner indicated the resident previously failed a gradual dose reduction of Seroquel (an antipsychotic medication used to treat mood and behavioral symptoms) and the resident was considered stable on the current medication regimen.

However, the clinical record lacked documentation that the attending physician reviewed the pharmacist's recommendation regarding Mirtazapine or provided clinical rationale explaining why a gradual dose reduction was not attempted or was clinically contraindicated (not recommended due to potential harm). A review of the clinical record failed to reveal documentation from the attending physician addressing the pharmacist's identified irregularity, including the reason for continuing the current dose of Mirtazapine without a gradual dose reduction.

During an interview conducted on April 3, 2026, at approximately 1:00 PM, the Assistant Director of Nursing (ADON) stated the facility had experienced an ongoing issue obtaining documentation from the attending physician in response to consultant pharmacist recommendations. 28 Pa.

Code 211.9 (k) Pharmacy services. 28 Pa.

Code 211.12 (c) Nursing services. 28 Pa.

Code 211.2 (d)(3) Medical Director.

395984 04/03/2026

Aventura at Creekside 45 North Scott Street Carbondale, PA 18407

The facility failed to ensure Resident 8's drug regimen was free from unnecessary antibiotics by initiating Ceftriaxone without sufficient clinical indication supported by McGeer's Criteria and without evidence the medication would be effective based on culture results.

During an interview on April 3, 2026, the Director of Nursing reviewed the above findings related to the facility's failure to ensure Resident 8 was free from the use of an unnecessary antibiotic. 28 Pa.

Code 211.2(d)(3)(5) Medical Director 28 Pa.

Code 211.12(d)(3)(5) Nursing services 28 Pa Code 211.10 (c) Resident care policies.