Pennsylvania Department of Health
AVENTURA AT CREEKSIDE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

AVENTURA AT CREEKSIDE
Inspection Results For:

There are 113 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


AVENTURA AT CREEKSIDE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit survey completed on February 27, 2024, it was determined that Aventura at Creekside corrected the federal deficiencies cited during the surveys of November 20, 2023, and January 24, 2024, under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care but continued to be out of compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on review of nursing time schedules and the resident census and staff interviews, it was determined that the facility failed to provide a minimum of one nurse aide per per 12 residents on the evening shift on six shifts out of 21 shifts reviewed (2/19/2024, 2/20/2023, 2/22/2024. 2/23/2024, 2/24/2024, and 2/25/2024).

Findings include:

The facility census on 2/19/2024, was 76 residents, which required 6.33 nurse aides during the evening shift. A review of the nursing time schedules revealed only 5.00 nurse aides were on the evening on 2/19/2024.

The facility census on 2/20/2024, was 73 residents, which required 6.08 nurse aides during the evening shift. A review of the nursing time schedules revealed only 4.75 nurse aides were on the evening shift on 2/20/2024.

The facility census on 2/22/2024, was 72 residents, which required 6.00 nurse aides during the evening shift. A review of the nursing time schedules revealed only 4.75 nurse aides were on the evening shift on 2/22/2024.

The facility census on 2/23/2024, was 72 residents, which required 6.00 nurse aides during the evening shift. A review of the nursing time schedules revealed only 5.88 nurse aides were on the evening shift on 2/23/2024.

The facility census on 2/24/2024, was 72 residents, which required 6.00 nurse aides during the evening shift. A review of the nursing time schedules revealed only 5.88 nurse aides were on the evening shift on 2/24/2024.

The facility census on 2/25/2024, was 70 residents, which required 5.83 nurse aides during the evening shift. A review of the nursing time schedules revealed only 4.75 nurse aides were on the evening shift on 2/25/2024.

During an interview on February 27, 2024, at 10:30 a.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to provide the minimum nurse aide staffing ratios on the above shifts.

Plan of Correction - To be completed: 03/18/2024

1. Facility is unable to correct past deficiency.

2. The facility has an active recruitment/retention plan to fill open positions which includes supplemental staffing bonuses to cover vacancies. The facility will ensure that shift ratios are met on every shift.

3. Agency will be utilized for open shifts as needed and available. 
Calculation of daily shift ratios will be completed during Daily Labor Meeting and reviewed daily for accuracy by the scheduler, DON, and Administrator. All efforts will be made to meet the staffing ratio. 

If call offs occur, all efforts will be made to attempt to fill that position with CNA's that are working in ancillary departments.

4.The DON or designee will conduct an audit of the CNA ratios to ensure ratios are being met weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and re-evaluation.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on review of nursing time schedules and the resident census and staff interviews, it was determined that the facility failed to provide a minimum one LPN (licensed practical nurse) per 40 residents during the night shift on three of seven days reviewed (2/19/2024, 2/23/2024, and 2/24/2024).

Findings include:

Review of the facility's census indicated that on 2/19/2024, the resident census was 76, which required 1.90 LPNs during the night shift. A review of the nursing time schedules revealed that the facility only had 1.88 LPNs on the night shift on 2/19/2024.

Review of the facility's census indicated that on 2/23/2024, the resident census was 72, which required 1.80 LPNs during the night shift. A review of the nursing time schedules revealed that the facility only had 1.63 LPNs on the night shift on 2/23/2024.

Review of the facility's census indicated that on 2/24/2024, the resident census was 72, which required 1.80 LPNs during the night shift. A review of the nursing time schedules revealed that the facility only had 1.00 LPNs on the night shift on 2/24/2024.

No additional excess higher-level staff were available to compensate this deficiency for failing to provide a minimum of 1 LPN per 30 residents on the evening shifts on the above dates.

During an interview on February 27, 2024, at 10:30 a.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of one LPN per 40 residents on the night shift.

Plan of Correction - To be completed: 03/18/2024

1. Facility is unable to correct past deficiency.

2. The facility has an active recruitment/retention plan to fill open positions which includes supplemental staffing bonuses to cover vacancies. The base starting rate for LPN's has recently been increased.

3. Staff Scheduler, DON, HR will be educated on the importance of meeting LPN ratios, and that the facility is actively recruiting LPNs.

Agency will be utilized for open shifts as needed and available. 
Calculation of daily shift ratios will be completed and reviewed daily during Daily Labor Meeting for accuracy by the scheduler and DON. All efforts will be made to meet the staffing ratio. 
If call offs occur, all efforts will be made to attempt to fill that position with LPN's that are working in ancillary departments.

4.The DON or designee will conduct an audit of the LPN ratios to ensure ratios are being met weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and re-evaluation.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement