Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regents Park At Aventura during CMS and state inspections, most recent first.
An unattended computer at a nursing station was observed with the screen open displaying residents' health care information. An LPN stated that resident information should only be shared with authorized individuals and that computers should not be left open or visible when unattended; the facility HIPAA policy also identifies leaving a secured application unattended while logged on as a violation.
A resident with an indwelling urinary catheter was left exposed during hygiene care when the privacy curtain did not fully extend, and the roommate entered the room while care was ongoing. The LPN continued care despite being aware of the lack of privacy, citing concern that the resident might refuse care if interrupted. Facility policy requires staff to maintain resident dignity and privacy.
A resident with an indwelling urinary catheter received improper care when an LPN placed the drainage bag and tubing on the bed at bladder level, causing urine backflow. The LPN emptied the bag without cleaning the port, despite physician orders to keep the bag below bladder level. Staff interviews confirmed the correct procedure was not followed, and there was no facility policy on catheter bag positioning.
A resident with COPD and dementia fell and sustained fatal injuries during a mechanical lift transfer when CNAs failed to operate the lift safely. Despite prior training, the lift unexpectedly rose, leading to the resident's fall. The facility's investigation found the lift in working order, and the neglect was deemed unsubstantiated.
A resident fell and sustained fatal injuries during a transfer using a mechanical lift in an LTC facility. CNAs involved failed to ensure the lift's safe operation, leading to the lift rising unexpectedly. Despite training, one CNA may have inadvertently pressed the remote, causing the incident. The resident, with a history of COPD and dementia, required total assistance and was transferred to the hospital, where they later expired.
A resident with chronic health issues and dementia fell from a mechanical lift during a transfer, resulting in fatal injuries. Two CNAs were involved in the transfer when the lift unexpectedly rose, leading one CNA to grab the lift pad, causing the resident to fall. The facility's policies on lift inspections and staff training were not effectively implemented, contributing to the incident.
The facility was cited for failing to provide adequate supervision and interventions to prevent accidents, resulting in repeated falls and injuries to residents. During a recertification survey, a razor was found on a resident's nightstand, indicating a failure to maintain a safe environment free of accident hazards.
The facility failed to adhere to food safety standards, affecting 164 residents. Observations revealed issues such as a leaking ceiling, improper food storage, and unsanitary handling of silverware. Food temperatures were not maintained at regulatory levels, and the kitchen had cleanliness issues, including mold and condensation. These deficiencies indicate a significant risk to resident safety and health.
The facility failed to maintain a safe and clean environment across multiple areas, including the first, second, and third floors, as well as the maintenance and laundry departments. Issues included condensation dripping from air-conditioning vents, unattended hazardous materials, soiled floors, damaged furniture, inadequate privacy curtains, and malfunctioning bathroom fixtures. Additionally, staff failed to document issues in housekeeping and maintenance logbooks, contributing to the deficiencies.
The facility failed to follow the approved menu portion sizes, serving insufficient roast turkey portions during a lunch meal. Observations revealed that the turkey portions were smaller than the required 3 ounces, with a weighed portion measuring only 2.46 ounces. This affected 88 residents on a Regular diet.
The facility failed to maintain resident dignity and provide adequate care, as observed in several instances. A resident reported delayed assistance leading to incontinence issues, while another was left without proper bedding due to staff miscommunication. Additionally, a resident with limited understanding was not assisted with her meal, and staff were overheard using undignified terms for residents needing help with eating.
Two residents experienced a decline in daily living abilities due to inadequate care. One resident, with severe cognitive impairment, was left unsupervised during meals, resulting in poor food and fluid intake and significant weight loss. Another resident's dentures were improperly maintained, with visible residue indicating inadequate cleaning. These deficiencies highlight the facility's failure to provide necessary care to prevent the decline in residents' daily living abilities.
