Aventura At Pembrooke

F 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

Based on review of the Pennsylvania Professional Nursing Practice Act, observation, clinical records review, and staff interview, it was determined the facility failed to maintain the professional standard of practice in providing wound care for one of three residents reviewed (Resident Resident R2).Findings include:The Professional Code, Title 49, Professional and Vocational Standards (Pennsylvania Professional Nursing Practice Act), Chapter 21.145(a) states that the Licensed Practical Nurse (LPN) is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, and experience in nursing competency. The LPN participates in the planning, implementation, and evaluation of nursing care, using focused assessment in settings where nursing takes place. Clinical records review revealed Resident Resident R2 had a Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss) to

the sacrum and left medial thigh MASD (Moisture-Associated Skin Damage- A skin condition caused by prolonged exposure to moisture, leading to inflammation, irritation, and potential skin breakdown).A review of the physician order dated August 23, 2025, revealed an order to cleanse the area to the left lower leg with normal saline solution, apply Medihoney (A dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns), cover with an abdominal dressing, and Kling.A review of the physician's order dated October 30, 2025, revealed an order to cleanse the sacral wound with normal saline, apply nickel-thick Santyl, and cover with a dry dressing every day.A review of October 2025, Treatment Administration Record (TAR), revealed Resident Resident R2's left leg MASD was treated by Licensed Nurse Employee E9 on October 30th and 31st and November 1st and 3rd, 2025.A review of

the November 2025 TAR revealed Resident Resident R2's sacral wound was treated by Nursing Employee E9 on November 3, 2025.An observation conducted on November 3, 2025, at 11:35 a.m., in the presence of licensed nurses, Nursing Employee E8 and E9 revealed that Resident Resident R2 was lying in bed, and both legs had a wound dressing that was observed loose. The left leg dressing had a date of 10/29/25 written on it and the right leg dressing was undated. Additional observation revealed that Resident Resident R2's sacral wound did not have a dressing and was open to air.An interview was conducted with Nursing Employee E9 on November 3, 2025, at 11:40 a.m. Employee E9 reported that they were Resident Resident R2's nurse. Employee E9 confirmed they documented Resident Resident R2's wound treatments for the day were done around 9:30 to 10:00 a.m., while completing the resident's behavior documents. Employee E9 confirmed that wound treatments to the sacrum and legs had not been performed for the day, despite documenting that they had already been done. Employee E9 confirmed documenting that wound treatment to the left leg was done on October 30, 31, and November 1, 2025. When asked if treatment to the left leg was done on the mentioned dates since wound dressing indicated a date of 10/29/25, Employee E9 was unable to provide an answer.The facility failed to ensure professional standards of practice were maintained in providing wound care and treatment to Resident Resident R2.28 Pa. Code 211.5(f) Clinical RecordsPreviously cited 8/25/2528 Pa. Code 211.12(d)(1)(5) Nursing ServicesPreviously cited 8/25/25

Residents Affected - Few

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/03/2025

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)

F 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

November 3, 2025, at 12:15 p.m. Right and left leg wounds were measured by the DON and revealed the following: Right leg venous ulcer had a measurement of 9.5 x 7.5 cm and left leg MASD wound had a measurement of 8.5 x 2.5 cm. Surrounding area of both wounds were reddened. Interview conducted with

the DON on November 3, 2025, at 3:00 p.m., confirmed Resident's Resident R2's bilateral leg wound treatment was not administered from October 30, 2025, until November 2, 2025.The facility failed to ensure wound treatment order for Resident Resident R2's right leg venous ulcer and left leg MASD was followed which resulted in actual harm with further deterioration of both wounds as evidenced by increased in size.Review of Resident Resident R1's clinical records revealed resident was readmitted to the facility on [DATE REDACTED], with diagnosis of wound infection. Review of the physician's order dated September 30, 2025, revealed the following: Ertapenem Sodium (Antibiotic) one gram intravenously (administered into a vein) one time a day for infected sacral (lower middle back) wounds for eight days: and Daptomycin Solution (antibiotic) 500-0.9 mg/50ml% use 445 mg intravenously one time a day for infected sacral wounds for eight days.Review of Resident Resident R1's October 2025, Medication Administration Records (MAR) revealed medications Ertapenem and Daptomycin were not administered to Resident Resident R1 on October 5 and 6, 2025.Review of Resident Resident R1's nursing progress note dated October 5, 2925, at 12:00 and 12:02 a.m., revealed that Resident Resident R1 did not have IV (intravenous) access and is a hard stick (difficult in finding peripheral vein), will put in an order for IV access via company.Review of Resident Resident R1's nursing progress note dated October 6, 2025, at 10:34 and 10:35 a.m., revealed IV not in the arm.Review of Resident Resident R1's nursing progress note dated October 6, 2025, at 12:15 p.m., revealed resident without an IV access, physician was notified and ordered to place new midline (IV).Review of Resident Resident R1's clinical record revealed that although the physician was notified of

