Pennsylvania Department of Health
AVENTURA AT CREEKSIDE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

AVENTURA AT CREEKSIDE
Inspection Results For:

There are 114 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 an Abbreviated Complaint survey completed on March 13, 2024, at Aventura at Creekside, it was determined that the facility was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e)

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

Observations:
Based on observation, staff interviews and a review of employee credentials and current staffing of the facility's food and nutrition services department it was determined that the facility failed to consistently provide qualified staff to provide oversight of the food and nutrition services department.

Findings include:

During a tour of the food and nutrition services department on March 13, 2024, at approximately 10:00 a.m., the facility's designated Dietary Manager stated that she started working at the facility three days prior to this survey and her responsibilities included oversight of food preparation, service and storage of food. The Dietary Manager, stated that presently she did not possess the regulatory required qualifications for this position, which was confirmed during review of the employee's personnel file.

During an interview on March 13, 2024 at 1 PM, the Nursing Home Administrator (NHA) confirmed that there was no qualified dietary manager in the facility from January 30, 2024 through March 4, 2024, when the current Dietary Manager came to the facility from a sister facility and was designated as the facility's Dietary Manager. The NHA confirmed that the employee was not currently qualified for the position and would not begin the process of becoming a certified dietary manager until 60 days after employment.

During that time from January 30, 2024, through March 4, 2024, the facility contracted with a Registered Dietitian to provide full time services but only remotely. She stated that the RD performed clinical nutriton duties only and provided no oversight of the dietary department, kitchen and dietary staff. The food ordering was completed by dietary staff at a sister facility and the menu was completed by the cook on duty.

The NHA stated during interview on March 13, 2024, that the facility's dietary Manager, was working at this facility, for 3 days prior to the current survey ending March 13, 2024, and the the facility's dietitian does not come onsite at the facility to oversee the dietary department. The NHA confirmed that she herself, although not a qualified nutrition professional, provided oversight of the facility's dietary department from January 30, 2024 through March 4, 2024, and confirmed that she is not a qualified nutrition professional.

The NHA stated that the Registered Dietitian works remotely and never comes into the facility to provide oversight of the dietary department, education to staff, diet consultation with residents, does not observe or interview residents as part of their nutritional assessments, including observing the residents' physical indicators of nutritional status and appearance/skin, etc, and works solely offsite.

At the time of the survey ending March 13, 2024, the facility failed to employ qualified nutrition professionals to provide oversight of the food and nutrition services department, including oversight of kitchen, dietary staff and daily operations of the department.

Refer F803

28 Pa Code 201.18 (e)(1)(6) Management.

Plan of Correction - To be completed: 04/08/2024

1. The facility is unable to retroactively correct cited issue.
2. The facility will have met the needs of the residents by verifying there is qualified dietary staff or full-time coverage of dietitian.
3. Vice President of Clinical Operations will educate the Administrator on the qualified dietary staff regulation. A registered dietitian will provide full-time hours of oversight of the food and nutrition services department weekly, and these hours will not solely be remote hours.

4. NHA/designee will audit 4 times a week for 2 months and then weekly for 2 months to ensure full-time dietitian regulation being met. Results will be reviewed by QA committee for 2 months and then reevaluated if needed.

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed:

§483.60(c) Menus and nutritional adequacy.
Menus must-

§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

§483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

§483.60(c)(5) Be updated periodically;

§483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

§483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.

Observations:
Based on observations, review of the facility's planned written menus, menu extensions, and select facility policy, and staff interviews, it was determined that the facility failed to follow planned menus, failed to ensure that the facility's dietitian periodically updated the planned menus to reflect variety, the preferences of the current resident population and nutritional adequacy and failed to assure consistent availability of food to serve the emergency menu in the event of an emergency.

Findings included:

A review of the current facility census at the time of the survey on March 13, 2024, revealed 71 residents were currently residing in the facility.

Review of the facility's Week 3 lunch menu for Wednesday March 13, 2024, revealed that the planned menu included barbecued chicken (4 oz), mashed sweet potatoes (1/2 cup), cauliflower (1/2 cup), dinner roll, chilled peaches (1/2 cup), apple juice (4 oz), 2% milk (4 oz) and coffee (8 oz).