A facility failed to prevent accident hazards by allowing a resident to keep multiple razors in their room, despite a care plan indicating a risk for bleeding due to medication. The resident, with a history of cerebrovascular disease and hemiplegia, was observed with razors in their nightstand, contrary to the facility's policy. Interviews with the resident and staff confirmed the deficiency, highlighting a lapse in supervision and policy enforcement.
A resident with multiple health conditions experienced significant weight loss due to the facility's failure to monitor and document weights as per policy. The resident's weight was not recorded for several weeks, resulting in an 11.4% weight loss over one month without timely nutritional evaluation. The registered dietician acknowledged the oversight in weight monitoring.
The facility failed to secure medications in a medication room and for three residents. An RN left a medication room unlocked, and residents with cognitive impairments or legal blindness had medications at their bedside without being assessed for self-administration. The RN/Unit Manager confirmed that medications should be locked unless residents are assessed for self-administration.
The facility failed to provide food in the correct form for residents requiring pureed and mechanical soft diets. Observations revealed that pureed foods contained lumps, and a resident with cerebral ischemia received meals not compliant with their mechanical soft diet order. The cook lacked training and did not taste test pureed foods, affecting 31 residents with pureed diets and 43 with mechanical soft diets.
The facility failed to implement an effective QAPI program, resulting in repeated deficiencies in Resident Rights, Pharmacy Services, Food and Nutrition Services, and QAPI itself. The Administrator acknowledged issues such as condensation in the kitchen and medication management but lacked documentation and tracking through QAPI to address these problems.
The facility failed to follow its Enhanced Barrier Precautions (EBP) policy for two residents, as isolation gowns were not available at their doors. Additionally, a dietary aide was observed transporting uncovered soiled food trays through the hallway, contrary to facility policy. These lapses were identified during a survey, highlighting deficiencies in infection prevention and control practices.
Failure to Protect Confidential Resident Information
Penalty
Summary
Staff failed to keep residents' personal and medical records private and confidential at one of the two nursing stations on the second floor. During an observation on 01/06/2026 at 12:56 PM, an unattended computer at the 2 west Nursing Station was found with the screen open and displaying residents' health care information. During an interview on 01/07/2026 at 09:30 AM, an LPN stated that HIPAA means protecting patient privacy, not discussing resident information over the phone except with authorized individuals listed in the chart, and ensuring a computer is not left open or visible when walking away; the LPN also stated that paperwork containing patient information is shredded when no longer needed. The facility policy titled HIPAA Policy: 11/2019 states that violations include the negligent mishandling of confidential information or workstations that house such information and leaving a secured application unattended while logged on.
Failure to Ensure Privacy During Hygiene and Catheter Care
Penalty
Summary
The facility failed to provide adequate privacy during hygiene and catheter care for one resident with an indwelling urinary catheter. During an observation, an LPN performed hygiene care for the resident while the privacy curtain did not fully extend around the bed, leaving the resident exposed. While care was ongoing, the resident's roommate entered the room, further compromising privacy. The LPN acknowledged awareness of the incomplete privacy but continued care to avoid the resident refusing it. The facility's policy requires staff to protect and promote resident rights, including maintaining dignity and privacy during care.
Improper Catheter Care and Drainage Bag Positioning
Penalty
Summary
Staff failed to provide appropriate catheter care for a resident with an indwelling urinary catheter. During hygiene and catheter care, an LPN placed the resident's urinary drainage bag and tubing on the bed next to the resident's feet, at the same level as the bladder, resulting in backflow of urine in the tubing. The LPN later lowered the drainage bag and emptied the urine without cleaning the port before or after the procedure. The resident had a history of hemiplegia and hemiparesis following a cerebral infarction and was noted to have severe cognitive impairment. Physician orders specified that the urine collection bag should always be kept below the level of the bladder. Interviews with staff, including the LPN, Infection Control Preventionist, and DON, confirmed that the drainage bag should be kept below the bladder to facilitate urine flow and prevent backflow. The LPN acknowledged that leaving the bag on the bed could cause reflux and that the port should be cleaned with an alcohol pad before and after draining urine. The Infection Control Preventionist and DON both stated that the bag should not touch the floor and must hang by gravity, and that the exit port should be cleaned with soap and water. It was also revealed that there was no facility policy regarding the correct positioning of the indwelling urinary catheter drainage bag.
