Health inspection·February 7, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and physician interviews, and review of facility policy, the facility failed to notify a resident's physician of abnormal laboratory results. This affected one (#77) of three residents reviewed for notification of change. The census was 74. Findings include: Review of Resident #77's closed medical record revealed an admission dated of 07/29/23. Diagnoses listed included obstructive sleep apnea, muscle weakness, type two diabetes mellitus, urine retention, and chronic kidney disease. Resident #77 was transferred to a local hospital on [DATE]. Resident #77 passed away while at the hospital on [DATE]. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #77 was moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight. Resident #77 had an indwelling catheter. Review of progress notes revealed Resident #77 was noted with penile discharge with a foul odor on 12/19/23. Resident #77 was assessed by physician on 12/19/23 for the penile discharge. Physician ordered an urinalysis (UA ) with culture and urology consult. The urologist was notified on 12/19/23. Resident #77 was transferred to a local hospital on [DATE] by emergency squad for low oxygen saturation levels and decreased level of consciousness. Resident #77 passed away at a local hospital on [DATE]. Review of physician orders revealed an order dated 12/19/23 to obtain an UA with culture. Review of laboratory results revealed the sample for for UA and culture was obtained on 12/20/23. UA results dated 12/21/23 revealed abnormal bacteria levels were present at too numerous to count (TNTC) when normal level was absent. Culture results dated 12/24/23 revealed the presence of two bacterial organisms (proteus mirabilis and enterococcus faecalis) at greater than 100,000 colony forming units per milliliter cfu/ml. Further review of Resident #77's closed medical record revealed no documentation of UA results dated 12/21/23 or culture dated 12/24/23 being addressed by staff. There was no documentation of Resident #77's physician or urologist being notified of the UA or culture results. There was no documentation of any treatment being ordered. During an interview on 02/07/24 at 2:45 P.M. the Director of Nursing (DON) and Administrator (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 4 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 02/07/2024 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)