Pennsylvania Department of Health
AVENTURA AT CREEKSIDE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on April 14, 2026, at Aventura at Creekside, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 067702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 14, 2026, it was determined that Aventura at Creekside was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one story, Type V (111), protected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Corridor - Doors:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain one corridor opening, affecting one of one floor.

Findings include:

1. Observation on April 14, 2026, at 11:22 a.m., revealed the Resident Room 101 door was not smoke-tight.

Exit interview on April 14, 2026, between 12:15 p.m., and 12:20 p.m., with the Facility Administrator and the Facilities Manager, confirmed the corridor opening deficiency.

Plan of Correction - To be completed: 04/28/2026

Door 101 was fixed to be smoke tight

Doors were check by 4/22/2026 by maintenance to ensure that they are smoke tight

Staff Development / designee will educate Maintenance staff to ensure that doors are smoke tight.

Maintenance Director / Designee will conduct audits to ensure that the corridor doors are smoke tight. The audits will be completed weekly x4 weeks and then monthly for 3 months. Audit results will be reviewed and reported to the monthly Quality Assurance and Performance Improvement committee to determine compliance.

4/28/2026

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain cylinder storage in one location, affecting one of one floor.

Findings include:

1. Observation on April 14, 2026, at 11:35 a.m., revealed free-standing, "e-style," oxygen cylinders were located within Oxygen Storage Room.

Exit interview on April 14, 2026, between 12:15 p.m., and 12:20 p.m., with the Facility Administrator and the Facilities Manager, confirmed the cylinder storage deficiencies.

Plan of Correction - To be completed: 04/28/2026

Oxygen cylinders that were standing on their own have been placed into a cylinder holder for safety.

Cylinder storage areas were checked by the Maintenance Director to ensure oxygen cylinders were stored properly and not free standing.

Staff development / designee will educate the staff on the safety of ensuring that oxygen cylinders regarding full or empty are placed in a holder at all times.

Maintenance Director / Designee will conduct audits to ensure that full or empty oxygen cylinders are placed in a cylinder holder at all times. The audits will be completed 5 x a week, x4 weeks and then weekly for 3 months. Audit results will be reviewed and reported to the monthly Quality Assurance and Performance Improvement committee to determine compliance.

4-28-2026

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