Health inspection·September 11, 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. Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's representative was notified of development of new pressure ulcer and treatment plan. This affected one (#75) out of three residents reviewed for pressure ulcers. The facility census was 61. Findings include: Review of the medical record for Resident #75 revealed an admission date of 04/03/24 with medical diagnoses of cerebral atherosclerosis, protein calorie-malnutrition, chronic obstructive pulmonary disease, and obstructive and reflux uropathy. Review of the medical record for Resident #75 revealed a quarterly Minimum Data Set (MDS) assessment, dated 06/17/24, which indicated Resident #75 had severe cognitive impairment and required partial/moderate staff assistance with toilet hygiene, bed mobility, and transfers. The MDS indicated Resident #75 required substantial/maximum staff assistance with bathing and no pressure ulcer/injuries were noted. Review of the medical record for Resident #75 revealed a wound observation evaluation, dated 07/25/24, which stated Resident #75 had a Stage III pressure ulcer to the left heel. The evaluation stated the wound was first observed on 07/25/24, the physician was notified, and a treatment was ordered. Review of the evaluation revealed no documentation to support the facility notified Resident #75's representative of the new pressure ulcer or treatment plan. Interview on 09/11/24 at 10:56 A.M. with Administrator confirmed the medical record for Resident #75 did not contain documentation to support Resident #75's representative was notified of the left heel pressure ulcer and treatment. Review of the facility policy titled, Change in Resident's Condition or Status, revised May 2017 stated the facility shall promptly notify the resident, his/her attending physician, and representative of changes in the resident's medical/mental condition and/or status. This deficiency represents non-compliance investigated under Complaint Number OH00156810. Page 1 of 3 365876 365876 09/11/2024 Aventura at Carriage Inn 5040 Philadelphia Drive Dayton, OH 45415

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 365876 Page 2 of 3 365876 09/11/2024 Aventura at Carriage Inn 5040 Philadelphia Drive Dayton, OH 45415

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 365876 Page 3 of 3