Health inspection·July 25, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, medical record review, and interviews with residents and staff, it was determined the facility failed to provide a dignified existence for 1 of 1 (Resident 98) by not allowing the resident to transfer to a more appropriate unit. Findings include: Review of Resident 98's medical records revealed the following diagnosis: unspecified dementia, unspecified severity, with other behavioral disturbance (confusion or mild cognitive impairment can't be clearly diagnosed as a specific type of dementia), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), mood disorder due to known physiological condition with depressive features (prominent and persistent period of depressed mood or markedly diminished interest/pleasure thought to be related to the direct physiological effects of another medical condition). Review of Resident 98's Minimum Data Set (standardized assessment tool that measures health status in nursing home residents) revealed Resident 98 possesses a Brief Interview for Mental Status (BIMS, a points-based assessment that helps identify cognitive impairment in older adults) of 15 out of 15 (indicating intact cognition). Interview conducted with Resident 98 on July 22, 2024, at 10:15 a.m. revealed Resident 98 has requested multiple times to transfer off Nursing unit 3 (Memory care unit) due to being cognitively intact and not being able to interact with other residents with the same cognition level. Review of a grievance list revealed Resident 98 filed a grievance report on May 31, 2024. Review of grievance detail revealed the following Resident is upset that he is located on the dementia unit and wants to move units. Further review of Resident 98's grievance revealed section Actions Taken To Address which states Resident to remain on the 3rd floor - Resident's behaviors and medical diagnosis support, resident remaining on 3rd floor at this time. Interview conducted with Licensed Practicable Nurse (LPN) employee 4 (E4) on July 24, 2024, at 1:26 p.m. reported Resident 98 is a high functioning resident and does not belong in the memory care unit. Interview conducted with employee 3 (E3) on July 25, 2024, at 11:17 a.m. reported Resident 98 does Page 1 of 6 395166 395166 07/25/2024 Aventura at Pembrooke 1130 West Chester Pike West Chester, PA 19380

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not participate in any activities taking place in the memory care unit due to the activities being designed for residents with impaired cognition. Interview conducted with the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the above and confirmed Resident 98 does not belong in the memory care unit and will transfer Resident 98 to a floor. 28 Pa. Code 201.29 (j) Resident Rights 395166 Page 2 of 6 395166 07/25/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records review and staff interviews, it was determined that the facility failed to follow physician orders regarding administration of medications for one of the 23 residents reviewed (Resident 69). Additionally, the facility failed to follow physician orders regarding referrals for one of the 23 residents reviewed (Resident 29). Residents Affected - Few Findings include: Review of Resident 29's clinical records revealed medical diagnosis that include Pleural Effusion (excess fluid between lungs and chest wall), Acute Kidney Failure (kidney failure), Parkinson's Disease (chronic and progressive movement disorder) and Rheumatoid Arthritis (inflammatory disease affecting the joints). Review of Resident 29's clinical records revealed a progress note dated July 1, 2024, stating the resident returned from Neurologist appointment with a prescription for Physical and Occupational Therapy. Review of Resident 29's clinical records revealed an after-visit summary dated July 1, 2024, from [NAME] Medicine Neurology, documenting referrals for consult to physical therapy and occupational therapy. Additionally, a referral was made for a consultation to a Deep Brain Stimulation (DBS) Clinic. Review of Resident 29's clinical records on July 25, 2024, failed to reveal referrals were made for physical therapy, occupational therapy, or the DBS Clinic. During interview on July 25, 2024, at 12:12 p.m., with NHA, DON and E7 it was confirmed that referrals for neither physical and occupational therapy nor the DBS Clinic were followed for Resident 29. Review of Resident 69's clinical records revealed medical diagnosis that include Cellulitis of Left Lower Limb (bacteria skin infection of leg), Hypertension (high blood pressure), Atherosclerotic Heart Disease (plaque buildup), End Stage Renal Disease (condition that affects kidney function), Congestive Heart Failure (inability of heart to pump blood), Diabetes and Chronic Kidney Disease (kidney failure). Review of Resident 69's physician orders dated June 9, 2024, revealed an order for Mildodrine HCI Oral Tablets 5MG, give 5mg by mouth three times a day for hypertension related to chronic diastolic (congestive) heart failure, hold if B/P (blood pressure) greater than 100/60. Review of Resident 69's Medication Administration Report (MAR) dated June 2024, revealed medication was given outside of the prescribed perimeters for 20 of 22 days administered. Review of Resident 69's MAR dated July 2024, revealed medication was given outside of the prescribed perimeters for 21 of 25 days administered. On July 24, 2024, at 12:20 p.m. Employee E7 confirmed that the resident has been receiving Mildodrine HCI 5MG, outside of the prescribed perimeters. E7 stated that staff would receive in-service training. 395166 Page 3 of 6 395166 07/25/2024 Aventura at Pembrooke 1130 West Chester Pike West Chester, PA 19380

