Health inspection·December 10, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 policy review, the facility failed to properly assess a surgical wound to include measurements and description of the wound. This affected one (#64) out of three residents reviewed for wounds. The facility census was 62. Findings include: Review of the medical record for Resident #64 revealed an admission date of 06/10/25 with medical diagnoses of right femur fracture, chronic obstructive pulmonary disease, dementia, chronic kidney disease Stage IV, and pneumonitis. Review of the medical record revealed Resident #64 was discharged to the hospital on [DATE]. Review of the medical record for Resident #64 revealed an admission Minimum Data Set (MDS) assessment, dated 06/16/25, which indicated Resident #64 had severely impaired cognition and was dependent upon staff for toilet hygiene, bathing, bed mobility and transfers. The MDS indicated Resident #64 required substantial/maximum staff assistance for eating and had a surgical wound. Review of the medical record for Resident #64 revealed an admission Observation and Assessment, dated 06/10/25, which indicated Resident #64 had a surgical site to right hip with 29 staples that were well approximated. The observation did not have document to support measurements or a description of the wound. Review of the medical record revealed a weekly skin observation, dated 06/18/25, which stated Resident #64 had an unstageable to right thigh. The observation did not contain documentation to support information related to Resident #64's surgical site or measurements or description for the wound to Resident #64's right thigh. Interview on 12/10/25 at 9:45 A.M. with Licensed Practical Nurse (LPN) #136 stated she assessed Resident #64's skin on 06/11/25 and noted the surgical wound to her right hip/thigh areas and denied any other skin issues. LPN #136 confirmed the medical record for Resident #64 did not contain documentation of the surgical wound measurements or description of the wound during Resident #64's stay from 06/10/25 to 06/21/25. Review of the facility policy titled, Wound Care, revised October 2010 stated the purpose of the procedure was to provide guidelines for care of wounds to promote healing. The policy stated to verify there was a physician order for the procedure. The policy stated the following information should be recorded in the resident's medical record: 1) type of wound; 2) date and time wound care was given; 3) position in which the resident was placed; 4) the name and title of the individual performing the wound care; 5) any change in the resident's condition; 6) all assessment data (wound bed color, size, drainage, etc.); 7) how the resident tolerated the procedure; 8) any problems or complaints made by the resident related to the procedure; 9) if resident refused treated and reason why; 10) the signature and title of the person recording the data. This deficiency represents non-compliance investigated under Complaint Numbers 1263342 (OH00167356) and 1263337 (OH00163933). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365876 If continuation sheet Page 2 of 5 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 12/10/2025 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 0687 Provide appropriate foot care. 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, review of hospital records, staff interviews, and policy review, the facility failed to provide wound care as ordered for an arterial ulcer to a resident's foot and failed to complete a comprehensive wound assessment for surgical wound on a resident's foot. This affected one (#66) out of three residents reviewed for wounds. The facility census was 62. Findings include: Review of the medical record for Resident #66 revealed an admission date of 12/01/24 with medical diagnoses of chronic obstructive pulmonary disease, diabetes mellitus, and peripheral vascular disease. Review of the medical record revealed Resident #66 was discharged to the hospital on [DATE], readmitted to the facility on [DATE] and admitted to the hospital on [DATE]. Review of the medical record for Resident #66 revealed a quarterly Minimum Data Set (MDS) assessment, dated 03/08/25, which indicated Resident #66 was cognitively intact and required supervision with bed mobility, eating, and transfers and partial/moderate staff assistance with toilet hygiene and bathing. The MDS indicated Resident #66 had a surgical wound and care was provided. Review of the medical record for Resident #66 revealed an initial wound evaluation completed on 02/04/25 which indicated an arterial ulcer to the right foot second digit. The evaluation indicated the wound had 100% eschar and measured 1 centimeter (cm) by 1 cm with an order to apply barrier skin wipes/spray daily and as needed. Review of the medical record for Resident #66 revealed a Wound Physician note, dated 02/04/25, which stated Resident #66 had an arterial ulcer to the right foot second digit which measured 1.0 cm by 1.5 cm with 100% eschar. The note indicated an order for barrier wipes/spray daily and as needed. The note stated the right foot toes were dusky, warm and capillary refill was present but diminished. Review