Health inspection·October 30, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected two (Residents #10 and #11) of three residents reviewed for medication administration. The facility census was 65 residents. Findings include: 1.Review of the medical record for Resident #10 revealed an admission date of 06/28/24 with diagnoses including infection and inflammation of internal right hip prosthesis, chronic obstructive pulmonary disease, alcoholic cirrhosis of liver with ascites, and hypertension. Resident #10 was discharged to the hospital on [DATE] and returned on 04/05/25. Review of the hospital discharge orders for Resident #10 revealed an order dated 04/05/25 for Levaquin (an antibiotic) 750 milligrams (mg) once daily by mouth until 05/13/25. Review of the Medication Administration Record (MAR) for Resident #10 dated April 2025 revealed Levaquin was administered twice daily on 04/06/25, 04/07/25, 04/08/25, and 04/09/25. Interview on 10/30/25 at 1:03 P.M. with the Administrator confirmed the facility staff had not administered Resident #10's Levaquin as ordered. 2. Review of the medical record for Resident #11 revealed an admission date of 09/17/25 with diagnoses including nontraumatic subarachnoid hemorrhage, atrial fibrillation, and chronic obstructive pulmonary disease. Resident #11 was discharged to the hospital on [DATE] and returned on 10/23/25. Review of the hospital discharge orders for Resident #11 revealed an order dated 10/23/25 revealed to hold Eliquis (an anticoagulant) 5 mg until 10/26/25 and an order for cefuroxime (an antibiotic) 500 mg twice daily by mouth for three days. Review of the MAR for Resident #11 dated October 2025 revealed Eliquis was administered once on 10/23/25 and twice on 10/24/25 and10/25/25. Further review of the MAR dated 10/23/25 to 10/30/25 revealed cefuroxime was not signed off as administered. Interview on 10/30/25 at 1:03 PM with the Administrator confirmed the facility had not administered Resident #11's Eliquis nor the cefuroxime as ordered. Review of the facility policy titled Administering Medication dated April 2019 revealed medications should be administered in accordance with prescriber orders, including any required timeframe.This deficiency represents noncompliance investigated under Complaint Number 1263206 and is a recite to the survey dated 10/21/25. Residents Affected - Few Page 1 of 2 365876 365876 10/30/2025 Aventura at Carriage Inn 5040 Philadelphia Drive Dayton, OH 45415

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure laboratory services were provided as ordered. This affected one (Resident #10) of three residents reviewed. The facility census was 65 residents.Findings include: Review of the medical record for Resident #10 revealed an admission date of 06/28/24 with diagnoses including infection and inflammation of internal right hip prosthesis, chronic obstructive pulmonary disease, alcoholic cirrhosis of liver with ascites, and hypertension. Resident #10 was discharged to the hospital on [DATE] and returned on 04/05/25. Review of the hospital discharge orders for Resident #10 dated 04/05/25 revealed an order for Vancomycin (antibiotic) intravenous (IV) one gram every 12 hours and an order to obtain a Vancomycin level every Monday. Review of the Medication Administration Record (MAR) for Resident #10 revealed the resident was given the first dose of IV Vancomycin on 04/06/25 at 8:00 P.M. Review of the lab results for Resident #10 revealed the facility did not obtain obtain a Vancomycin level for Resident #10 until 04/14/25. Interview on 10/30/25 at 12:20 PM with Pharmacist #165 confirmed Vancomycin levels should be drawn prior to the administration of the fourth dose of Vancomycin for safe dosing. Pharmacist #165 further confirmed the pharmacy sent recommendations to the facility on [DATE] indicating the need to obtain a pre-dose Vancomycin level. Interview on 10/30/25 at 1:15 PM with the Administrator confirmed Resident #10 had an order for Vancomycin every 12 hours and an order to obtain Vancomycin levels every Monday. The Administrator further confirmed the facility began administration of Vancomycin to Resident #10 on 04/06/25 at 8:00 P.M. but did not obtain a Vancomycin level until 04/14/25. This deficiency represents noncompliance investigated under Complaint Number 1263206. 365876 Page 2 of 2