the missing IV access, there was no documented evidence the physician was notified of the missed doses of Ertapenem and Daptomycin for October 5, and 6, 2025.Review of Resident Resident R1's clinical record revealed that the resident only received a total of six doses of both the Ertapenem and Daptomycin instead of the ordered eight doses. Interview with the DON (Director of Nursing) confirmed Resident Resident R1 did not receive

the ordered eight doses of both Ertapenem and Daptomycin medications. The facility failed to ensure Resident Resident R1's medication order to treat his/her wound infection was followed as ordered.28 Pa. Code 211.5(f) Clinical RecordsPreviously cited 8/25/2528 Pa. Code 211.12(d)(1)(5) Nursing ServicesPreviously cited 8/25/25

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/03/2025

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)

F 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, clinical records review, and staff interview, it was determined the facility failed to follow the wound treatment order for a sacral, Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss) for one of three residents reviewed (Resident Resident R2).Findings include:A review of Resident Resident R2's wound consult dated October 28, 2025, revealed Resident Resident R2 had a Stage four pressure injury to the sacrum that measures 1.2 x 0.8 x 0.2 cm (centimeters), with moderate serous (clear liquid) drainage.A review of Resident Resident R2's physician order dated October 30, 2025, revealed an order to cleanse the sacral wound with normal saline (sterile salt water), apply nickel-thick Santyl (ointment used to decrease dead tissue in the wound), and cover with a dry dressing every day.A review of November 2025, Treatment Administration

Record (TAR) revealed the resident's sacral wound was treated on November 3, 2025 (day shift). Further

review revealed that sacral wound treatment was not done on November 2, 2025.A sacral wound

observation was conducted on November 3, 2025, at 11:35 a.m., in the presence of licensed nurses, Employee E8 and E9. When asked to open the resident's incontinence brief, a large bowel movement was observed. Further observation revealed the resident's sacral wound had no dressing.An interview was conducted with Employee E9 on November 3, 2025, at 11:40 a.m. Employee E9 reported that they were Resident Resident R2's nurse. Employee E9 confirmed they had documented Resident Resident R2's wound treatments for

the day were done around 9:30 to 10:00 a.m., while completing the resident's behavior documents.

Employee E9 confirmed the wound treatments to the sacrum had not been performed for the day, despite documenting they had already been done.An interview with the Director of Nursing (DON) was conducted

on November 3, 2025, at 3:00 p.m. The DON was unable to provide an answer as to why sacral wound treatment was not done on November 2, 2025.The facility failed to ensure Resident Resident R2's sacral wound treatment order was followed as ordered by the physician. 28 Pa. Code 211.5(f) Clinical RecordsPreviously cited 8/25/2528 Pa. Code 211.12(d)(1)(5) Nursing ServicesPreviously cited 8/25/25

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/03/2025

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)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

that they had been caring for the resident for a few years. Employee E5 reported that Resident Resident R1 requires two-person assistance with bed mobility. Employee E5 stated, (Resident Resident R1) cannot do anything.Interview conducted with licensed nurse Employee E6 on November 3, 2025, at 3:05 p.m. Employee E6 reported not being on the unit consistently but had been caring for Resident Resident R1 when assigned to work on the unit.

Employee E6 reported Resident Resident R1 required two-person assistance with bed mobility. Employee E6 further stated, (Resident Resident R1) cannot do anything, they're dependent.Interview conducted with NA Employee E7 on November 3, 2025, at 3:05 p.m. Employee E7 indicated they were on the unit consistently and had been caring for Resident Resident R1. Employee E7 confirmed Resident Resident R1 required two-person assistance with bed mobility. Employee E7 stated, (Resident Resident R1) cannot do anything, even with eating, they need help.Interview conducted with the NHA (Nursing Home Administrator) on November 3, 2025, at 3:00 p.m. The NHA reported Employee E4 was an agency staff.The above findings were conveyed to the NHA and DON on November 3, 2025, at 4:30 p.m.The facility failed to ensure Resident Resident R1 was provided with adequate supervision while providing care. This failure resulted in a fall, causing actual harm, requiring hospitalization, and ICU monitoring for diagnosis of Acute Subarachnoid Hemorrhage. 28 Pa. Code 211.5(f) Clinical RecordsPreviously cited 8/25/2528 Pa. Code 211.12(d)(1)(5) Nursing ServicesPreviously cited 8/25/25

Event ID:

Facility ID:

If continuation sheet