F 0684 28 Pa. Code 211.5(f) Clinical Records Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Residents Affected - Few 395166 Page 4 of 6 395166 07/25/2024 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 clinical record review, and observation, it was determined that the facility failed to accurately monitor and assess residents for side effects of antipsychotic medications for one of five residents reviewed for unnecessary medications (Resident 6). Findings include: Review of Resident 6's clinical record revealed an order dated December 12, 2023, for Rexulti (antipsychotic medication) 1.5 milligrams (mg) one time daily. Further review of Resident 6's orders revealed an order to monitor for side effects for antipsychotic medications every day, evening, and night shift. Review of Resident 6's Abnormal Involuntary Movement Scale (AIMS) dated May 13, 2024, revealed no issues. Review of Resident 6's AIMS dated June 3, 2024, revealed the resident was experiencing mild involuntary facial and oral movements, mild involuntary upper and lower extremity movements, and minimal involuntary trunk movements, with overall severity of symptoms scored as moderate. Observation of Resident 6 on July 25, 2024, at approximately 10:30 a.m. revealed the resident was experiencing tremors in the left arm and leg and lip puckering. Review of Resident 6's May 2024, June 2024, and July 2024 Medication Administration Record revealed the resident was documented as not having side effects from antipsychotic medications with a 0 or N/A, or not documented at all, every shift except for May 30, 2024 evening shift, where the resident was documented having a stiff neck. Interview with the Nursing Home Administrator and Director of Nursing on July 25, 2024, at 11:10 a.m. confirmed staff were not documenting Resident 6's side effects to antipsychotic medications accurately. 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 5 of 6 395166 07/25/2024 Aventura at Pembrooke 1130 West Chester Pike West Chester, PA 19380

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined the facility failed to provide therapy services to prevent a decline in Activity of Daily Living performance for one of 23 residents reviewed. (Resident 29) Residents Affected - Few Findings Include: Review of Resident 29's clinical records revealed medical diagnosis that include Pleural Effusion (excess fluid between lungs and chest wall), Acute Kidney Failure (kidney failure), Parkinson's Disease (chronic and progressive movement disorder) and Rheumatoid Arthritis (inflammatory disease affecting the joints). Review of Resident 29's clinical records revealed a progress note dated July 1, 2024, stating the resident returned from Neurologist appointment with a prescription for Physical and Occupational Therapy. Review of Resident 29's clinical records revealed an after-visit summary dated July 1, 2024, from [NAME] Medicine Neurology, documenting referrals for consult to physical therapy and occupational therapy. Review of Resident 29's clinical records revealed an Occupational Therapy evaluation and plan of treatment for certification period of May 23, 2024, through July 21, 2024, with a goal of improving the resident's use of hands. Further review of the resident's clinical records revealed that the resident was discharged from Occupational Therapy on June 6, 2024, with a prognosis to maintain CLOF (current level of function) being good with consistent staff follow through. Discharge recommendations included resident perform 1x10 BUE (both upper extremities) Theraputty (resistive putty material used for occupational therapy) exercises to improve joint mobility and reduce risk of contractures, functional transfer to MWC (manual wheelchair) x1 a week to improve out of bed experience and encouraged participation in repositioning to improve functional independence in bed mobility. Review of Resident 29's clinical records failed to reveal the resident received any physical or occupational therapy since June 6, 2024. During interview on July 25, 2024, at 12:12 p.m., with NHA, DON and E7 it was confirmed that Resident 29 had not received physical or occupational therapy since June 6, 2024, despite having a referral since July 1, 2024. 28 Pa. Code: 211.12 (d)(1)(3) Nursing services 28 Pa. Code: 211.12(d)(1)(5) Nursing services 395166 Page 6 of 6