Aventura Rehab and Nursing Center

Inspectors wroteBased on observations, interviews and record reviews, the facility did not implement a fall care plan for one (Resident #95) of five sampled residents. Resident # 95 in bed, which was positioned high, and the call light was out of reach. There were 24 residents on the facility's Fall Management Program at the time of survey.

Inspectors wroteBased on observations records reviewed and interviews it was determined that the facility did not accurately complete Level I Preadmission Screening and Resident Review (PASRR) forms for one out of three sampled residents diagnosed with a Serious Mental Illness (SMI). Resident # 9's diagnosis of Anxiety was omitted on the Level I PASRR form despite being admitted to the facility with this diagnosis. There were 78 residents residing in the facility.

Inspectors wroteBased on observations, records reviewed and interviews it was determined that the facility failed to provide care and services in accordance with professional standards for administering medications via Percutaneous Endoscopic Gastrostomy (PEG) tube for one out of two sampled residents (Resident #52) with a PEG tube. Facility staff did not check the placement of Resident #52's PEG tube before administering medications. This practice had the potential to cause severe medical complications. There were four residents with PEG tubes residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide an environment free of accident hazards for one (Resident # 95) out of five sampled residents on fall management program; and on the fourth floor and with the fourth-floor housekeeping cart as evidenced by; Resident # 95 was left in a high positioned bed, the call light not in reach while and no staff present. There were 24 residents on the facility's Fall Management Program at the time of survey. 2) Housekeeping cart left unattended with hazardous chemical easily accessible on the cart. There were 78 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interview and record review the facility failed to provide pharmaceutical services to ensure accurate and timely medication administration for two (Resident # 52 and Resident #73) out of five residents reviewed for medication administration observation as evidenced by:1 An omission of a supplement order for Resident # 52 for wound healing. 2. Medications administered 1.5 to 2 hours late to Resident # 46 and Resident #73. There were 78 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews, and record reviews facility failed to ensure the medication error rate was below 5 % as evidenced by a medication rate of 24.24 %. Observations included: Medications administered 1.5 to 2 hours late to Resident #46 and Resident #73. There were 78 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews, and record reviews facility failed to properly store medications during medication administration as evidenced by: Observation of medications on top of the 4th floor medication cart, unattended. Two observations of the facility's staff leaving medications unattended during medication administration. There were 78 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, record review and interviews, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate an effective plan of action to correct repeated deficiencies in the problem area as evidenced by repeated deficient practices for F761; failed to properly store and label medications during medication administration, F689; failed to prevent accident hazards. These repeated deficient practices have the potential to affect the 78 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide supervision to prevent the elopement of one (Resident #1) out of three sampled residents; as evidenced by, on 04/18/2025 newly admitted Resident #1 who is moderately impaired left the facility undetected at approximately 11:22 AM and boarded a city bus; was located 10 hours later 2.0 miles from the facility by a stranger that observed Resident #1 pacing back and forth before his home and alerted law enforcement. According to Accu weather. com on that day the temperature ranged between 72 degrees and 86 degrees.

Inspectors wroteBased on observations, interviews, and record review the facility failed to keep residents' health care information private on two out of four medication carts as evidenced by computer screens left open and unattended on the first-floor South medication cart and third floor medication cart with residents' information visible There were 77 residents resided in the facility at the time of survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to keep furniture in good repair for one Resident (Resident #60) out of six sampled and the ceiling in good repair on third floor as evidenced by a nightstand with a broken door and four ceiling tiles with water stains and active dripping water and failed to clean three out of three the lint traps in The Laundry room as evidenced by three lint traps observed filled with lint despite staff signed that it was cleaned. There were 77 residents residing in the facility at the time of survey. The findings Included: 1) On 9/16/24 at 9:58 AM The nightstand in Resident #60's room had a broken door (photo evidence) On 9/16/24 at 1:26 PM; the Assistant Director Of Nursing (ADON) stated: When I make rounds, and I see something that needs repair I notify maintenance personnel via text. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to provide an environment that is free from potential accident and hazards for one resident (#13) out of 12 residents sampled as evidenced by observations of bilateral side rails in the upward position with foam padded top railing for Resident #13. There were 77 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that psychotropic medications were used only to treat a documented condition for one resident (#74) out of six sampled as evidenced by a psychotropic medication ordered for Resident #74 for the diagnosis of Schizophrenia and no supporting documentation for that diagnosis.

Inspectors wroteBased on observation, record review and interview, the facility failed to store medications properly on two out of four medication carts and one out of four medication rooms as evidenced by an observation of partially crushed pills inside a pill crusher bag in the pill crushing machine on top of the third floor medication cart, an observation of an open drawer on the first floor south medication cart while unattended, and an observation of four expired tracheostomy kits in the first floor medication room. There were 77 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to accommodate a resident's choice to have a shower for one resident (Resident #26) out of one resident reviewed for choices and preferences. There were a total of 79 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a hand splint was worn to prevent a worsening right hand contracture for one (Resident #67) out of six residents reviewed for position and mobility out of nine residents with contractures. There were a total of 79 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain an accurate record for one (Resident #26) out of one resident reviewed for choices and preferences. The resident did not receive showers as documented in the medical record. There were a total of 79 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to comply with infection control standards as evidenced by Staff A LPN failing to perform hand hygiene during wound care for one resident (Resident #23) out of 5 residents who have pressure ulcers.