Health inspection·December 11, 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 clinical record review, staff interview and review of facility provided documentation, and review of clinical records, it was determined that facility failed to timely monitor and assess a resident's medical condition for one of eight residents reviewed. (Resident R1) Findings include: Review of Resident R1's clinical record revealed the resident was admitted to facility on [DATE], with diagnosis of history of hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, acute or chronic diastolic (congestive) heart failure, hypertensive heart disease with heart failure, chronic obstructive pulmonary disease, anemia and schizophrenia (mental disease characterized by loss of reality contact). Review of Resident R2's Minimum Data Set (MDS- assessment of resident needs), completed on [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident was cognitive intact. Review of Resident R1's clinical record revealed that on Friday, [DATE] at 8:33 pm, the resident was found unresponsive on the floor in (his/her) room. Cardiopulmonary Resuscitation was initiated and continued until EMS arrival at approximately 8:38 pm - at which point EMS (Emergency Medical Staff) personnel relieved staff and continued resuscitation efforts until 9:15 pm, when resident was pronounced deceased by EMS. Review of facility provided statement, completed by Licensed nurse, Employee E11, on [DATE] states the following: This nurse was passing medications when the CNA (nurse aide) came out of residents room said resident fell and is on the floor. This nurse went into residents room and resident was lying on the floor. Checked for pulse was faint, started CPR immediately and told CNA to alert nurse and call a STAT (immediate) code to room. CPR continued by staff until 911 EMS arrived. This nurse last seen resident at approximately 19:45 was sitting in chair in his room. Review of statement completed by licensed nurse, employee E7, who worked over night shift, from Thursday, [DATE], 11:00 pm, through Friday, [DATE], 7:00 am, and who was assigned to care for Resident R1, states the following I worked 11-7 Thursday Oct. 23, 2025. Between the hours of 12A-1A. [Resident R1] approached me in his wheelchair complaining of generalized body aches stated (he/she) had cold symptoms, but (he/she) requested Tylenol which I gave to (him/her) per (his/her) orders. I did not hear any cough/congestion like resident was complaining of but did endorse to 7-3 nurse that [Resident R1] was complaining of cold symptoms. Throughout the shift since (XXXX) is on Q (every) 15 minute checks I did note [Resident R1] sitting up in (his/her) wheelchair on the bathroom randomly throughout the shift (unlike resident). The last time I saw him was around 6:15 am when I brought medication to B and C bed. [Resident R1 was sleeping in his bed in no acute distress. Review of Resident R1's clinical record indicated no documented evidence of Licensed nurse, Employee E7 checked Resident R1's vital signs during shift after the resident expressing experiencing cold symptoms and no evidence of further assessment related to why he was found in bathroom randomly throughout shift. Interview with nurse aide, Employee E6, on [DATE], at 2:37 pm, who was assigned to care for Resident R1 on Friday, [DATE], during day shift, 7:00 am to 3:00 pm revealed that Resident R1 was Residents Affected - Few Page 1 of 3 395203 395203 12/11/2025 Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few found with a bucket next to him at 7:10 am and stated that he had nausea and vomiting started at approximately 4:00 am. Further interview with Employee E6 revealed that he informed charge nurse of R1's vomiting - stating it's not his norm, check him immediately. At 10 :00 am [Resident R1] was still vomiting and vomited again after lunch meal service E6 also noted Resident R1 in his room after lunch, undressed, rocking back and forth, stating ‘I feel neither hot nor cold ' - at which point, Employee E6 notified charge nurse again. Further review of Resident R1's clinical record revealed only one set of vital signs were taken on Friday, [DATE], at 9:15 am. Review of progress note, completed by facility's director of nursing, dated [DATE], at 11:46 am, stating that [Resident R1] complained of one episode of vomiting this morning, followed by throat