Aventura at Oakwood Village

Inspectors wroteBased on record review, resident interview, staff interview, observation, and review of the facility policy, the facility failed to provide foods planned by the Registered Dietitian (RD) as listed on the dietary spreadsheet. This affected all of the residents in the facility who received food from the facility kitchen. The facility census was 109 residents. Findings Include: Review of the menu spreadsheets dated 02/28/26, 03/01/26 and 03/02/26 revealed residents on all types of diets should have received two ounces of scrambled eggs at breakfast. Residents on cardiac diets should receive an egg substitution product and no bacon. There was no notation on the spreadsheets of any food substitutions. Review of Temperature Guide dated 02/28/26 revealed no notation of any food substitutions. Review of Temperature Guide dated 03/01/26 revealed substitute eggs with sausage links. [...]

Inspectors wroteBased on medical record review, review of facility Self-Reported Incidents (SRIs), review of facility investigation reports, review of staff witness statements, staff interview, and review of the facility policy, the facility failed to ensure residents were free from unnecessary physical restraints. This affected one (Resident#110) of one resident reviewed for physical restraints. The facility census was 109 residents.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure a medication error rate below five percent (%). The facility had 28 medication opportunities with two medication errors for an error rate of seven This affected one (Resident #39) of six residents observed for medication administration. The facility census was 109 residents.

Inspectors wroteBased on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure staff performed appropriate hand hygiene during incontinence care and wound care. This affected one (Resident #31) of 88 facility-identified residents who required incontinence care and one (Resident #12) of 18 facility-identified residents with wounds that required a dressing change. The facility census was 109 residents.

Inspectors wroteBased on medical record review, review of statements, staff interview and policy review, the facility failed to ensure residents were free from resident to resident abuse. This affected one (Resident #108) out of three residents reviewed for abuse. The facility census was 100. Based on medical record review, review of statements, staff interview and policy review, the facility failed to ensure residents were free from resident to resident abuse. This affected one (Resident #108) out of three residents reviewed for abuse. The facility census was 100. Findings Include:1. Review of the medical record revealed Resident #107 was admitted on [DATE] and discharged on 11/11/25. Diagnoses included Parkinson's disease, epilepsy, and intellectual disabilities. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #107 was severely cognitively impaired. [...]

Inspectors wroteBased on medical record review, review of statements, staff interview, review of the Self-Reported Incidents and policy review, the facility failed to ensure allegations of resident to resident abuse were thoroughly investigated and reported to the State Agency when Resident #107 verbally assaulted one resident and had physical aggression towards another unknown resident. This affected one (#108) out of three residents reviewed for abuse. The facility census was 100. Based on medical record review, review of statements, staff interview, review of the Self-Reported Incidents and policy review, the facility failed to ensure allegations of resident to resident abuse were thoroughly investigated and reported to the State Agency when Resident #107 verbally assaulted one resident and had physical aggression towards another unknown resident. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure fall interventions were in place for a resident who was at high risk for falls. This affected one (#92) out of three residents reviewed for falls. The facility census was 100. Findings Included:Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure fall interventions were in place for a resident who was at high risk for falls. This affected one (#92) out of three residents reviewed for falls. The facility census was 100. Findings Included:Review of the medical record revealed Resident #92 admitted to the facility on [DATE]. Diagnoses included palliative care, Parkinson's disease, chronic obstructive pulmonary disease, and dementia. [...]

Inspectors wroteBased on medical record reviews, observations and staff interviews, the facility failed to ensure the medication error rate did not exceed five percent (%). Three errors occurred within 27 opportunities for an error rate of 11.11%. This affected two (#20 and #21) of two residents reviewed for medication administration. The facility census was 108.

Inspectors wrote3. Review of medical record for Resident #32 revealed admission date of 11/12/24 with vascular dementia, chronic obstructive pulmonary disease, hypertension, diabetes mellitus. Review of the quarterly MDS dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. MDS revealed Resident #32 was dependent on staff for toileting, showering, dressing, and personal hygiene. Review of the care plan dated 11/13/24, revised 02/25/25, revealed Resident #32 had a potential for falls related to impaired cognition and weakness, interventions included evaluate medication regimen, fall risk assessment per protocol, hospice to supply Bariatric shower chair, keep environment clutter free, keep room well lighted, nonskid footwear at all times, perimeter mattress, and place resident on get up list. Observation on 05/13/25 at 8:49 A.M. [...]