Neglect During Mechanical Lift Transfer Results in Resident's Death
Penalty
Summary
The facility failed to protect a resident from neglect by its staff during a transfer using a mechanical lift. Certified Nursing Assistants (CNAs), identified as Staff A and Staff B, were involved in the incident where the mechanical lift malfunctioned, causing the resident to fall and sustain fatal injuries. The lift unexpectedly rose, and when Staff B attempted to stabilize the situation by grabbing the lift pad, the resident fell to the floor, resulting in head injuries. The resident was subsequently transferred to the hospital, where they expired approximately four hours later. The resident involved had a history of Chronic Obstructive Pulmonary Disease (COPD) and dementia, requiring total assistance with activities of daily living due to impaired mobility. The resident's care plan included the use of a mechanical lift for transfers. On the day of the incident, the CNAs were performing a routine transfer from the bed to a chair when the lift malfunctioned. Despite having completed training on the use of mechanical lifts, the CNAs were unable to prevent the resident from falling. The facility's mechanical lifts had been inspected for safety and functionality, with the most recent inspections occurring before and after the incident. However, during the transfer, it was reported that Staff A may have inadvertently pressed the remote control, causing the lift to rise unexpectedly. This led to Staff B's attempt to hold the lift pad, which resulted in the resident's fall. The facility's investigation concluded that the neglect was unsubstantiated, and the mechanical lift was found to be in working order after the incident.
Removal Plan
- Competency/training Mechanical Lift operations completed for CNAs Staff A and Staff B
- Medical Equipment Company checked all mechanical lifts to make sure they were functioning properly
- Safe Handling policy for Mechanical lifts were reviewed with DON, ADON, NHA, Unit Managers
- Safe and Proper Handling of Mechanical lifts training/competencies-completed for all nurses and CNAs
- Reviewed interviews for alert residents and family interviews for alert residents about safety and abuse/neglect
- Abuse and Neglect policy reviewed and revised, revisions were implemented in the employee training section
- New Abuse Investigate Protocol checklist was implemented, DON, ADON, NHA, SSD were in-serviced on the new form
- In service on Abuse, Neglect and Exploitation was completed for all staff at the facility
- The sixty residents requiring Mechanical lift for transfers, care plans were reviewed
Failure in Safe Transfer with Mechanical Lift
Penalty
Summary
The facility's Certified Nursing Assistants (CNAs), Staff A and Staff B, failed to ensure the safe transfer of a resident from the bed to a chair using a mechanical lift. During the transfer, the mechanical lift unexpectedly rose, and when Staff B attempted to stabilize the situation by grabbing the lift pad, the resident fell from the lift, sustaining head injuries. The resident was subsequently transferred to the hospital, where they expired approximately four hours later. The facility's policy on safe resident handling and transfers mandates that mechanical lifting equipment be inspected prior to use to ensure functionality. However, the mechanical lift involved in the incident was not effectively inspected or maintained, leading to its malfunction during the transfer. The CNAs involved had completed training on the use of mechanical lifts, but during the incident, Staff A may have inadvertently pressed the remote control, causing the lift to rise unexpectedly. The resident involved had a history of Chronic Obstructive Pulmonary Disease (COPD) and unspecified dementia, requiring total assistance with activities of daily living due to impaired mobility. The resident's care plan included the use of a mechanical lift for transfers. Despite the facility's protocols and training, the incident occurred, resulting in the resident's fall and subsequent death due to blunt force trauma.
Removal Plan
- Lift #846 was inspected and found to be functioning correctly, stored in the maintenance room.
- Competency/training Mechanical Lift operations completed for CNAs Staff A and Staff B.
- Safe and Proper Handling of mechanical lifts training/competencies completed for all nurses and CNAs.