pain and chest discomfort. On assessment, he was AAO x 4 (people, place, time and situation), VSS (vital signs). No radiation of pain noted. Call placed to on-call service. (Physician, Employee E10) returned call. TVO (telephone verbal order) received for Pepcid 20mg (milligrams) PO (by mouth) x 1 dose. If pain continues, 9Employee E100 said to send to ER (Emergency Room) for evaluation. Orders read back and confirmed. Nursing made aware. Interview with Physician, Employee E10, on [DATE], at 12:17 pm, revealed that he was contacted on morning of Friday, [DATE], related to Resident R1's one episode of vomiting, burning throat, discomfort sensation in chest. Further review of late entry progress note, dated [DATE], at 3:58 pm, completed by day shift Licensed nurse, Employee E1, who was assigned to care for Resident R1 on Friday, [DATE], states received in nursing report resident was complaining of cold symptoms. Upon entering room, nurse was told resident was in his room vomiting. Nurse assessed resident, obtained VS (vital signs), 97.3, 115/71, 60HR, 20RR, 97% on RA (room air). Nurse notified ADON (Assistant Director of Nursing) of resident status, ADON assessed resident whom notified the MD, new order for Pepcid. Nurse administered medication. Made oncoming nurse aware of resident status for continuing follow up. However, interview with Licensed nurse, Employee E2, on Friday, [DATE] at 11:47 am, who was assigned to care for Resident R1 on Friday, [DATE], during evening shift of 3:00 pm to 11:00 pm, revealed that he was not assigned to care for Resident R1, further stating that he only checked Resident R1's blood glucose. Further interview with Licensed nurse, EmployeeE2 revealed that he did not receive information related Resident R1's status during change of shift report. 28 Pa Code 211.12(d)(1)(5) Nursing services28 Pa Code 211.12(e) nursing services 395203 Page 2 of 3 395203 12/11/2025 Aventura at Prospect 815 Chester Pike Prospect Park, PA 19076

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Resident R2 ' s quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 5, 2025, revealed the resident was rarely/never understood and had diagnoses of hemiplegia or hemiparesis, and functional quadriplegia. Continued review of Resident R2's quarterly MDS dated [DATE], revealed the resident had functional limitation in range of motion impairments on both sides of upper extremity.Review of Section GG0170. Mobility of Resident R2's quarterly MDS dated [DATE], revealed the resident was dependent (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff to roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed). Review of Resident R2's comprehensive care plan dated August 13, 2021, revealed the resident was at risk for falls related to immobility. Review of intervention dated August 13, 2021, revealed Resident R2 required two-assist for bed mobility.Review of Resident R2's nursing Kardex (a documentation system that helps nurses organize and access key patient information for care planning) revealed a nursing rehab task dated June 29, 2025, that indicated Resident R2 required bed mobility assistance of two [people] during reposition and bed mobility. Review of Resident R2's clinical record revealed a nursing note dated October 14, 2025, that revealed Licensed Nurse, Employee E3, was called to Resident R2's room by nurse aide, identified as Employee E4. Nurse aide, Employee E4, stated when Resident R2 was rolled to the other side of the bed to remove the bed sheets, the resident rolled off the bed. Review of facility documentation revealed an undated incident report that indicated while Nurse Aide, Employee E4, was rolling Resident R2 to the opposite side [of the bed] to remove the soiled sheets, the resident rolled off the bed. Interview on October 22, 2025, at 12:00 p.m. with the Director of Nursing, Employee E2, revealed that Nurse Aide, Employee E4, rolled Resident R2 away from him/her when removing the bed sheets. Director of Nursing, Employee E2, indicated that residents should always be rolled toward the caregiver when turning them in bed. Interview on October 22, 2025, at 12:20 p.m. with the Nursing Home Administrator, Employee E1, confirmed Nurse Aide, Employee E4, should have followed Resident R2's plan of care and provided 2-person assistance for bed mobility. 28 PA. Code 211.12(d)(5) Nursing services 395203 Page 3 of 3