The Week 3 lunch meal, Renal diet extension, revealed baked chicken (3 oz) no BBQ sauce, Mashed sweet potatoes (1/2 cup), cauliflower (1/2/cup), dinner roll, chilled peaches (1/2 cup), apple juice (4 oz), 2% milk(4 oz) and coffee (8 oz).

However, observation of the lunch meal served on March 13, 2024, at 12:00 PM revealed that macaroni and cheese was served in place of the mashed sweet potatoes. There was no dinner rolled served with the lunch meal.

Observation of the lunch tray line revealed no baked chicken or mashed sweet potatoes as planned for the renal diet extension.

Interview with the dietary manager, who was recently hired on March 4, 2024, on March 12, 2024, at 11:45 PM confirmed that the substitution of macaroni and cheese for the lunch meal was made because the original starch item, mashed sweet potatoes, was not received in the weekly food order. She stated that the certified dietary manager at a sister facility orders the food, based on the weekly menu, but the food order gets changed at the corporate level and the dietary staff do not know about the changes until the food order arrives at the the facility. She stated that the dietary staff does not have invoices for food delivery received at the facility and the facility staff are not able to check the food delivered in comparison to what was ordered to fulfill the planned menu which results in menu changes at the time of meal preparation. The dietary manager stated that the cook made the decision to prepare macaroni and cheese this morning due to the unavailability of the sweet potaotes planned.

The dietary manager stated that the facility does not maintain a current a substitution log despite making frequent substitutions to the menu because the facility does not have the food planned on the menu. There were no Substitution Log/Records for January 2024, February 2024, and March 2024, available at the time of the survey ending March 13, 2024.

A review of the facility's disaster manual regarding emergency menus and associated food supplies. The plan included emergency menus for 7 days and an "emergency menu staple products" list.

A review of the facility's disaster plan included 3 days of menus and a list of "disaster food inventory" to include all the foods to be in storage to prepare and serve the disaster menus to the residents in the facility at that time.

An observation of the dietary department dry storage areas as well as the freezers on March 13, 2024, revealed no emergency food supply for the 71 residents in the facility in the event of an emergency.

During an interview with the dietary manager at the time of the observation on March 13, 2024, she confirmed that the facility does not currently maintain a 3 day emergency food supply or a 7 day supply as indicated in the facility's disaster plan.

During an interview March 13, 2024 at 1 P.M., the Nursing Home Administrator confirmed that the Registered Dietitian (RD) did not approve the menu changes for March 13, 2024, lunch meal. She stated that the RD preforms only clinical nutrition duties and the she, the NHA, who was not a qualified nutrition professional, was running the kitchen during the absence of a certified dietary manager. The menu changes were completed by the cook and the NHA was unable to confirm that the menu/recipes were reviewed for nutritional adequacy, portion sizes, variety, and appropriate combinations for each therapeutic and mechanically altered diet provided to residents at the facility by a qualified dietitian.

The administrator further confirmed that the facility was unable to provide evidence that the facility's registered dietitian periodically reviewed and updated the menus, that the facility followed the planned menus as written, that the facility maintained a 3-day emergency food supply and that the facility prepared foods to maintain nutritive value and appearance and served portion sizes of foods to meet nutritional needs of residents.

