Health inspection·September 8, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews with the staff it was determined that the facility failed to develop and implement a baseline care plan for one of 32 residents (Resident 125). Findings include: Review of Resident 125 clinical record revealed resident was admitted on [DATE], with a gastronomy tube (feeding tube). Review of Resident 125's clinical record including physician orders revealed, staff should flush peg-tube(feeding tube) with 60 ml (mililiters) before and after medications each shift. Further review of Resident 125's clinical record failed to reveal a care plan indicating the resident had a feeding tube or the interventions for care. Interview with Regional Employee E3 on September 7, 2023, at 2:10 p.m. confirmed Resident 125 did not have a care plan for the gastronomy tube (feeding tube). The facility failed to implement a baseline care plan for gastronomy tube for Resident 125.

F655 Baseline Care plan Previously cited 10/14/2022 28 Pa. Code 211.11(a)(b)(c)(d) Resident care plan Previously cited 10/14/22 Page 1 of 7 395166 395166 09/08/2023 Aventura at Pembrooke 1130 West Chester Pike West Chester, PA 19380

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 Based on clinical records review and staff interviews, it was determined that the facility failed to follow physician orders regarding administration of medications for three of the 30 residents reviewed (Resident 9, 86, and 132). Residents Affected - Some Findings include: Review of Resident 9's Hospice progress note dated August 31, 2023, revealed the following recommendations: Morphine (medication to treat severe pain) 20mg/ml 0.25 ml (mililiter) every six hours for Dyspnea (Shortness of breath) around the clock and Ativan (medication to treat anxiety) 0.5 mg (miligrams) tablet every 12 hours for anxiety and nausea, may dissolve if cannot swallow. Review of Resident 9's Physician's order dated August 31 revealed the following orders: Ativan oral tablet 0.5 mg, one tablet by mouth every 12 hours for anxiety and Morphine Sulfate Solution 20mg/ml, give 0.25 ml by mouth every eight hours for dyspnea. Review of Resident 9's August 2023, Medication Administration Record (MAR) revealed, Morphine and Ativan medications were ordered on August 31, 2023, but were not administered to Resident 9 until September 4, 2023. Interview with the Director of Nursing (DON) on September 8, 2023, at 12:17 p.m., revealed, Ativan and Morphine medications was not delivered by the pharmacy until September 4, 2023. The DON confirmed, both Ativan and Morphine medication were available in the facility, but the staff failed to obtain a script from the physician to take out the medication from the emergency medication supply storage/box therefore ordered medications were not administered to the resident until delivered by the pharmacy on September 4, 2023, four days after the Morphine and Ativan medication was ordered by the physician on August 31, 2023. The facility failed to ensure Resident 9's Morphine and Ativan medication order was followed. Review of Resident 86's clinical record revealed diagnosis including but not limited to End Stage Renal Disease. Review of Resident 86's physician order dated September 21, 2022, revealed Midodrine (medication to increase blood pressure) HCL tablet 10mg Give 10mg by mouth one time a day every Monday, Wednesday, Thursday, and Friday. Give for blood pressure less than 100/70. Review of Resident 86's July 2023 Medication Administration Records (MAR), revealed Midodrine medication was administered nine times to Resident 86 with a blood pressure higher than 100/70 mm Hg. Interview with licensed nurse Employee E3 on September 8, 2023, at 11:30 a.m., confirmed that the facility failed to follow the physician's order to administer Midodrine medication to Resident 86 within the parameters. Review of Resident 132's diagnosis revealed Osteomyelitis (infection to the bone) to the left foot and ankle. Review of Resident 132's physician orders dated June 26, 2023, revealed an order of Baclofen oral 395166 Page 2 of 7 395166 09/08/2023 Aventura at Pembrooke 1130 West Chester Pike West Chester, PA 19380

F 0684 Level of Harm - Minimal harm or potential for actual harm tablet five milligrams Give one tablet by mouth every eight hours for pain. The medication was scheduled for 12:00 a.m., 8:00 a.m., and 4:00 p.m. Review of Resident 132's June 2023, MAR revealed Baclofen was not administered to Resident 132 on June 26 at 4:00 p.m., June 27 and 28, 2023, at midnight. Residents Affected - Some Review of Resident 132's nursing progress notes dated June 28, 2023, at 12:39 a.m., revealed awaiting pharmacy for the Baclofen medication. Interview with the Director of Nursing (DON) conducted on September 8, 2023, confirmed Baclofen medication was not administered to Resident 132 on June 26, 2023, September 27 and 28 at midnight, due to awaiting pharmacy delivery. However, the DON confirmed that Baclofen medication was available on the facility's medication backup which was used to administer to Resident 132 on June 27, 2023, at 8:00 a.m., and 4:00 p.m. Clinical records review failed to reveal a reason why Baclofen medication was not administered despite availability of the medication in the facility. The facility failed to ensure physician's order for Baclofen medication for Resident 132 was followed. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services 395166 Page 3 of 7 395166 09/08/2023 Aventura at Pembrooke 1130 West Chester Pike West Chester, PA 19380

