Health inspection·March 6, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews and policy review, the facility failed to provide a resident with timely incontinence care and timely assistance with the use of a bed pan. This affected one (#44) of three residents reviewed for incontinent care. The facility census was 75. Residents Affected - Few Findings include: Review of medical record for Resident #44 revealed admission date of 02/18/24. Diagnoses include diabetes mellitus type two, morbid obesity and hypertension. The resident was scheduled to be discharged [DATE] to another facility. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #44's Brief Interview Mental Status (BIMS) score was 15 indicating intact cognition. Resident #44 required maximum assistance for bed mobility, dependent for transfers and maximum assistance for eating. Review of Resident #44's admission skin assessment dated [DATE] revealed bruising to the right forearm and healed pressure area to the sacrum. Review of Resident #44's Body assessment dated [DATE] revealed Moisture Associated Skin Damage to bilateral thighs and buttocks. In the summary it was documented, Resident #44 voiced complaint of burning skin and being left on bed pan from previous shift. Administrator asked this nurse to perform skin assessment. Interview on 03/06/24 at 9:42 A.M. with Resident #44 revealed about a week or two ago, she had been left on a bed pan throughout the night and was not taken off until the morning staff came in. Resident #44 said the call light had gone unanswered. During the interview with State Tested Nursing Assistant (STNA) #320 who entered the room to provide care. Observation during incontinence care revealed several open areas on her coccyx, right and left posterior thigh. Observation on 03/06/24 at 9:48 A.M. of incontinence care for Resident #44 by STNA #320 revealed Resident #44 incontinence brief was saturated. Resident #44 was turned onto her left side and a strong urine smell filled the room. Further observation revealed a large, yellow tinged stain on Resident #44's bed blanket. Interview on 03/06/24 at 10:02 A.M. with STNA #320 revealed she had not yet provided incontinence care for Resident #44. STNA #320 stated she arrived at the facility and her shift started at 7:00 A.M. STNA #320 stated she was unsure of the last time Resident #44 was provided with incontinence care. (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 03/06/2024 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)