Aventura at Humility House

Inspectors wroteBased on open and closed medical record review and staff interview, the facility failed to ensure physician ordered daily weights for the monitoring of medical conditions were obtained. This affected three (#30, #55, and #85) of three residents reviewed for daily weights. The facility census was 64.

Inspectors wroteBased on review of the Facility Assessment and staff interview, the facility failed to ensure a comprehensive Facility Assessment was developed to identify the staffing resources needed to provide care for the residents. This had the potential to affect all 64 residents in the facility. The facility census was 64.

Inspectors wroteBased on review of Food Committee minutes and interviews, the facility failed to investigate, address, and implement corrective actions related to repeated food service complaints raised through the Food Committee. This affected 15 residents (#216, #222, #225, #226, #228, #231, #242, #243, #244, #246, #249, #252, #253, #258, and #260) of 15 residents reviewed for resident rights and had the potential to affect all residents receiving food from the kitchen. The facility census was 65.

Inspectors wroteBased on observation, record review, staff interview, review of photographs and facility policy review, the facility failed to follow its planned and posted menu and failed to serve meals in a manner consistent to meet the nutritional value for Resident #222. This affected two residents (#222 and Resident #249) of three residents reviewed for palatable and nutritional food. This had the potential to affect all residents receiving meals at the facility . The facility census was #65.

Inspectors wroteBased on observation, record review, interview, review of the food committee meeting minutes and review of the facility policy, the facility failed to ensure dietary menus were followed. This affected one (Resident #13) of three reviewed for dietary concerns and had the potential to affect all residents receiving meals from the kitchen. The facility identified one (Resident #45) who did not consume anything by mouth. The facility census was 66.

Inspectors wroteBased on record review, interview, review of hospital paperwork, and review of facility polices, the facility failed to implement an adequate and effective pressure ulcer prevention program for Resident #168. This affected one Resident #168 of two residents reviewed for pressure ulcers. The facility census was 68. Actual Harm occurred on 02/03/25 when Resident #168 developed an in-house acquired Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.) to the right leg from an Ace wrap and immobilizer brace. Resident #168 was admitted to the facility from the hospital on [DATE] with an Ace wrap and a knee immobilizer brace on his right leg. There were no orders on admission to manage the right knee immobilizer brace and/or the Ace wrap. [...]

Inspectors wroteBased on review of the facility arbitration agreement and interview, the facility failed to clearly state that residents or their representatives could consult with local, state, or federal officials before signing or within thirty days of signing the agreement. This affected Residents #3, #12, #14, #16, #21, #24, #26, #29, #32, #35, #38, #41, #43, #45, #49, #50, #52, #53, #58, #61, #62, and #119 who signed the arbitration agreement. The facility census was 68.

Inspectors wroteBased on record review, interview and review of the facility policies, the facility failed to maintain an accurate care plan for Residents #35 and #168 related to their care needs. This affected two resident (#35 and #168) reviewed for care planning. The facility census was 68.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed obtain daily weights as ordered by the physician for Resident #12 who had a diagnosis of congestive heart failure (CHF). This affected one resident (#12) of three residents reviewed for quality of care. The facility census was 68.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure appropriate infection control procedures were followed during medication administration. This affected three residents (Residents #10, #14, and #35) of four residents observed for medication administration and had the potential to affect all 17 residents residing in the Northeast Hall. Also, the facility failed to implement an infection control program that included the use of enhanced barrier precautions. This had the potential to affect all residents. The facility census was 68.

Inspectors wroteBased on observation, interview, medical record review, and review of facility policy, the facility failed to ensure wound care was completed per physician orders for one resident (Resident #10) of three residents who were reviewed for appropriate wound care services. The facility census was 68.

Inspectors wroteBased on observation, interview, medical record review and review of facility policy, the facility failed to ensure a medication error rate of less than five percent. A total of 35 medication administration opportunities revealed four medication errors, resulting in an 11.4 percent (%) error rate. This affected one resident (Resident #10) of four residents (#10, #14, #3, and #58) reviewed for medication administration. The facility census was 68.

Inspectors wroteBased on medical record review, infection control log review, antibiotic stewardship tool review, and staff interview, the facility failed to implement their antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. This affected nine (#1, #2, #10, #12, #31, #58, #60, #69, and #70) of nine residents identified as utilizing antibiotic for infections in the past three months. The facility census was 67.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to assist a resident, who was dependent on staff for assistance with incontinence care in a timely manner. This affected one (#23) of three residents reviewed for incontinence care. The facility census was 67.

Inspectors wroteBased on record review, observation, policy review, and staff interview, the facility failed to ensure a medication error rate was less than five percent. A total of 26 opportunities for error revealed two medication errors resulting in a 7.69 (%) percent error rate. This affected two (#2 and #31) of two residents observed for medication administration. The facility census was 67.

Inspectors wroteBased on observation, medical record review, policy reviews, and staff interview, the facility failed to ensure staff performed hand hygiene to prevent cross contamination during a medication administration and during a wound dressing change. This affected three (#1, #31 and #43) of six residents observed for infection control. The facility census was 67.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on personnel record review, review of staff timecards, review of staff assignments, review of court documents, policy review and staff interview, the facility failed to ensure all staff working at the facility had a completed background check and did not have a disqualifying offense. This had the potential to affect 16 (#6, #7, #8, #11, #13, #14, #17, #19, #28, #35, #36, #46, #47, #48, #67 and #72) residents identified by the facility as residing on the South Unit of the facility. The facility census was 70.

