Aventura at Assumption Village

Inspectors wroteBased on observation, medical record review, Self-Reported Incident (SRI) review, review of staff time punches, police record review, interview and policy review the facility failed to protect residents from potential abuse when a certified nursing assistant (CNA) was not immediately removed from duty after the facility gained knowledge of the employee's arrest warrant for resident abuse. This had the potential to affect Resident #6 but also placed the remaining 34 residents (Residents #1, #9, #16, #18, #19, #21, #25, #28, #29, #32, #34, #36, #42, #48, #50, #56, #59, #64, #65, #68, #71, #73, #76, #78, #80, #81, #82, #83, #84, #86, #87, #91, #97 and #99) who resided on the secured dementia unit at risk for abuse. The facility census was 100.

Inspectors wroteBased on record review, review of the facility self-reported incident (SRI), observation, policy review, police report review and interview, the facility failed to protect Resident #6's right to be free from physical abuse by a Certified Nursing Assistant (CNA) during care. This affected one resident (Resident #6) of three residents reviewed for abuse. The census was 100.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure Resident #77's pressure wound care was completed as ordered. This affected one (Resident #77) of three residents reviewed for pressure wounds. The facility census was 100.

Inspectors wroteBased on closed record review, review of emergency medical services (EMS) records, review of hospital documentation, facility policy review and interview, the facility failed to recognize and respond timely and appropriately to an acute significant change in condition for Resident #108 to ensure prompt and necessary medical intervention was provided. This resulted in Immediate Jeopardy and Actual Harm with subsequent death beginning on 03/09/26 at 1:38 A.M. when Resident #108 was documented to have respiratory distress and abdominal pain. The resident's oxygen saturation was 84% (with oxygen increased to 6 liters per minute (L) nasal cannula). However, record review revealed no evidence of monitoring or comprehensive re-assessment of the resident until 6:14 A.M. at which time the resident's oxygen remained abnormally low. On 03/09/26 at 7:14 A.M. [...]

Inspectors wroteBased on observation, review of medical records, interviews with staff, review of hospital records, review of the National Pressure Injury Advisory Panel (NPIAP) and review of the facility policy, facility failed to provide the necessary care and services to prevent the development, worsening, and to promote the healing of a facility acquired pressure ulcer for Resident #14. This affected one resident (#14) of three residents reviewed for pressure ulcers. The facility census was 107. Actual harm occurred on 12/23/25, when documentation first identified that the wound had progressed from Stage II to Stage III, with deeper tissue involvement and worsening characteristics because the facility failed to ensure consistent wound assessments, adherence to physician ordered treatments, proper pressure relief interventions, infection control practices, or accurate clinical documentation.

Inspectors wroteBased on review of resident council minutes, and staff and resident interviews, the facility failed to ensure concerns raised by the resident council were thoroughly documented, effectively addressed, and resolved. The facility also failed to ensure consistent follow up for repeated concerns voiced across multiple council meetings from 05/02/25 through 04/03/26. This had the potential to affect all 107 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure the privacy and confidentiality of resident information was maintained. The facility permitted staff to transmit protected resident information through an unsecured text-messaging application (WhatsApp) when communicating with physicians, nurse practitioners, and other providers. Additionally, resident-identifiable documents were observed unsecured on the floor and in the hallway of the 1500 unit containing information of residents' on the 1400 and 1500 units. This had the potential to affect all residents in the facility, including those residing on the 1400 and 1500 units, as any resident's protected health information could be improperly disclosed. The facility census was 107.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was nutritious and palatable. This deficient practice had the potential to affect all residents, excluding Residents #9, #42, and #70, who consumed nothing by mouth. The facility census was 107.

Inspectors wroteBased on review of dietary staff schedules and staff interviews, the facility failed to provide sufficient support personnel to meet the needs of the dietary service program. This deficient practice had the potential to affect all residents who received food prepared by the kitchen. The facility identified three residents (Residents #9, #42, and #70) as receiving nothing by mouth. The facility census was 107.

Inspectors wroteBased on review of Resident Council minutes, observations, and staff and resident interviews, the facility failed to ensure snacks were available to residents during nighttime hours. This deficient practice had the potential to affect all residents in the facility, excluding Residents #9, #42, and #70, who consume nothing by mouth. The facility census was 107.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure that food was stored, prepared, distributed, and served under sanitary conditions. This deficient practice had the potential to affect all residents receiving meals from the kitchen. Three residents (Residents #9, #42, and #70) were identified as consuming nothing by mouth. The facility census was 107.

