Health inspection·March 27, 2025

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, physician interview, and staff interview, the facility failed to ensure physician notes were signed at the time service was rendered. This affected three (#51, #52, and #60) of three residents reviewed for physician visits. The facility census was 90. Findings include: 1. Review of the medical record of Resident #51 revealed an admission date of 07/19/18. Diagnoses included emphysema, dementia, Alzheimers, anxiety, depression, hypertension, gastro-esophageal reflux disease, chronic pain syndrome, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident was independent with eating, supervision with toileting, and partial/moderate assistance with bathing, dressing, bed mobility, and transfers. Review of a physician visit dated 01/27/25 revealed the physician did not sign the progress note until 02/09/25. Interview on 03/27/25 at 1:43 P.M. Physician #340 stated he signs his notes the minute he completes them. Interview on 03/27/25 at 1:58 P.M. the Director of Nursing (DON) verified the physician did not sign his progress note at the time of service. 2. Review of the medical record of Resident #52 revealed an admission date of 08/28/24. Diagnoses included stage 3 chronic kidney disease, depression, and rheumatoid arthritis. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. The resident required supervision for eating, bed mobility, and transfers, partial/moderate assistance for toileting, substantial/maximal assistance for bathing, and dressing. Review of a physician visit dated 09/10/24 revealed the physician did not sign the progress note until 10/19/24. Review of a physician visit dated 10/07/24 revealed the physician did not sign the progress note until 10/19/24. Page 1 of 3 365603 365603 03/27/2025 Aventura at West Park 2950 West Park Drive Cincinnati, OH 45238

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/27/25 at 1:58 P.M., the DON verified the physician did not sign his progress note at the time of service. 3. Review of the medical record of Resident #60 revealed an admission date of 10/08/24. Diagnoses included pulmonary embolism, chronic kidney disease, post-traumatic stress disorder, chronic pain syndrome, polyneuropathy, depression, osteoarthritis, hypertension, anxiety, barrett's esophagus, history of bariatric surgery. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. The resident required supervision with eating, bed mobility and transfers, and partial/moderate assistance with toileting, showering, dressing. Review of a physician visit dated 10/21/24 revealed the physician did not sign the progress note until 11/16/24. Interview on 03/27/25 at 1:58 P.M., the DON verified the physician did not sign his progress note at the time of service. This deficiency was an incidental finding that was discovered during the complaint investigation. 365603 Page 2 of 3 365603 03/27/2025 Aventura at West Park 2950 West Park Drive Cincinnati, OH 45238

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and interview, the facility failed to secure all medications in a locked storage area and to limit access to authorized personnel. This had the potential to affect 12 residents (#3, #7, #11, #13, #24, #25, #26, #28, #34, #41, #66 and #74) that are independently mobile on the 400 floor. The facility census was 90. Findings include: Observation of medication administration on 03/27/25 at 8:29 A.M. revealed Licensed Practical Nurse (LPN) #315 to retrieve a medication that needed to be re-stocked on the cart. LPN #315 went to the medication storage room on level 4 of the facility. The door was observed to be unlocked. Interview with LPN #315 on 03/27/25 at 8:29 A.M. revealed that the medication storage room was never locked and had not been since the electronic key pad lock was taken off the door. On 03/27/25 at 8:41 A.M. this surveyor went back to the medication storage room and was able to gain access due to the door not being locked. Observation on 03/27/25 at 8:47 A.M. revealed that the door to the medication storage room was ajar. Interview on 03/27/25 at 8:48 A.M. with Employee #360 revealed that she was restocking a wound supplies cart. Employee #360 revealed that she has keys somewhere if the door gets locked but usually it was left unlocked. Interview with the Director of Nursing (DON) on 03/27/25 at 2:00 P.M. revealed that a key pad lock had been placed on the medication storage room door that day in an attempt to correct the deficiency. 365603 Page 3 of 3