Regents Park at Aventura

Inspectors wroteBased on observations, interviews, and record reviews, the staff failed to keep residents' information confidential at one of the two nursing stations on the second floor. As evidenced by an unattended computer with an open screen displayed a resident's confidential health care information at the 2 [NAME] Nursing station. There were 173 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide adequate privacy during hygiene and catheter care for one resident (Resident #7) out of three residents sampled with an indwelling urinary catheter. Resident #7's roommate entered the room while Resident #7 was exposed. At the time of the survey, nine residents with an indwelling urinary catheter resided in the facility.

Inspectors wroteBased on observations, record review and interviews facility failed to provide appropriate catheter care to facilitate the flow of urine for one (Resident#7) out of three sampled residents who had indwelling urinary catheter, as evidenced by during catheter care Resident#7's indwelling urinary catheter drainage collection bag and tubing were positioned on top of bed with backflowing urine noted in the tubing. This deficient practice prevented the free flowing of urine that would be accumulated in the bladder causing discomfort and increasing the risk for catheter-associated urinary tract infections and other serious medical issues. There were nine residents with indwelling urinary catheters residing in the facility at the time of this survey.

Inspectors wroteBased on observation, interviews and record review the facility failed to protect Resident #1's right to be free from Neglect by the facility's staff. Certified Nursing Assistants (CNAs), (Staff A) and (Staff B) failed to safely transfer Resident #1 from her bed to the chair with a Mechanical Lift. The facility neglected to effectively inspect and operate the Mechanical Lift in a safe manner during the transfer of Resident #1. This failure to operate the mechanical lift in a safe manner on [DATE] at 9:57 AM Staff A and Staff B who reported that during the transfer the Mechanical lift kept rising and when Staff B grabbed the lift pad to stop it from going higher Resident #1 suddenly fell from the Mechanical lift and landed face down on the floor sustaining injuries to her head. Resident #1 expired at the hospital approximately four hours later. [...]

Inspectors wroteBased on observations, interviews and record review the facility's Certified Nursing Assistants (CNAs), (Staff A) and (Staff B) failed to ensure Resident #1 was safely transferred from the bed to the chair with a mechanical lift. The facility failed to effectively inspect, complete accurate safety check and maintain the mechanical lift to ensure it is safely operating during the transfer of Resident #1. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F689-Free of Accident Hazards/Supervision/Devices. As evidenced by: F689 was cited during a complaint survey ending 12/14/23 when the facility failed to provide adequate supervision and additional interventions to ensure the safety of vulnerable residents and to prevent repeated falls that resulted in injuries and during the recertification survey with exit dated 08/21/24 razors were observed on Resident #382 's nightstand

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to store prepare, distribute and serve food in accordance with professional standards for food service safety that potentially effects 164 of the facility residents.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, orderly, and comfortable interior on the facility's first floor, second floor residential units, third floor residential units, maintenance department, and laundry area.

Inspectors wroteBased on observation, interview, and record review, it was determined that portion sizes documented on the approved menu were not followed and potentially effected 88 of the facility residents with physician ordered Regular diet.

Inspectors wroteBased on observations, interviews and record review the facility failed to treat residents in a dignified manner who wear adult briefs for 2 out of 40 sampled residents (Residents #72 and Resident #136 and failed to ensure that residents are treated in a dignified manner with bedding while in bed for 1 out of 40 sampled residents (Resident #154) and failed to treat residents in a dignified manner during dining observation (Resident #6).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide necessary care and services so that activities of daily living do not diminish for 1 (Resident #64) of 5 sampled resident for nutrition review for independence in self-feeding and 1 (Resident #177) of 1 sampled resident for daily dental care.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure resident's room free of accident hazards (razors at bedside) for 1 of 40 sampled residents (Resident #382).

Inspectors wroteBased on observations, interviews, and record review the facility failed to monitor weights and identify weight loss in a timely manner for 1 of 10 residents sampled for nutrition (Resident #162).

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure medications secured in med room for one of two med rooms observed and failed to secure medication for 3 of 40 sampled residents (Resident #136, Resident #120, and Resident #382.)