Inspectors wroteBased on observation, staff review, and policy review, the facility failed to ensure an implement their water management policy to prevent the presence of microorganisms in their water system including legionella. This had the potential to affect all 104 residents residing in the facility. Additionally, the facility failed to ensure staff handled food in an appropriate manner while assisting a resident with a meal. This affected one (#25) out of three residents reviewed for infection control. The facility census was 104.

Inspectors wroteBased on observations, resident and staff interviews and policy review, the facility failed have an effective pest control program. This affected six (#9, #29, #30, #55, #60, and #81) out of six residents reviewed for effective pest control. The facility census was 104.

Inspectors wroteBased on record review, observations, staff and resident interviews and policy review, facility failed to ensure a resident was afforded dignity during a meal when staff did not stand while providing feeding assistance. This affected one (#25) of three residents reviewed for dignity. Facility census was 104.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to notify resident responsible party/power of attorney (POA) of significant weight loss. This affected one (#37) of three residents reviewed for weight loss. The facility census was 104.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure a resident was free from unnecessary medications by ensuring as needed psychotropic medications were limited to 14 days. This affected one (#61) of five reviewed for unnecessary medications. Facility census was 104.

Inspectors wroteBased on observations, staff interviews and record review, facility failed to ensure the activity careplan had appropriate and resident centered interventions. This affected one Resident (#49) of one reviewed for activities. Facility census was 104.

Inspectors wroteBased on record review, observations, staff interviews and policy review, the facility failed to ensure facility offered a resident activities of interest. This affected one (#49) of one resident reviewed for activities. The facility census was 104.

Inspectors wrote2. Review of medical record for Resident # 58 revealed admission date of 02/19/2024 with end stage renal disease, diabetes mellitus type 2, dependence on renal dialysis, heart failure, and chronic obstructive pulmonary disease. Review of the quarterly MDS dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Review of the care plan dated 03/27/25 revealed Resident #58 had renal insufficiency related to end stage chronic kidney disease stage 3 (CKD-3). Interventions included monitoring, documenting, and reporting to physician as needed the following signs and symptoms. [...]

Inspectors wrote2. Review of the medical record for Resident #91 revealed an admission date of 03/25/25 with diagnoses of unspecified sequelae of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and anxiety disorder. Review of the Medicare-5 Day MDS dated [DATE] revealed resident had moderate cognitive impairment. Review of the Care Plan, dated 04/15/25 revealed resident is at risk for altered Cardiovascular, has Seizure Disorder/Narcolepsy, uses antidepressant medications related to anxiety depression, and mood disorder, and is at risk for negative mood / behavior related to diagnosis of major depressive disorder. Interventions include administer medications as ordered. [...]

Inspectors wroteBased on medical record review, review of arbitration agreements and staff resident interviews, the facility failed to ensure a resident was capable of understanding an arbitration agreement before signing. This affected one (#90) of three residents reviewed for arbitration agreements. The facility census was 104.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to report an incident regarding an injury of unknown origin as required. This affected one (Resident #4) of three residents reviewed for injuries. The census was 108. Findings Include: Resident #4 was admitted to the facility on [DATE], diagnoses included fracture of unspecified part of neck of right femur, cerebrovascular disease, dementia, anxiety disorder, atrial fibrillation, polyneuropathy, atherosclerotic heart disease, brief psychotic disorder, hyperlipidemia, difficulty walking, degenerative disease of nervous system, hypertension, and cognitive communication deficit. Review of the 11/08/24 minimum data set (MDS) assessment revealed the resident had a severe cognitive impairment. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to complete a thorough investigation regarding an injury of unknown origin as required. This affected one (Resident #4) of three residents reviewed for injuries. The census was 108. Findings Include: Resident #4 was admitted to the facility on [DATE], diagnoses included fracture of unspecified part of neck of right femur dated 12/18/24, cerebrovascular disease, dementia, anxiety disorder, atrial fibrillation, polyneuropathy, atherosclerotic heart disease, brief psychotic disorder, hyperlipidemia, difficulty walking, degenerative disease of nervous system, hypertension, and cognitive communication deficit. Review of her minimum data set (MDS) assessment, dated 11/08/24, revealed she had a severe cognitive impairment. [...]

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to obtain a laboratory value (labs) as ordered by physician. The affected one (#4) out of four residents reviewed for lab services. The census was 107.

Inspectors wroteBased on record review, staff interview, and review of Self-Reported Incidents (SRIs), the facility failed to thoroughly investigate an allegation of resident-to-resident abuse. This affected two (Residents #4 and #21) of three residents reviewed for abuse. The facility census was 102.

