Aventura at West Park

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure resident dignity was maintained when a resident's naked upper body was exposed. This affected one (Resident #10) of three residents reviewed for resident rights. The facility census was 86 residents.

Inspectors wroteBased on medical record review, review of text message communication, review of facility Self-Reported Incidents (SRIs), review of employee written statements, resident interview, staff interview, and review of the facility employee handbook the facility failed to prevent resident financial exploitation. This affected one (Resident #12) of three residents reviewed for financial exploitation. The facility census was 86 residents.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on record review, Self-Reported Incident (SRIs) review, hospital record review, review of emergency medical services (EMS) run sheet review, observation, staff interview, review of the facility investigation, review of the United States Food and Drug Administration (FDA) Guide to Bed Safety: Bed Rails in Hospitals, Nursing Homes and Home Healthcare, review of the Direct Supply Multi-Bed Pivoting Assist Device Owner's Manual, and policy review, the facility failed to thoroughly assess residents for the risk of entrapment and appropriateness for the use of bed rails. This resulted in Immediate Jeopardy and serious life-threatening harm/death when Resident #11's head and neck became wedged between the mattress and the bed rail. Resident #11 asphyxiated and died. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to affect all of the residents residing in the facility with the exception of three facility-identified residents who did not receive food from the kitchen. The facility census was 88 residents.

Inspectors wroteBased on observation, staff interview, and policy reviews, the facility failed to ensure garbage cans in the kitchen were covered with lids. This had the potential to affect all of the residents residing in the facility with the exception of three facility-identified residents who did not receive food from the kitchen. The facility census was 88 residents.

Inspectors wroteBased on record review, employee file review, staff interview, review of online resources from the Centers for Disease Control and Prevention (CDC), and facility policy review, the facility failed to ensure a comprehensive water management plan was implemented to minimize the risk of waterborne pathogens including Legionella. The facility also failed ensure new employees were screened for tuberculosis (TB) and/or were screened annually for TB. This had the potential to affect all residents living in the facility. The facility census was 88 residents.

Inspectors wroteBased on observation, resident interview, staff interview, and facility policy review, the facility failed to ensure appropriate water temperatures in the north hallway shower room and in individual resident rooms and failed to maintain bathrooms and shower rooms in a clean and sanitary manner. This affected five facility-identified (Residents #12, #42, #55, #82, #90) who use the north hallway shower room and three (Residents #7, #12, #78) and had the potential to affect all of the residents residing in the facility. The facility census was 88 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure insulin vials were properly labeled and stored. This affected four (Residents #50, #78, #99 and #107) of 34 residents with medications stored in the rehabilitation medication carts one and two and the fourth floor central-one medication cart. The facility census was 88 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Preadmission Screening and Resident Review (PASARR) assessments were completed as appropriate. This affected one (Resident #3) of two residents reviewed for PASARRs. The facility census was 88 residents.

Inspectors wroteBased on medical record review, resident interview, observation, staff interview, and facility policy review, the facility failed to develop comprehensive resident care plans. This affected two (Residents #7 and #80) of 18 residents sampled. The facility census was 88 residents.

Inspectors wroteBased on medical record review and staff interview facility failed to update resident care plans for weight loss. This is affected one (Resident #57) of four residents reviewed for nutritional care plans. The facility census was 88 residents.

Inspectors wroteBased on medical record review, staff interview, review of the facility policy, and review of online guidelines per the National Pressure Injury Advisory Panel (NPIAP), the facility failed to regularly monitor and obtain measurements of resident pressure ulcers. This affected two (Residents #7 and #9) of four residents reviewed for pressure ulcers. The facility census was 88 residents.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and facility policy review the facility failed to provide adequate resident supervision to ensure safe smoking. This affected two (Residents #7 and #36) of three residents reviewed for smoking. The facility census was 88 residents.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to identify and implement interventions to eliminate or mitigate re-traumatization triggers associated with post-traumatic stress disorder (PTSD) This affected one (Resident #3) of three residents reviewed for PTSD and trauma-informed care. The facility census was 88 residents.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure accurate documentation in the medical record. This affected one (Resident #101) of three residents reviewed for documentation. The facility census was 83 residents.

Inspectors wroteBased on observation and interview, the facility failed to secure all medications in a locked storage area and to limit access to authorized personnel. This had the potential to affect 12 residents (#3, #7, #11, #13, #24, #25, #26, #28, #34, #41, #66 and #74) that are independently mobile on the 400 floor. The facility census was 90.