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on facility policy and clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for three of seven residents reviewed for nutrition (Resident 41, 104, and 125). Residents Affected - Some Findings include: Review of the facility policy Weight assessment and intervention, dated August 2022, states, Residents are weighed upon admission and at intervals established by the interdisciplinary team and weights are recorded in each unit's weight record chart and in the individual's medical record. Review of Resident 41's weights revealed there was no monthly weight completed for January and February 2023. Interview with Licensed Dietitians E4 and E5 on August 8, 2023 at 10:40 a. m. revealed they expected weights to be completed at least monthly on all residents and there were no monthly weight completed for January and February 2023 for Resident 41. Review of Resident 104's physician orders revealed a physician order dated February 6, 2023 for weekly weights for four weeks. Review of resident 104's weights revealed a weight completed on February 15 and March 3, 2023. Interview with Licensed Dietitians E4 and E5 on August 8, 2023 at 10:40a.m. revealed the order for monthly weight on February 6, 202 was not completed as ordered. Review of the clinical record for Resident 125, revealed an admission date of June 17, 2023, with a diagnosis of gastronomy tube (feeding tube) and a weight of 160 pounds. Upon further review of the clinical record there were no additional weights recorded. An interview with Regional Employee E3, on September 7, 2023, at 1:20 p.m., revealed that there was a weight chart on the unit and presented this surveyor with the weight chart a short time later. Review of the weight chart which identified the resident's by their room number and last name, the surveyor found a weight for August (no day noted and no weight for July) which was 126.8 (a weight loss 33.2 pounds). Interview with Regional Employee E3, conducted on September 8, 2023, at 11:30 a.m., revealed the weight recorded in the weight chart, was inaccurate, but failed to provide further documentation of the resident's weight. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services 395166 Page 4 of 7 395166 09/08/2023 Aventura at Pembrooke 1130 West Chester Pike West Chester, PA 19380

F 0756 Level of Harm - Minimal harm or potential for actual harm Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on clinical records review and staff interview, it was determined that the facility failed to respond to recommendations made by the consultant pharmacist for one of the five residents reviewed (Residents 47). Residents Affected - Few Findings include: Clinical records review and progress notes dated March 23, 2023, February 26, 2023, and December 27, 2022, revealed that a monthly review was completed by the consultant pharmacist and a recommendation was provided for staff to review. Interview conducted with the Director of Nursing (DON) on September 8, 2023, at 11:38 a.m. revealed the facility was unable to locate documentation of the pharmacy consultant's recommendations made on the dates mentioned above were addressed by the attending physician. The facility failed to provide documented evidence of the pharmacy recommendations of March 23, 2023; February 26, 2023; and December 27, 2022, were addressed. The facility failed to ensure pharmacy consultant's recommendation was addressed by the facility. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services 395166 Page 5 of 7 395166 09/08/2023 Aventura at Pembrooke 1130 West Chester Pike West Chester, PA 19380

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interviews it was determined that the facility failed to ensure residents are free from unnecessary drugs without adequate indications for its use for one of 32 residents (Resident 130). Residents Affected - Few Findings include: Review of Resident 130's clinical record revealed a physician's order inititiated on August 15, 2023 for Oxycodone 5 mg (miligrams) to give one tablet by mouth every 6 hours as needed for pain for 14 days with non-pharmaceutical interventions (NPI's) offered prior to administration. Review of Resident 130's clinical record revealed the August 2023 Medication Administration Record indicated Resident 130 received Oxycodone 5 mg on August 15, 16 (2 administrations) , 17 (2 administrations), 18, 19 (2 Administrations), 21, 22, and 24 (2 administrations), without NPI's documented prior to administration. Interview conducted with Regional Employee E3 on September 8, 2023 at 11:20 a.m. confirmed non pharmacological interventions were used prior to medication administration. 28 Pa Code 211.5 (f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services 395166 Page 6 of 7 395166 09/08/2023 Aventura at Pembrooke 1130 West Chester Pike West Chester, PA 19380

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on facility policy and procedure review, clinical record review, and staff interview it was determined the facility failed to monitor for side effects for antipsychotic medications for one of five residents reviewed. (Resident 90) Findings Include: Review of Policy and Procedure titled Antipsychotic Medication Use revealed Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician. Review of Resident 90's physician orders revealed an order for Seroquel 25 mg (antipsychotic medication) at bedtime dated July 19, 2023. Review of Resident 90's clinical record revealed there was no documented evidence facility staff had been monitoring the resident for side effects. Interview with nursing employee E3 on September 8, 2023 at 9:30 a.m. confirmed the facility was not monitoring Resident 90 for side effects from the antipsychotic medications. 28 Pa Code 211.5 (f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services 395166 Page 7 of 7