- ADHOC Quality Assurance and Performance Improvement (QAPI) meeting on Mechanical lift transfers completed with the QAPI team.
- Safe Handling policy for mechanical lifts were reviewed with DON, ADON, NHA, Unit Managers, attendees were documented on the QAPI sign in sheet.
- Medical Equipment Company checked all mechanical lifts to make sure they were functioning properly; no areas of concern were reported.
- Monthly Maintenance Mechanical lift logs completed by Maintenance Director.
- Residents' Kardex audited/updated for mechanical lift pad sizes.
- Mechanical sling size assessment for the 60 residents using mechanical lifts were completed by Unit Managers.
- Safe and Proper Handling of Mechanical lifts training/competencies completed for all nurses and CNAs.
Fatal Incident Due to Improper Mechanical Lift Operation
Penalty
Summary
The facility failed to effectively inspect and operate a mechanical lift safely during the transfer of a resident, resulting in a fatal incident. Two CNAs, Staff A and Staff B, were involved in transferring the resident from the bed to a chair using the mechanical lift. During the transfer, the lift unexpectedly continued to rise, and when Staff B attempted to stabilize the situation by grabbing the lift pad, the resident fell from the lift and sustained severe head injuries. The resident was subsequently transferred to a hospital, where they expired approximately four hours after the fall. The resident involved had a history of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and unspecified dementia. The resident was dependent on staff for transfers due to impairments in both upper and lower extremities. The care plan for the resident included the use of a mechanical lift for transfers, which was not executed safely during the incident. The facility's policies required that mechanical lifts be inspected before use and that staff be trained and competent in their operation, but these measures were not effectively implemented in this case. Interviews with staff revealed that the mechanical lift involved in the incident was functioning correctly at the time of the surveyor's inspection. However, the incident report suggested that Staff A may have inadvertently pressed the remote control, causing the lift to rise unexpectedly. This prompted Staff B to grab the lift pad, leading to the resident's fall. The facility's maintenance logs indicated that the lifts were inspected regularly, but the training and competency of the staff in using the lifts were called into question following the incident.
Removal Plan
- Lift #846 inspected and found to be functioning correctly, stored in the maintenance room.
- Competency/training Mechanical Lift operations completed for CNAs Staff A and Staff B.
- Safe and Proper Handling of Mechanical lifts training/competencies completed for all nurses and CNAs.
- ADHOC Quality Assurance and Performance Improvement meeting on Mechanical lift transfers completed with the QAPI team.
- Safe Handling policy for Mechanical lifts reviewed with DON, ADON, NHA, Unit Managers, attendees documented on the QAPI sign in sheet.
- Medical Equipment Company checked all mechanical lifts to ensure they were functioning properly; no areas of concern reported.
- Maintenance Mechanical lift logs completed by Maintenance Director.
- Residents' Kardex audited/updated for mechanical lift pad sizes.
- Mechanical sling size assessment for the 60 residents using mechanical lifts completed by Unit Managers.
