Inspection·September 11, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff and resident interviews, and policy review, the facility failed to follow infection control procedures. This affected one (#22) out of three residents reviewed for wound care. The facility census was 61. Residents Affected - Few Findings include: Review of the medical record for Resident #22 revealed an admission date of 02/21/22 with medical diagnoses of heart failure, diabetes mellitus, severe protein calorie malnutrition, peripheral vascular disease, and hypertension. Review of the medical record for Resident #22 revealed a quarterly Minimum Data Set (MDS) assessment, dated 06/30/24, which indicated Resident #22 was cognitively intact and was independent with eating, bed mobility, and transfers, required supervision with bathing, and set-up assistance with toileting. The MDS did not indicate Resident #22 had any skin areas. Review of the medical record for Resident #22 revealed a wound observation evaluation, dated 08/28/24, which stated Resident #22 had a Stage III pressure ulcer to her sacrum and treatment was in place. Review of the medical record for Resident #22 revealed a physician order dated 08/28/24 for treatment to gluteal cleft which was to apply alginate and cover with bordered foam dressing daily. Review of the medical record including physician orders and care plan revealed there was no documentation to support Enhanced Barrier Precautions (EBP) were ordered or implemented. Interview on 09/10/24 at 8:35 A.M. with Licensed Practical Nurse (LPN) #191 confirmed Resident #22 had a pressure ulcer and received wound care daily. LPN #191 confirmed Resident #22 did not have an order for EBP or a EBP sign posted on her door or personal protective equipment (PPE) cart located near her room. LPN #191 stated staff did not don a gown when providing wound care for Resident #22. Observation with interview on 09/10/24 at 9:00 A.M. revealed Resident #22 lying in bed. Resident #22 confirmed she had an open area to her bottom and staff complete dressing changes daily. Resident #22 confirmed staff did not wear gowns but did wear gloves when providing wound care. Interview on 09/10/24 at 11:20 A.M. with Administrator confirmed the facility had not had EBP in place for the residents with wounds or indwelling devices. Administrator stated the facility identified the issue that morning and entered orders for all residents with wounds, gastrostomy tubes, ostomies, and indwelling or suprapubic catheters. Administrator stated all staff would be educated on EBP and signs would be posted outside of those resident's rooms along with a cart with proper PPE. Review of the facility policy titled, Enhanced Barrier Precautions, stated Enhanced Barrier Precautions (EBP) are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) during high-contact resident care activities both inside and outside the residents' room, which can result in transferring multi-drug resistive organisms (MDRO) to staff hands and clothing. The policy stated PPE was to include gloves and gown and eye protection may be indicated if a splash risk exits. The policy stated EBP's are indicated for residents with infection or colonization with a Center for Disease Control targeted MDRO when contact precautions do not otherwise apply, wounds and/or indwelling medical devices (central lines, urinary catheters, feeding tubes, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365876 If continuation sheet Page 2 of 3 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 09/11/2024 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)

F 0880 tracheostomies). Level of Harm - Minimal harm or potential for actual harm This deficiency is based on incidental findings discovered during the course of this complaint investigation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365876 If continuation sheet Page 3 of 3