of the medical record for Resident #66 revealed a physician order dated 02/04/25 to apply barrier spray/wipes to the right foot second toe daily, every 12 hours as needed for skin integrity. Review of the medical record for Resident #66 revealed a February 2025 Treatment Administration Record (TAR) which revealed no documentation to support the facility completed treatment to the second digit on the right foot as ordered on 02/04/25. Review of the medical record for Resident #66 revealed a hospital note, dated 02/10/25, which stated resident complained of her right foot second toe being dead. Further review of the medical record revealed a hospital discharge summary and transfer orders dated, 02/28/25, which stated Resident #66 later underwent a right foot second digit toe amputation on 02/14/25 and a right transmetatarsal amputation on 02/25/25. Review of the medical record for Resident #66 revealed an admission nursing evaluation, dated 02/28/25, which indicated Resident #66 had amputated toes but no documentation to support which foot, measurements, or description of surgical site. Further review revealed weekly skin assessments completed on 03/02/25 and 03/10/25 which indicated amputation to right foot but did not have documentation to support measurements or description of the surgical wound. Review of the medical record revealed a nurses' note, dated 03/12/25 at 3:39 P.M. which stated the Wound Clinic informed the facility that Resident #66 was admitted to the hospital from the appointment for possible wound infection. Interview on 12/09/25 at 2:27 P.M. with Administrator confirmed the medical record for Resident #66 did not contain documentation to support the facility completed wound care to the second digit on the right foot as ordered by the Wound Physician on 02/04/25. Administrator stated the order for treatment to second digit on the right foot was entered into Resident #66's electronic health records for the treatment to be done as needed instead of daily and as needed. Administrator also confirmed Resident #66 was admitted to the hospital on [DATE] for right foot pain and later underwent an amputation of second digit on right foot on 02/14/25. Interview on 10/10/25 at 10:20 A.M. with Director of Nursing (DON) confirmed that the medical record did not have documentation to support Resident #66's surgical wound had been measured or an Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365876 If continuation sheet Page 3 of 5 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 12/10/2025 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 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete included description of the wound on 02/28/25 though stay until discharged on 03/12/25. Review of the facility policy titled, Wound Care, revised October 2010 stated the purpose of the procedure was to provide guidelines for care of wounds to promote healing. The policy stated to verify there was a physician order for the procedure. The policy stated the following information should be recorded in the resident's medical record: 1) type of wound; 2) date and time wound care was given; 3) position in which the resident was placed; 4) the name and title of the individual performing the wound care; 5) any change in the resident's condition; 6) all assessment data (wound bed color, size, drainage, etc.); 7) how the resident tolerated the procedure; 8) any problems or complaints made by the resident related to the procedure; 9) if resident refused treated and reason why; 10) the signature and title of the person recording the data. This deficiency represents non-compliance investigated under Complaint Number 1263342 (OH00167356) and 1263337 (OH00163933). Event ID: Facility ID: 365876 If continuation sheet Page 4 of 5 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 12/10/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on review of the facility menu, observations, staff interview, and policy review, the facility failed to ensure food was served per the facility menu. This affected nine (#28, #32, #33, #34, #35, #36, #40, #41, and #71) resident who did not receive coleslaw on their lunch trays. The facility census 62. Findings include: Review of the facility menu for the lunch meal for 12/10/25 revealed that residents would receive baked pork chop, baked beans, creamy coleslaw, cornbread, and whipped jello parfait. Observation of the lunch service on 12/10/25 at 1:04 P.M. revealed that the kitchen ran out of coleslaw and Resident #28, #32, #33, #34, #35, #36, #40, #41, and #71 did not receive coleslaw on their trays. Interview on 12/10/25 at 1:06 P.M. with Dietary Manager (DM) #179 verified the facility ran out of coleslaw. DM #179 verified Resident #28, #32, #33, #34, #35, #36, #40, #41, and #71 did not receive coleslaw and were not given any substitutions. Review of the facility policy titled, Menu Substitutions date 04/25/24 revealed substitutions shall be made when menu items are not available for service. This deficiency represents non-compliance investigated under Complaint Number 1263340 (OH00161682) and Complaint Number 1263335 (OH00161111). Event ID: Facility ID: 365876 If continuation sheet Page 5 of 5