Inspectors wroteBased on observation, record review, personnel file review, job description review, emergency medical services (EMS) and hospital document review, policy review, and interviews, the facility failed to be administered in a manner that ensured resources were used effectively and efficiently to maintain the highest practicable well being of residents. [...]

Inspectors wroteBased on interviews and record review, the facility failed to comply with applicable State and local licensure laws by allowing its food service license to lapse for over two months. This failure had the potential to affect all 107 residents residing in the facility, excluding Residents #9, #42, and #70, who consume nothing by mouth.

Inspectors wroteBased on interviews and a review of the facility's arbitration agreement, it was determined that the facility failed to explain the arbitration agreement to residents during the admission process and did not provide guidance on how residents could contact local, state, or federal officials with questions prior to signing. This failure had the potential to affect all 107 residents residing in the facility.

Inspectors wroteBased on personnel file reviews, job description review, and staff interviews, the facility failed to employ a full time Licensed Social Worker (LSW) as required. This failure had the potential to affect all 107 residents in the facility.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure residents received food and drink as requested, selected, and ordered. This deficient practice resulted in residents not receiving ordered supplements, not receiving selected menu alternatives, and experiencing repeated lack of basic food items and supplies. This deficient practice affected five (Residents #12, #81, #102, #41, and #83) of 10 residents reviewed for food preferences and had the potential to affect all residents who received food from the kitchen. The facility identified three residents (Residents #9, #42 and #70) who consumed nothing by mouth. The facility census was 107.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure complete and accurate medical records were maintained for Residents #77, #20, #14, #111, and #9. Specifically, the facility failed to ensure physician orders and laboratory orders were entered into the electronic medical record (EMR) as required; failed to ensure communication with physicians and documentation of follow up actions were recorded; failed to ensure staff did not alter documentation or apply inaccurate dates to resident treatments; failed to ensure residents with anticoagulation therapy had ordered laboratory monitoring of PT/INR; and failed to ensure required weekly weights for new admissions were completed and accurately recorded. This failure had the potential to negatively affect all residents. [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to maintain an effective infection prevention and control program to prevent the development and transmission of infections. The facility did not ensure proper separation and handling of clean and dirty linens, appropriate hand hygiene and glove use during incontinence care for Resident #71, proper handling of enteral feeding equipment for Resident #65, and adherence to aseptic wound care practices for Resident #14. This affected three residents (Residents #14, #65, and #71) of five residents reviewed for infection control and had the potential to affect all residents whose laundry was processed by the facility. The facility identified 11 residents (#9, #105, #116, #21, #91, #92, #123, #98, #45, #114 and #85) whose laundry was not processed by the facility. The facility census was 107.

Inspectors wroteBased on staff interview, resident interview, review of pest control log, and review of facility policy, the facility failed to maintain an effective pest control program designed to provide a safe, sanitary, and comfortable environment for residents. This failure resulted in confirmed sightings of mice and ants in multiple areas throughout the facility, including resident rooms, dry storage areas, windowsills, the soiled linen area, and the special care unit. This affected two residents (#3 and #58) of three residents reviewed for pest concerns and had the potential to affect all 107 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #31 was fully informed of the risks and benefits of prescribed psychotropic medications and failed to ensure the resident was provided the opportunity to participate meaningfully in care planning related to psychotropic medication management. This affected one (Resident #31) of five residents reviewed for unnecessary medications. The facility census was 107.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to notify the physician when a physician ordered stool sample could not be obtained. This affected one (Resident #53) of three reviewed for change in condition. The facility census was 107.

Inspectors wroteBased on record review, facility policy review and interview, the facility failed to ensure nursing staff adhered to professional standards of practice for accurate, complete, and truthful documentation to reflect the care and/or services provided to residents at the date/time completed. This affected two residents (#4 and #14) reviewed for documentation and had the potential to affect all 107 residents residing in the facility.

Inspectors wroteBased on medical record review, staff and resident interviews, and facility policy review, the facility failed to ensure bathing and grooming in accordance with Resident #119's assessed needs and stated preferences. This affected one resident (#119) out of three residents reviewed for activities of daily living (ADL). The facility census was 107.