Refer F801

28 Pa. Code 211.6 (a) Dietary services.

28 Pa. Code 201.18 (e)(2)(3) Management

Plan of Correction - To be completed: 04/08/2024

1. The facility is unable to retroactively correct cited issue.
2. Current menus were reviewed by registered dietitian and signed off as having variety, include the preferences of the current resident population and nutritional adequacy.
Any substitutions/changes to menu will need to be approved and signed off on by Registered Dietitian before being implemented.
Current "Disaster Food Supply" policy was amended and approved by Administrator, DON, RD and Dietary Manager to maintaining a 3-day supply of emergency food.
3. Administrator will educate Dining Room Manager on substitutions or menu changes requiring approval by Registered Dietitian before being implemented. The Dining Room Manager will educate Dietary Cooks on substitution logs and the process of making substitutions.
Dining Room Manger will educate Dietary Cooks on the requirement of following planned menus as written.
Administrator will educate Dining Room Manager on maintaining a 3-day supply of Emergency Food Supplies.
4. Administrator/designee will audit menus for variety 4x a week for 4 weeks and then weekly for 2 months.
Registered dietitian will audit menus 1 times a week for 2 months for nutritional adequacy and meeting nutritional needs of the residents.
Administrator will audit Substitution Log usage daily 4x a week for 4 weeks and then weekly x2 months to ensure all substitutions were approved by RD.
Administrator will audit Emergency Food Supply daily 4x a week for 4 weeks and then weekly x2 months to ensure proper supply.
Results will be reviewed by QA committee for two months and then reevaluated.

483.60(g) REQUIREMENT Assistive Devices - Eating Equipment/Utensils:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

§483.60(g) Assistive devices
The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.

Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide adaptive dining equipment as required by one of seven residents reviewed (Resident 1).

Findings include:

A review of the clinical record revealed that Resident 1 was admitted to the facility on February 9, 2024, and had a current physician's order dated February 13, 2024, for the use an adaptive lip plate (dishes with built up rims and ridges to allow the elderly, seniors or disabled to catch the food on your fork or spoon) and lidded cup for all meals.

Observation of the lunch meal on March 13, 2024, at approximately 12 p.m. revealed that the above resident, with physician orders for the adaptive lip plates, was served his lunch meal on a regular plate and cup and did not receive the lip plates as ordered.

Interview on March 13, 2024, at approximately 1 PM with the Nursing Home Administrator confirmed that the adaptive lip plate and lidded cup were not being utilized at the time of the meal observation and that the facility failed to provide the resident with the prescribed adaptive eating equipment, an adaptive lip plate and lidded cup.

28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Plan of Correction - To be completed: 04/08/2024

1.Resident 1 was provided with adaptive dining equipment, in accordance with his care plan.

2.An audit will be completed for all residents who need adaptive dining equipment, to ensure that equipment is in house and that each resident will be provided with appropriate equipment.

3.All Nursing and Dietary staff will be re-educated on the residents who require adaptive dining equipment to be provided with the necessary equipment in accordance with their plan of care. The Dietary staff will be educated on reading the tray tickets and ensuring the required adaptive equipment is on the tray, and nursing will be educated to ensure that the proper equipment is on the tray at time of serving meal.

4.Audits of residents who need adaptive dining equipment will be completed 4x per week by the DON or designee; to ensure that each resident is provided with equipment in accordance with their plan of care. Results will be reviewed by QA committee for 2 months and then reevaluated.

§ 204.17 LICENSURE Lounge and recreation rooms. :

A recreation or lounge room shall be a minimum of 15 square feet of floor space per bed provided for the first 100 beds and 13 1/2 square feet for all beds over 100. A facility shall provide recreation or lounge rooms for residents on each floor.

Observations:
Based on observation and staff interview, it was determined that the facility failed to provide minimum required recreation/lounge space for residents.

Findings include:

An observation March 13, 2024 of the resident hallway activity/lounge room revealed the room was locked and not accessible to residents. The room contained construction materials stored for ongoing facility construction projects.

The facility's required recreation/lounge space was 1215 square feet ( 204.16. dining area shall be a minimum of 15 square feet per bed for the first 100 beds and 13 1/2 square feet per bed for beds over 100. This dining space is required in addition to the space required for lounge and recreation rooms).

The actual activity/lounge space available at the time of the survey was 1081 square feet.

The measurements were provided by the facility Nursing Home Administrator who confirmed that the facility did not meet the required activity/lounge space for residents at the time of the survey.

Plan of Correction - To be completed: 04/08/2024

1. The facility is unable to retroactively correct cited issue.

2.All construction materials were removed from Lounge Area and door was unlocked. Lounge area is now able to be utilized for Resident Recreation.

3.Maintenance Director re-educated on the regulation requirement of minimum recreation/lounge space.

4.Audits of all recreation space being utilized for residents activities/leisure will be completed 4x per week by the DON or designee. Results will be reviewed by QA committee for 2 months and then reevaluated.

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