Failure to Ensure Resident Safety and Prevent Accident Hazards
Penalty
Summary
The facility was cited for failing to ensure the safety of residents by not providing adequate supervision and interventions to prevent accidents. During a complaint survey ending in December 2023, the facility was found to have failed in preventing repeated falls that resulted in injuries to vulnerable residents. Additionally, during a recertification survey in August 2024, a razor was observed on the nightstand of a resident, indicating a failure to maintain a safe environment free of accident hazards. The facility's survey history revealed that during a recertification conducted in late July to early August 2024, the same deficiency was cited. The facility did not ensure that a resident's room was free of accident hazards, as evidenced by the presence of razors at the bedside. This deficiency was noted for one of the forty sampled residents, highlighting a repeated issue with maintaining a safe environment for residents.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, affecting 164 residents. During an initial kitchen observation, a large section of the ceiling was dripping water onto the floor near food production areas, and staff were walking through the contaminated water. Soiled clothing was found in the dry food storage area, and a commercial package of macaroni salad lacked an expiration date. The food preparation area had a rust-laden electrical box, and soiled dishes were stored in a clean area, posing a risk of cross-contamination. Food utility carts were heavily soiled with black mold, and adaptive eating dishes were stained. The walls and floors of the food production area were dirty, with broken tiles, and a ceiling vent had condensation dripping onto clean equipment. During a second observation, dietary staff handled clean silverware unsanitarily, and hot and cold foods on the tray assembly line were not held at regulatory temperatures. A third observation revealed that raw chicken was thawing in hot water, contrary to regulations, and food temperatures were again not maintained. Condensation from a ceiling vent dripped onto clean carts and dishes, and rodent traps and flying insects were noted in the kitchen. A fourth observation found that food temperatures were still not compliant, and a pan of powdered thickener lacked a date. These deficiencies indicate a lack of adherence to food safety standards, with multiple instances of improper food storage, preparation, and handling. The facility's failure to maintain clean and safe kitchen conditions, as well as to ensure food is stored and served at appropriate temperatures, poses a risk to resident safety and health.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment across multiple areas, including the first, second, and third floors, as well as the maintenance and laundry departments. On the first floor, air-conditioning vents were observed to be covered with condensation and dripping onto the hallway floor. The maintenance department was left unattended with the door open, allowing resident access to hazardous chemicals and sharp tools. On the second floor, various rooms and common areas were found to be in disrepair, with issues such as soiled floors, damaged furniture, and inadequate privacy curtains. Additionally, there were reports of offensive odors, algae-covered windows, and malfunctioning bathroom fixtures. The third floor also exhibited deficiencies, including non-functional paper towel dispensers and privacy curtains that were too short to ensure resident privacy. In the laundry room, a staff member was observed sitting on a clean linen shelf, and the area was cluttered with personal items and food containers. The facility's housekeeping and maintenance logbooks, intended for staff to report issues, were not being utilized effectively, as staff were not documenting problems. These observations were made during a survey conducted over several days, highlighting significant lapses in housekeeping and maintenance services necessary for resident safety and comfort.
Insufficient Portion Sizes of Roast Turkey
Penalty
Summary
The facility was found to have not adhered to the approved menu portion sizes during a lunch meal service. Specifically, the portion size of roast turkey served to residents on a Regular diet was insufficient. During an observation in the main kitchen, it was noted that the turkey portions appeared smaller than required. A review of the facility's approved menu indicated that a minimum of 3 ounces of roast turkey should be served. However, when a portion was weighed by the Food Service Director using a calibrated food scale, it was found to be only 2.46 ounces. This discrepancy potentially affected 88 residents who were on a physician-ordered Regular diet.
Dignity and Care Deficiencies in Resident Assistance
Penalty
Summary
The facility failed to treat residents in a dignified manner, as evidenced by several observations and interviews. Resident #72, who has a self-care deficit and is incontinent, reported that staff sometimes take a long time to respond to calls for assistance, leading to instances where the resident soils himself. The resident mentioned wearing two diapers to prevent urine from going everywhere, indicating a lack of timely incontinence care. Similarly, Resident #136, who is legally blind and incontinent, reported that some staff members have her wear two diapers, which she did not request, suggesting inconsistency in care practices. Resident #154, who is dependent on staff for all activities of daily living, was found in her bed without sheets or a blanket, giving the appearance of being cold. This was observed during a facility tour, and staff interviews revealed a lack of communication and responsibility between CNAs, leading to the resident being left without proper bedding. Staff C and Staff F both acknowledged their roles in the situation, with Staff F leaving the resident without linens, assuming Staff C would return to complete the care. Resident #6, who has a BIMS score indicating she is rarely understood, was observed with an untouched breakfast tray and no staff present to assist her. Staff interviews revealed confusion about who was responsible for assisting the resident with her meal, resulting in inadequate assistance during dining. Additionally, during a breakfast meal observation, staff were overheard referring to residents as "feeders," which was identified as a dignity issue by the surveyor.