Inspectors wroteBased on record review, review of the hospital discharge paperwork, facility policy review and interview, the facility failed to ensure timely laboratory testing, monitoring, and follow up to diagnose and treat a urinary tract infection (UTI) for Resident #11. This affected one resident (#11) of three residents reviewed for bowel and bladder. The facility census was 107.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that Resident #27 received adequate nutrition care and services by not ensuring timely physician notification and timely implementation of recommended medication changes intended to address nutritional decline. This affected one resident (#27) of one resident reviewed for nutrition. The facility census was 107.

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to ensure oxygen was administered as ordered. This affected two residents (Residents #12 and #22) of three reviewed for respiratory care. The facility identified seven residents (Residents #3, #12, #22, #34, #61, #69 and #123) who received continuous oxygen. The facility census was 107.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that required pre and post dialysis assessments were completed for one resident (Resident #14) of two residents reviewed for dialysis services. The facility census was 107.

Inspectors wroteBased on record review, staff interview and medication administration policy review, the facility failed to provide physician prescribed medications to three residents (Residents #46, #52, and #110), resulting in missed doses of multiple medications across several dates. This affected three residents (#46, #52, and #110) of five residents reviewed for missed medications. The facility census was 107.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure that pharmacy medication regimen review (MRR) recommendations, including gradual dose reductions (GDRs), safety-related medication changes, and required clinical rationales, were addressed timely and completely for three (Residents #4, #31, and #57) of five residents reviewed for unnecessary medications. The facility census was 107.

Inspectors wroteBased on observations, record reviews, interviews, manufacturer instructions, and facility policy review, the facility failed to ensure that insulin pens were dated when opened. This affected three of three insulin pens observed during the medication storage review (Residents #21, #42, and #99). This had the potential to affect an additional 11 residents (#3, #13, #28, #40, #50, #59, #63, #75, #94, #101, and #101) who were identified as receiving insulin. The facility census is 107.

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to ensure that Resident #12's tube feeding pump and pole were maintained in a clean and sanitary condition. This deficiency affected one resident (Resident #12) out of three reviewed for environmental concerns. The facility census was 107.

Inspectors wroteBased on record review, interview, review of the facility self-reported incident (SRI) and facility policy review, the facility failed to accurately document controlled drug administration for Resident #12 to prevent a potential significant medication error and/or misappropriation. This affected one resident (#12) of two residents reviewed for controlled drug administration. The facility identified 27 residents (#1, #4, #6, #7, #8, #12, #16, #19, #23, #25, #26, #30, #31, #32, #33, #34, #35, #37, #40, #44, #,45 #48, #49, #51, #64, #66, and #78) who received controlled medications. The facility census was 98.

Inspectors wroteBased on observation, interview, record review, facility policy review, review of the memorandum from the Department of Health & Human Services, and review of guidelines from the Centers for Disease Control and Prevention, the facility failed to ensure staff used appropriate infection control practices using required proper hand hygiene for Residents # 605 and Resident #629 using appropriate standards of practice with use of gloves during incontinence care for Residents #605 and #629 This affected two residents and had the potential to affect all 106 residents residing in the facility.

Inspectors wroteBased on review of the medical record, interview, and review of facility policy, the facility failed to ensure Resident #24 received pain management medication as ordered to ensure an effective pain management program was in place. This affected one resident (Resident #24) of three residents reviewed for pain management. The facility census was 106.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #60's insulin was administered properly. This affected one resident (Resident #60) of three residents observed for medication administration.

Inspectors wroteBased on review of the medical record, interview and review of facility policy, the facility failed to ensure the medical record for Resident #60 contained complete and accurate documentation of specified assessment criteria to safely administer ordered medications. This affected one resident (Resident #60) of three residents observed for medication administration. The facility census was 106.

Inspectors wroteBased on observation, record review, interview and review of facility policy, the facility did not ensure residents were offered a substantial snack in the evening when the time between dinner and breakfast exceeded 14 hours. This had potential to affect all 92 residents receiving meals from the kitchen except for two residents (#70 and #86) the facility identified as receiving nothing by mouth (NPO). The facility census was 94.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all 92 residents who received food from the kitchen. The facility identified two residents (#70 and #86) as receiving nothing by mouth (NPO). The facility census was 94.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure weekly and always available menus were followed. This affected seven residents (#2, #18, #40, #50, #58, #66, #76) of 92 residents receiving meals from the kitchen, and had the potential to affect all residents except for two residents (#70 and #86) the facility identified as receiving nothing by mouth (NPO). The facility census was 94.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure palatable food was served to all residents. This affected eight residents (#2, #4, #18, #40, #50, #58, #66 and #76) of 92 residents receiving meals from the kitchen, and had the potential to affect all 92 residents excluding two residents (# 70 and #86) who the facility identified as receiving nothing by mouth (NPO). The facility census was 94.

