Health inspection·March 21, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to comprehensively assess a wound identified upon admission and failed to place a treatment order timely for one of three residents reviewed (Resident CL1). Residents Affected - Few Findings include: Review of the facility's policy titled Wound Care Management, undated revealed that all residents are assessed on admission, quarterly, and with a change of condition. Documentation will include the length, width, and depth of the wound and the appearance of the wound. Review of Resident CL1's clinical records revealed Resident CL1 was admitted to the facility on [DATE], with a diagnosis of Sepsis - (The body's extreme reaction to an infection, without prompt treatment can lead to organ failure, tissue damage, and death). Review of Resident CL1's clinical record including Nursing admission Screening/History dated February 20, 2024, at 5:30 p.m., revealed a resident with a wound on the sacrum (tail bone) with a measurement of 5.0 x 3.0 x 3.0 cm. The wound assessment revealed no information regarding the wound's appearance which includes wound bed, drainage, etc. The same form revealed Wound treatment or required to cleanse the wound with normal saline, apply Medihoney- (A dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns), and cover with a dry dressing. Review of Resident CL1's clinical record failed to reveal that the Medihoney wound treatment was put in as an order and therefore was not transcribed into the resident's Treatment Administration Record. Interview with licensed nurse Employee E3 was conducted on March 21, 2024. Employee E3 reported that the nursing supervisor was responsible for assessing wounds identified on admission. Employee E3 confirmed that the initial wound assessment was not done comprehensively. Employee E3 reported that an agency nurse worked that day and was unable to say the reason why the wound treatment on Resident CL1's sacrum was not ordered. Review of Resident CL1's clinical record including wound consult dated February 21, 2024, revealed that Resident CL1's wound was assessed and evaluated by the wound physician. The sacral wound was identified as Unstageable (Obscured full-thickness skin and tissue loss) necrosis, measuring 3.0 x 2.5 x 0.5 cm, 50% thick adherent necrotic tissue, with light serous drainage. The treatment plan is as follows: Leptospermum Honey is applied once daily covered with bordered dressing daily for 30 days. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395166 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 395166 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Pembrooke 1130 West Chester Pike West Chester, PA 19380 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)