Failure to Maintain Residents' Daily Living Abilities
Penalty
Summary
The facility failed to provide necessary care and services to prevent the decline in activities of daily living for two residents. Resident #64, who has severe cognitive impairment and multiple medical diagnoses including Alzheimer's Disease and dysphagia, was observed during a breakfast meal in a nearly lying position, attempting to feed themselves with their hands, resulting in food spillage and inability to consume beverages. The resident received no supervision or assistance from staff during the meal, consuming less than 50% of the meal and none of the fluids. The resident's clinical records indicated a significant weight loss over several months, with a BMI within the health range, but noted a need for assistance with meals and a risk for nutritional issues. Resident #177, also with severe cognitive impairment, was observed with dentures improperly maintained. The top denture was out of the mouth and the bottom denture had a greenish-brown film, indicating inadequate cleaning. Despite the RN/UM's assertion that CNAs clean the dentures, the film was easily removed with a toothbrush, suggesting a lack of proper care. These observations highlight the facility's failure to ensure residents maintain their ability to perform daily activities, such as self-feeding and dental care, without medical justification for the decline.
Failure to Prevent Accident Hazards in Resident's Room
Penalty
Summary
The facility failed to ensure a resident's room was free from accident hazards, specifically regarding the presence of razors at the bedside. This deficiency was identified for one resident who was admitted with diagnoses including unspecified sequelae of cerebrovascular disease and hemiplegia affecting the left nondominant side. The resident's care plan highlighted a risk for bleeding and easy bruising due to their medication regimen, which included Clopidogrel Bisulfate for blood clot prevention. Despite this, observations revealed multiple safety razors in the resident's room, contrary to the facility's policy that prohibits residents from possessing or using sharp objects independently. Interviews with the resident and staff further confirmed the deficiency. The resident admitted to using razors almost every day and showed the surveyor several razors stored in the nightstand. The Director of Nursing and a Licensed Practical Nurse both stated that razors should be disposed of immediately after use in a sharps container, indicating a lapse in adherence to the facility's policy. This oversight in supervision and enforcement of safety protocols led to the presence of potential accident hazards in the resident's environment.
Failure to Monitor Resident's Weight Loss
Penalty
Summary
The facility failed to adequately monitor and identify significant weight loss in a timely manner for a resident, leading to a deficiency in nutritional care. The facility's policy required residents to be weighed within 24 hours of admission and weekly for the first four weeks, with further monitoring if significant weight changes were observed. However, the resident in question, who had multiple diagnoses including cerebral atherosclerosis, type 2 diabetes mellitus, and mild protein-calorie malnutrition, experienced significant weight loss without timely intervention. The resident's weight was not recorded for several weeks, and a significant weight loss of 11.4% was noted over a one-month period without a timely nutritional risk evaluation. The registered dietician acknowledged the oversight in obtaining and recording the resident's weights, despite the facility having a system in place for weight monitoring. The dietician confirmed that the resident had experienced significant weight loss and that some weekly weights were missed. This lapse in monitoring and documentation contributed to the failure to address the resident's nutritional needs promptly, as required by the facility's policy.
Medication Security Deficiency
Penalty
Summary
The facility failed to ensure that medications were secured in one of the two medication rooms observed. During an inspection, a Registered Nurse (RN) led a surveyor to an unlocked room containing various over-the-counter medications and an unlocked treatment cart with Hydrocortisone Acetate 1%. Additionally, an adjoining room inside the unlocked medication room was found with its door wide open, containing various creams, ointments, and solutions for wound care. The RN acknowledged that the room should have been locked and admitted to forgetting to lock the cart and the medication room after cleaning. The facility also failed to secure medications for three residents. One resident, with moderate cognitive impairment, was observed with Biotene dry mouth lozenges on their overbed table. The RN confirmed that residents should not have medications at the bedside unless assessed for self-administration, which had not been done for this resident. Another resident, who is legally blind, was found with Emergen C vitamin C gummies, vitamin C lozenges, and Vicks vapor ointment on their overbed table. The LPN and RN/Unit Manager confirmed that the resident had not been assessed for self-administration, and the medications should have been locked. A third resident, with a cognitive response, was observed with Tums, Aspercreme, and other medications in their nightstand drawer, along with several safety razors. The resident stated that they use the Tums for gas and the razors almost every day. The RN/Unit Manager confirmed that residents should not have medications unlocked at the bedside unless assessed for self-administration, which had not been done for this resident.