Inspectors wroteBased on medical record review, interviews and review of the facility policy, the facility failed to notify the physician/nurse practitioner and resident representative of a significant weight change. This affected one resident (Resident #70) out of three residents reviewed for nutrition. The facility census was 94.

Inspectors wroteBased on observation, interview, review of the medical record and review of the facility policy, the facility failed to ensure residents received the required level of assistance for meals. This affected one resident (Resident #36) of two residents reviewed for activities of daily living (ADL). The facility census was 94.

Inspectors wroteBased on observation, interview, medical record review and facility policy review, the facility failed to ensure Resident #70's weekly weights were obtained as ordered and failed to monitor and follow Resident #57's fluid restriction. This affected two residents (#57 and #70) out of three residents reviewed for nutrition. The facility census was 94.

Inspectors wroteBased on medical record review, staff interviews and review of communication forms from dialysis center, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for Resident #57. This affected one resident (#57) of one resident reviewed for dialysis but had the potential to affect two additional residents (#15 and #77) identified by the facility as receiving dialysis. The facility census was 94.

Inspectors wroteBased on observation, resident and staff interviews, medical record review and review of the facility policy, the facility failed to ensure medications were not left unattended. This affected two of four residents (#4 and Resident #27) who were observed with medications at the bedside and had the potential to affect 20 additional residents (#2, #6, #8, #9, #16, #19, #31, #32, #33, #38, #39, #40, #41, #43, #50, #54, #78, #80, #81 and #88) who received medications in the 1400 and 1600B hall. The facility census was 94.

Inspectors wroteBased on observation, interview, record review and review of facility policy the facility failed to ensure residents on mechanical soft diets received appropriate meal consistency. This affected one resident (Resident #6) of eight residents reviewed for food and nutrition. The facility identified 13 residents (#4, #6, #8, #11, #14, #30, #40, #46, #69, #73, #76 #86, and #146) who received a mechanical soft diet. The facility census was 94.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control procedures to prevent the spread of infection. This affected three residents (#68, #148 and #151) of three observed for isolation precautions. This had the potential to affect nineteen residents (#10, #15, #47, #51, #56, #60, #68, #71, #82, #83, #87, #89, #144, #145,#146 #147, #148, #150 and #151) residents residing on the 1100, 1200 and 1300 halls. The facility census was 94.

Inspectors wroteBased on record review, observation and interview the facility failed to develop and implement a comprehensive, person-centered care plan to meet the needs of Resident #65 for his highest practicable well-being regarding leave of absence (LOA) from the facility. This affected one resident (#65) of three residents reviewed for care plans. The facility census was 104.

Inspectors wroteBased on record review, interview, and admission contract review, the facility failed to convey a final accounting of overpayment to Resident #102's spouse within thirty days of discharge. This affected one resident (#102) of three residents who were discharged as private pay residents. The facility census was 101.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #9 received proper assistance with activities of daily living to prevent a fall. This affected one resident (Resident #9) out of three residents reviewed for falls.

Inspectors wroteBased on record review, observation and staff interview, the facility failed to provide adequate supervision and assistance by staff when rolling Resident #75 in bed to provide incontinence care which resulted in Resident #75 falling out of the bed sustaining injuries to his face and upper extremities. This affected one resident (#75) of three residents reviewed for falls. The facility census was 70.

Inspectors wroteBased on medical record review, review of facility policy and interview, the facility failed to ensure antipsychotic medications were only used to treat appropriate diagnoses with clinical rationale. This affected four residents (#24, #32, #78, and #341) of five residents reviewed for unnecessary medications. The census was 96.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #20 received timely treatment for a urinary tract infection. This affected one resident (#20) of three residents viewed for medications. The facility census was 96.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Resident #20's behavior, including frequent episodes of loud and continuous yelling out was monitored and addressed timely. This affected one resident (#20) of three residents reviewed for behavioral health treatment.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of an incident investigation, and interview, the facility failed to ensure Resident #100 received adequate and proper assistance during a transfer to prevent an injury. Actual harm occurred to Resident #100 on 07/11/23 when State Tested Nursing Assistant (STNA) #185 transferred the resident without the assistance of a second staff person and mechanical lift (as required/ordered) resulting in pain and fractures to the resident's tibia and fibula. This affected one resident (#100) of four residents reviewed for quality of care. The census was 97.