Inspectors wroteBased on interview and record review the facility failed to notify Resident #215's physician about Resident #215 being administered an intravenous (IV) medication without an order. This affected one Resident (#215) of two residents reviewed for IV medication administration. The facility census was 61.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain Resident #7's privacy during a medical treatment. This affected one Resident (#7) of three residents reviewed for privacy. The facility census was 61.

Inspectors wroteBased on interview and record review the facility failed to provide showers as scheduled to Resident #27. This affected one Resident (#27) of three residents reviewed for showers. The facility census was 61.

Inspectors wroteBased on observation, interview, and record review the facility failed to change Resident #2's oxygen tubing and humidification bottle as scheduled and did not date the tubing and bottle. This affected one Resident (#2) of three residents reviewed for respiratory care. The facility census was 61.

Inspectors wroteBased on interview and record review the facility administered an intravenous (IV) medication to Resident #215 without a physician's order. This affected one Resident (#215) of two residents with orders for IV medications. The facility census was 61.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure insulin pens were properly dated in the Southeast medication cart for Resident #28, #48 and #216. This affected three Residents (#28, #48, and #216) of two medication carts reviewed for storage. The facility census was 61.

Inspectors wroteBased on record review and interview, the facility failed to ensure laboratory tests were obtained per physician's order. This affected one Resident (#50) of three residents reviewed for laboratory services. The facility census was 61.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Resident's #2, #3, #5, #7, #9, #10, #15, #18, #20, #21, #24, #30, #31, #33, #39, #40, and #43 received restorative/maintenance programs to maintain function for activities of daily living (ADLs) and/or prevent decline in ADL's after being discharged from skilled therapy. This affected 17 of 17 sampled residents. Actual Harm occurred when skilled therapy recommendations were not followed/implemented by the quality of life (QOL) program resulting in an avoidable declines in ambulation for Resident's #10, #18, #21, and #33, an avoidable decline in ambulation and transfers for Resident #15, and avoidable declines in the ability to sit to stand for Resident #7 and Resident #20.

Inspectors wrote14. Review of Resident #18's medical record revealed an admission date of 06/29/19. Diagnoses included dementia, protein-calorie malnutrition, repeated falls, osteoarthritis of both hands, and Parkinson's disease. An OT evaluation dated 07/01/19 revealed ROM in the upper arms/hands and lower legs/feet were within normal limits. A QOL Program Recommendation Referral dated 08/12/19 indicated Resident #18 had recommendations for an ambulation program and recommendations for upper extremity ROM doing balloon volley and using a two pound dowel for the left upper extremity and ROM to both lower extremities using two pound dowels and three sets of repetitions in all planes. There was no recommendation as to the frequency the ROM exercises should be provided. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure effective management of chronic pain for one resident ( Resident #32). This resulted in actual harm when Resident #32 was unable to participate in her activities of daily living (ADLs) due to severe pain. This affected one of three residents reviewed for pain. The facility census was 57.

Inspectors wroteBased on record review and interview the facility failed to maintain sufficient nursing staff to ensure the implementation of services via a quality of life (QOL) program to ensure all residents identified to be in the program received the necessary range of motion, splinting, ambulation and/or activities of daily living (ADL) services following the residents discharge from skilled therapy. This affected 36 residents (#1, #2, #3, #4, #5, #7, #9, #10, #11, #12, #14, #15, #18, #19, #20, #21, #22, #24, #27, #28, #30, #31, #32, #33, #34, #39, #40, #41, #43, #44, #46, #48, #49, #53, #54 and #56) who were identified by the facility to require a QOL program and had the potential to affect all 57 residents residing in the facility.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to correct a known area of deficiency related to pain control in the facility. This affected Resident #32 and had the potential to affect all 57 residents residing in the facility.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to identify and implement an appropriate plan of action for a known area of deficiency with the quality of life (QOL) program. This had the potential to affect all 36 residents (Residents #1, #2, #3, #4, #5, #7, #9, #10, #11, #12, #14, #15, #18, #19, #20, #21, #22, #24, #27, #28, #30, #31, #32, #33, #34, #39, #40, #41, #43, #44, #46, #48, #49, #53, #54, and #56) ordered to receive QOL programs. The facility census was 57 residents.

Inspectors wroteBased on interview and record review the facility failed to ensure individualized care plans were implemented for Resident's #10, #15, #18, #21, and #33, who had quality of life (QOL) programs. This affected five of 31 residents reviewed for plans of care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure fall interventions were in place for Resident's #32, #49, #54 and #108 as physician ordered or planned. This affected four of five residents revealed for accidents.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to provide devices to prevent skin impairment for one (Resident #18) of one resident reviewed for non-pressure related skin impairment and failed to implement the facility's bowel protocol for two (Residents #22 and #51) of five residents reviewed for medication use.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #49 received her bifocal eyeglasses as needed. This affected one of one resident reviewed for visual impairment.

Inspectors wroteBased on record review and interview, the facility failed to ensure one (Resident #2) of five residents reviewed for urinary catheters had adequate indications for use of a urinary catheter.

Inspectors wroteBased on observation, medical record review, and interview, the facility failed to ensure a record of actual intakes was maintained for supplements for one (Resident #48) of 24 residents screened for nutritional status to determine effectiveness.

Inspectors wroteBased on observation, policy review and interview, the facility failed to implement appropriate infection control practices during provision of incontinence care and while monitoring blood glucose levels. This affected two (Residents #2 and #57) of all 57 residents observed for infection control practices.