Inspectors wroteBased on medical record review, physician interview, and staff interview, the facility failed to ensure physician notes were signed at the time service was rendered. This affected three (#51, #52, and #60) of three residents reviewed for physician visits. The facility census was 90.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility Self-Reported Incidents (SRI), staff interview, and policy review, the facility failed to ensure residents were free from verbal abuse. This affected one (#64) of three residents reviewed for abuse. The facility census was 89.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, review of witness statements, review of a facility Self-Reported Incident (SRI) and policy review, the facility failed to ensure misappropriation of resident funds. This affected three (#21, #22, and #23) residents of the six Residents (#11, #14, #15, #21, #22, and #23) reviewed for resident funds. The facility census was 57.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure new residents were provided written admission Agreements at the time of admission. This affected four (#8610, #8611, #8613 and #8618) of five residents reviewed for admission procedures. The facility census was 66. Findings Include: 1. Review of the medical record for Resident #8610 revealed an admission date of 05/27/24. Diagnoses included diabetes mellitus type II, lumbar disc degeneration, congestive heart failure and acute myocardial infarction. Resident #8610 was discharged home on [DATE]. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure carpets were maintained in a clean and sanitary manner. This affected all 10 residents (#6, #7, #17, #30, #33, #41, #43, #54, #62 and #63) residing on the third floor. The facility census was 66.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure medications were available to administer as ordered. This affected one (Resident #80) of five patients reviewed for medication administration. The facility census was 65.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents were free from significant medication errors when they gave double the dose of Morphine to a resident. This affected one (Resident #80) of five residents sampled for medication administration. The facility census was 65.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, staff interview, Physician Assistant (PA) interview, review of facility witness statements, review of facility policy and review of the American Heart Association (AHA) guidelines, the facility failed to ensure cardiopulmonary resuscitation (CPR) was provided to a resident who was a full code. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or death when Resident #76, who was a full code, was found unresponsive and without vital signs on [DATE] at 7:20 A.M. and staff failed to immediately perform CPR and the resident was subsequently pronounced dead. This affected one (Resident #76) of three residents reviewed for death over the last three months. The facility census was 78. [...]

Inspectors wroteBased on staff interview, observation, record review, and review of the facility policy, the facility failed to ensure all food temperatures were checked prior to the start of meal service. This had the potential to affect all 78 residents in the facility.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure kitchen equipment was maintained in a sanitary manner. The facility also failed to ensure staff wore hair restraints which fully contained the hair while preparing food. This had the potential to affect all 78 residents in the facility.

Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to properly implement the Legionella plan. This had the potential to affect all of the residents residing in the facility. The facility census was 78.

Inspectors wroteBased on medical record review, staff interview, review of the facility policy, the facility failed to conduct care conferences as required. This affected four (Residents #16, #19, #23, and #41) of five residents reviewed for care planning. The facility census was 78.

Inspectors wroteBased on observation, staff interview, and review of facility recipes, the facility failed to properly prepare pureed food. This had the potential to affect five (Residents #12, #22, #47, #49, #50) of five facility-identified residents who received a pureed diet. The facility census was 78.

Inspectors wroteBased on medical record review, review of facility Self-Reported Incident (SRI), review of daily staffing sheet, review of time clock records, resident interview, staff interview, and review of the facility policy the facility failed to ensure residents were protected during abuse investigations. This affected one (Resident #14) of one reviewed for abuse. The facility census was 78.

Inspectors wroteBased on record review, observation, staff interview, and review of the facility policy, the facility failed to properly transfer the resident using an appropriate assistive lift device. This affected one (Resident #14) resident of two residents reviewed for falls. The facility census was 78.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to implement nutritional recommendations made per the licensed dietitian for residents with weight loss. This affected one (Resident #11) of three residents reviewed for nutrition. The facility census was 78.

Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to implement physician orders following pharmacy recommendations. This affected three (Residents #5, #16, and #23) of five residents reviewed for unnecessary medications. The facility census was 78.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure a medication error of below five percent for medication administration observation. The medication error rate was eight percent (%.) This affected one (Resident #55) of four residents observed for medication administration. The facility census was 78.

Inspectors wroteBased on medical record review, observation, staff interviews, and review of the facility policy, the facility failed to ensure insulin pens were properly labeled and stored. This affected two (Residents #23 and #55) of 39 residents with medications stored in the 700 hall cart. The facility census was 78.

Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to provide the pneumococcal vaccine in a timely manner. This affected three (Residents #10, #11, and #21) of five resident reviewed for vaccinations. The facility census was 78.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to administer ordered medications with an error rate of less than 5 percent (%). There were six errors observed of 26 opportunities, resulting in an error rate of 23.08%. This affected two Residents (#17 and #24) of four observed for medication administration. The facility census was 71.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to label open vials of insulin and failed to dispose of expired medications in a timely manner. This affected two medication carts of three observed, and one out of one medication room observed for medication storage. The facility census was 71.

Inspectors wroteBased on personnel record review, staff interview, and facility policy review, the facility failed to implement their abuse policy to ensure reference checks were completed for six employees, Registered Nurse (RN) #6, Licensed Practical Nurses (LPNs) #5, #13, #30, and State Tested Nursing Assistants (STNAs) #4 and #19, of 11 personnel records reviewed. This had the potential to affect all 71 resident of the facility.