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to prepare food in a form to designed to meet the individual needs for 31 residents out of which eight included eight sampled residents (Resident #6, Resident #22, Resident #50, Resident #111, Resident #118, Resident #144, Resident #154, Resident #177), and failed to provide 43 residents with physician ordered Mechanical Soft that included sampled Resident #161.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement an effective Quality Assurance and Performance Improvement Program (QAPI) with appropriate plans of action. The facility failed to regularly review and analyze data and act on available data to make improvements regarding 4 out of 4 federal repeated deficiencies (F550, F761, F812 and F867).

Inspectors wroteBased on observations, interview and record review the facility failed to follow facility policy for 2 out of 31 residents on Enhanced Barrier Precautions (EBP) Residents #177 and #69 as evidenced by no isolation gowns at the residents' doors and failed to ensure that food trash/soiled residents food trays are covered during transportation.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a thermometer was in the ice cream box. This has the potential to affect 154 out of 171 residents who eat orally residing in the facility at the time of the survey.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure residents are treated with respect and dignity for three residents (Resident #87, Resident #104, Resident #143) out of three residents who were observed during dining, as evidenced by staff members were observed standing while feeding residents. This deficient practice has a potential to affect 24 residents who need assistance with eating of the 154 resident who eat orally.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's clinical record contained documentation that the resident was provided with written information regarding the right to formulate an advanced directive for three (Resident # 133, Resident #143, Resident #122) out of seven residents whose clinical records were triggered and reviewed for written evidence of provision of information regarding formulating an advanced directive. There were a total of 171 residents residing in the facility at the time of this survey.

Inspectors wroteBased on record review and interview, the facility failed to ensure the electronic transmittal requirements for the Minimum Data Set was implemented related to a resident discharge return not anticipated for 1 (Resident #156) out of 1 sampled for resident assessment. Record review of Resident #156's clinical records revealed the resident was admitted to the facility on [DATE] and discharged to an Acute Care hospital on [DATE]. Medical Diagnoses included, but were not limited to, Sepsis, Unspecified Organism, Type 2 Diabetes Mellitus without Complications, Malignant Neoplasm of prostate, Hypothyroidism Unspecified, Bipolar Disorder, Current Episode Mixed, Unspecified Extended Spectrum Beta Lactamase (ESBL) Resistance, Dysphagia, Oropharyngeal Phase, Other Abnormalities of Gait and Mobility and Fracture of unspecified Metatarsal Bone(s), Left Foot. [...]

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level II for serious mental illness (SMI) or intellectual disability (ID) was requested at the time of admission for resident one (Resident #94) and Level I PASRR was not completed for six residents (Resident # 21, Resident # 133, Resident #36, Resident # 51, Resident # 74, and Resident #54) out of seven residents whose PASRR was reviewed. This deficiency had the potential to affect 172 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident's comprehensive care plan was followed related to the use of splints for a resident with a left hand contracture for one (Resident #130) out of one resident reviewed for position and mobility out of thirty-eight residents with contractures. There were a total of 171 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 left hand splint was worn to prevent worsening hand contracture for one (Resident #130) out of one resident reviewed for position and mobility out of thirty-eight residents with contractures. There were a total of 171 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to properly store medications. This affected 1 (Resident #91) out of 1 residents observed for Glucose Monitoring. This practice has the potential to affect the 154 residents admitted to the facility.

Inspectors wroteBased on observation, interview and policy review the facility failed to assure the garbage and refuse area was clean and expired water jugs and cardboard boxes were properly disposed and contained on the facility grounds.

Inspectors wroteBased on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in problem area related to repeated deficient practices for F578 Request/Refuse/Discontinue Treatment; Formulate Advance Directives related to the facility failure to ensure a resident's clinical record contained documentation that the resident was provided with written information regarding the right to formulate an advanced directive for three residents (Resident # 122, Resident #133, Resident # 143) out of seven residents investigated, and F812 Food Procurement Store/Prepare/Serve/Sanitary as evidenced by the facility failed to ensure a thermometer was in the ice cream box. There were 171 residents residing in the facility at the time of survey.