Inspectors wroteBased on record review and staff interview, the facility failed to communicate with the physician about family concerns related to the discontinuation of a medication. This affected one (Resident #4) out of four residents reviewed for medication changes. The facility census was 102.

Inspectors wroteBased on medical record review, observation, staff interview and review of the facility policy the facility failed to ensure fall prevention interventions were in place to prevent resident injury from falls. This affected two (Residents #20 and #41) of three residents reviewed for falls. The facility census was 111 residents.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to ensure safe and sanitary storage of food and to ensure trash cans were covered when in the kitchen. This had the potential to affect all residents, excluding Resident #24 who does not eat food from the kitchen. Facility census was 105.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to follow the facility menu and spreadsheets for residents with altered textured diets. This affected 24 (#1, #2, #3, #7, #11, #16, #26, #30, #35, #40, #50, #52, #59, #62, #64, #67, #70, #71, #73, #76, #87, #89, #210 and #204) of 24 residents with orders for pureed and mechanical soft diets. Facility census was 105.

Inspectors wroteBased on record review and staff interview, the facility failed to notify residents that the amount of funds in their accounts was 200 dollars less than the social security income resource limit and that the resident's may lose eligibility for Medicaid or social security income. This affected two (#16 and #40) of five residents reviewed for personal funds. The facility census was 105.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to have accurate advance directives in the electronic and medical record. This affected two (#70 and #71) of four residents reviewed for advanced directives. The facility census was 105.

Inspectors wroteBased on observation, record review, fall alarm list review, incident report review, and staff interview, the facility failed to ensure a resident was assessed to utilize a position change alarm (pull-tab alarm). This affected one (#86) of seven residents reviewed for falls. The facility identified three residents with pull-tab fall alarms in the facility. The facility census was 105.

Inspectors wroteBased on observation, record review, policy review and staff interview, the facility failed to develop resident care plans for anticoagulant medication use, oxygen use, and psychotropic medication use. This affected three (#51, #60, and #73) resident of 22 residents reviewed for care plans. The facility census was 105.

Inspectors wroteBased on observation, record review, policy review, and staff interview, the facility failed to ensure a resident's fall care plan was updated to include new fall interventions. This affected two (#86 and #66) of 22 residents reviewed for care plans. The facility census was 105.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a physician's response to a pharmacy recommendation was followed. This affected one (#52) of five residents reviewed for unnecessary medications. The facility census was 105.

Inspectors wroteBased on observation, staff interviews, and record review, facility failed to ensure facility made pureed food in a way to keep nutritive values. This affected three (#1, #40 and #67) of three residents with orders for pureed diets. Facility census was 105.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain resident furniture/equipment in safe working order. This affected one (#72) of one resident reviewed for environment. Facility census was 105.

Inspectors wroteBased on facility record review, staff interview, review of the facility's policy, review of the online resources from the Centers for Disease Control and Prevention (CDC), and memorandums from the centers for Medicare and Medicaid services (CMS), the facility failed to implement a water treatment program that followed the American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRA) industry standards and the CDC toolkit for prevention of Legionella. This had the potential to affect all 80 resident who resided in the facility.

Inspectors wroteBased on observation, resident and staff interview, and review of the facility's policy, the facility failed to provide a safe and comfortable environment for the residents. This affected one (#38) of 24 residents reviewed for physical environment and had the potential to affect all 80 residents who resided in the facility.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure residents personal funds were managed appropriately. This affected two (#4 and #49) of five resident reviewed for personal funds. The facility identified six residents with a personal funds account managed by the facility. The facility census was 80.

Inspectors wroteBased on resident record review and staff interview, the facility failed to notify the resident/resident representative of the bed hold and reserve bed payment policy upon the resident's transfer to the hospital. This affected one (#79) of two residents reviewed for hospitalization. The facility census was 80.

Inspectors wroteBased on medical record review, resident and family interview, staff interview, and policy review, the facility failed to have quarterly care conferences and include the resident and the resident's representatives to participate in care planning. This affected one (#5) of one resident reviewed for care planning. This had the potential to affect all 80 residents residing in the facility.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure the physician documented rationale for disagreeing with the pharmacy recommendations. This affected two (#12 and #47) of five residents reviewed for unnecessary medications. The facility census was 80.

Inspectors wroteBased on medical record review and staff interview, the facility failed to obtain lab work as ordered by the physician and the facility failed to ensure laboratory results were promptly reported to the advanced provider. This affected two (#19 and #47) of eight residents reviewed for laboratory orders. The facility census was 80.