Failure to Provide Appropriate Diets for Residents
Penalty
Summary
The facility failed to prepare food in a form designed to meet the individual needs of residents, specifically those requiring pureed and mechanical soft diets. During observations, it was noted that pureed foods, such as cilantro rice and eggs, contained lumps and pieces, indicating they were not of the required smooth consistency. The cook admitted to not having specific training on preparing pureed foods and did not taste test the mixtures to ensure they met the necessary consistency. This affected 31 residents with physician-ordered pureed diets, including several sampled residents. Additionally, the facility did not provide the correct mechanical soft diet to 43 residents, including a resident with a principal diagnosis of cerebral ischemia. This resident was observed receiving meals that did not comply with the mechanical soft diet requirements, such as whole pieces of chicken instead of ground meat. The registered dietician confirmed that the meals provided were inappropriate for a mechanical soft diet. These deficiencies highlight a failure in adhering to physician-ordered dietary requirements for residents with specific dietary needs.
Ineffective QAPI Implementation Leads to Repeated Deficiencies
Penalty
Summary
The facility failed to develop and implement an effective Quality Assurance and Performance Improvement Program (QAPI) as evidenced by repeated deficiencies in four federal areas: Resident Rights (F550), Pharmacy Services (F761), Food and Nutrition Services (F812), and Quality Assurance Performance Improvement (F867). The facility's QAPI plan lacked regular review and analysis of data, and there was no effective action taken on available data to make necessary improvements. During a QAPI review, the Administrator acknowledged that while they meet monthly to review past deficiencies, they had not yet started a QAPI for the identified condensation issue in the central kitchen, which was related to the repeated deficiency under Food and Nutrition Services. Additionally, the Administrator mentioned issues related to Resident Rights, specifically staff standing over residents during dining, which was resolved without a QAPI. The Administrator also identified problems with medications at the bedside and residents ordering medications online, but there was no QAPI paperwork available to track and trend these issues. The lack of documentation and tracking indicates a failure to effectively address and monitor these deficiencies through the QAPI process.
Infection Control Lapses in EBP and Food Tray Handling
Penalty
Summary
The facility failed to adhere to its policy on Enhanced Barrier Precautions (EBP) for two residents, as observed by surveyors. Resident #177, who was on EBP due to a wound, did not have isolation gowns available at the door as required by the facility's policy and CDC guidelines. During an interview, the Registered Nurse/Unit Manager acknowledged the absence of gowns and indicated that they were supposed to be next to the door but had run out. Further investigation revealed that additional gowns were stored in an unlocked room at the end of another hallway, contrary to the expectation that they should be readily accessible. Similarly, Resident #69, who was also on EBP, did not have isolation gowns available in the room. Additionally, the facility failed to ensure that food trash and soiled resident food trays were covered during transportation. An observation was made of a dietary aide pushing an uncovered meal tray cart with dirty trays through the hallway. The dietary aide mentioned that the cover was missing, suggesting it might have been discarded. These observations indicate lapses in infection prevention and control practices as per the facility's policies.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 327 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Aventura
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vi At Aventura | 0.8 mi | ★★★★★ | 0 | 0 |
| North Beach Healthcare And Rehabilitation Center | 1.2 mi | ★★★★★ | 11 | 0 |
| Serenity Bay Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 14 | 0 |
| Palm Garden Of Aventura | 1.6 mi | ★★★★★ | 0 | 0 |
| Aventura Rehab And Nursing Center | 2.4 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.