Inspection·January 8, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, and policy review, the facility failed to ensure pressure ulcer treatments were completed as prescribed and failed to ensure pressure ulcer assessment were completed. This affected two (Residents #10 and #12) of three residents reviewed for pressure ulcers. The facility census was 73. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 02/20/23. Diagnoses included peripheral vascular disease and cognitive communications deficit. The resident was cognitively impaired. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 required assistance with eating, toileting, bed mobility, and transfers. Review of the 12/13/23 wound evaluation revealed a Suspected Deep Tissue Injury (SDTI) (purple or maroon localized area of discolored intact skin due damage of underlying soft tissue from pressure) on the left proximal foot measuring 1.5 centimeters (cm) by (x) 1.5 cm and left proximal foot SDTI measuring 2.3 cm x 1.1 cm. Documents revealed Physician #114 was contacted. Review of the weekly wound assessments revealed no documentation a weekly assessment was completed on 12/20/23 for the left distal or proximal left foot wounds. Review of physician orders revealed an order with a start date of 12/21/23 to cleanse with normal saline, pat dry, apply xeroform and cover with dry, clean dressing every day shift. Review of the December and January Treatment Administration Record (TAR) revealed no documentation the treatment was provided as ordered on 12/12/23, 12/28/23, or 01/03/24. Interview on 01/09/24 at 3:30 P.M. with the Director of Nursing verified there was no documentation of a wound assessment for the distal and/or proximal wound to the left foot on 12/20/23. 2. Review of the medical record for Resident #12 revealed an admission date of 12/07/23. Diagnoses included rhabdomyolysis, type two diabetes mellitus, and anxiety. The resident was cognitively impaired. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 required assisstance with activities of daily living. Further review revealed the resident had two stage (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365876 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365876 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Carriage Inn 5040 Philadelphia Drive Dayton, OH 45415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)