Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Aventura At Humility House during CMS and state inspections, most recent first.
Missed physician-ordered daily weights were found for three residents with conditions including CHF, CKD/ESRD, dementia, and diabetes. Records showed repeated gaps in weight documentation across multiple days, despite orders for daily monitoring, and the DON verified the missed weights and stated they should have been identified.
Facility Assessment failed to identify the staffing resources needed from 11:00 P.M. to 7:00 A.M. Review showed the assessment addressed staffing needs only from 7:00 A.M. to 11:00 P.M., and the Administrator confirmed the overnight gap during interview. The issue was found during a complaint investigation and had the potential to affect all 64 residents.
The facility failed to investigate or respond to repeated food-related complaints raised through resident Food Committee meetings, including concerns about food quality, temperature, portion sizes, presentation, menu variety, use of Styrofoam, lack of fresh bread, unannounced substitutions, and inconsistent snack service. Meeting minutes over several months documented ongoing dissatisfaction, yet there was no evidence of a plan of action, follow-up, or feedback to residents. The Dietary Manager and Administrator acknowledged awareness of complaints and confirmed there was no tracking system for resolution, while the Ombudsman reported multiple unresolved food complaints. Several residents reported being served burnt or tough food, unwanted substitutions, cold meals, plastic silverware, and repetitive menus, and stated that despite voicing concerns in resident groups, nothing changed.
Surveyors found that the facility failed to follow its posted menu and did not ensure meals were palatable and properly documented, including serving burnt lasagna and unplanned substitutions without resident request or menu notation. A resident with multiple comorbidities reported receiving burnt food, cold meals, and no fresh bread despite raising concerns in Resident Council and Food Committee meetings. Another resident, cognitively intact and independent in ADLs, described poor food quality, overuse of sandwiches, plastic silverware, and inconsistent, low-variety snack service. The Ombudsman reported multiple unresolved food complaints from several residents, and the Administrator acknowledged there was no system to track and resolve food-related concerns raised through the Food Council.
The facility did not follow posted dietary menus, serving meals that differed from what was planned and failing to update or communicate these changes to residents. A resident with multiple chronic conditions reported not being given meal choices or advance notice of menu changes, and the Dietary Manager confirmed last-minute substitutions were not reflected on the master menu. The Administrator acknowledged ongoing issues with menu adherence and communication.
The facility failed to follow infection control procedures during medication administration, affecting several residents. An LPN did not perform hand hygiene or use gloves while handling medications, and communal medication bottles were contaminated. Additionally, the facility lacked an infection control program with enhanced barrier precautions, as PPE carts lacked signage and staff did not use PPE appropriately. The facility's policies did not align with mandated standards for enhanced barrier precautions.
A facility failed to follow physician orders for wound care for a resident with chronic lymphedema and circulatory issues. The resident's care plan required specific wound care interventions, but an LPN did not apply dressings as ordered and used Tubigrip stockings against medical advice. Interviews confirmed the non-compliance with prescribed wound care procedures.
A facility failed to maintain a medication error rate below five percent, resulting in an 11.4% error rate. A resident with a complex medical history did not receive all prescribed medications, including potassium, an inhaler, and eye drops. An LPN confirmed the errors and inaccurately marked the MAR as if all medications were administered, violating facility policy.
Missed Physician-Ordered Daily Weights
Penalty
Summary
The facility failed to ensure physician-ordered daily weights were obtained for three residents being monitored for medical conditions. Resident #30 had diagnoses including Alzheimer's disease, dementia, diabetes, edema, and CHF, and a physician order dated 03/02/26 required daily weights every night shift. The record showed multiple missed weights in March 2026, with no evidence weights were obtained on several dates throughout the month. Resident #36 had diagnoses including ESRD, SOB, CKD, diabetes, and CHF, and a physician order dated 03/27/26 required daily weights every day shift for health monitoring with notification for a four-pound or greater gain. The record showed missed weights in April 2026 on several dates. Resident #85, whose closed record showed diagnoses including CHF, dementia, Alzheimer's disease, COPD, and acute kidney failure, had a physician order dated 06/24/25 for daily weights related to monitoring fluid status. The record showed multiple missed weights in March and April 2026. A facility in-service record dated 03/10/26 showed staff education on obtaining daily weights. During interviews, the DON verified the missing weights for the three residents, stated the missed weights should have been identified, and said she did not have an explanation for why the weights were not completed as ordered.
Facility Assessment Did Not Address Overnight Staffing Needs
Penalty
Summary
The facility failed to ensure a comprehensive Facility Assessment was developed to identify the staffing resources needed to provide care for residents competently during day-to-day operations and emergencies. Review of the Facility Assessment, updated 01/25/26, showed that it addressed staffing needs from 7:00 A.M. until 11:00 P.M., but it did not identify the staffing resources needed from 11:00 P.M. until 7:00 A.M. The facility census was 64 residents, and the deficiency had the potential to affect all 64 residents. During an interview on 05/07/26 at 2:40 P.M., the Administrator verified that the Facility Assessment identified staffing resources for 7:00 A.M. until 11:00 P.M. but did not identify staffing resources for 11:00 P.M. until 7:00 A.M. This was an incidental finding discovered during the complaint investigation.
Failure to Address Repeated Food Committee Complaints and Resident Group Concerns
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to organize and participate in resident/family groups by not investigating, addressing, or implementing corrective actions for repeated food service complaints raised through the Food Committee. Review of Food Committee minutes from November 2025 through January 2026 showed multiple ongoing complaints about food quality, temperature, portion sizes, presentation, menu variety, use of Styrofoam, lack of fresh bread, dislike of certain foods, inconsistent snack pass, and lack of coffee availability. Meeting minutes from several dates documented concerns about meals being served cold, limited alternatives for resident preferences, repetitive menus, and dissatisfaction with the amount and type of pasta served, as well as food being overcooked or undercooked. Despite these recurring issues, there was no documented plan of action, investigation, follow-up, or feedback to residents in the Food Committee records. Interviews further confirmed the lack of response to resident group concerns. The Dietary Manager acknowledged awareness of some complaints but could not provide documentation of investigations, changes to food service practices, or communication back to residents. The Ombudsman reported multiple food complaints from several residents, including burnt lasagna, lack of fresh bread, unannounced food substitutions, and use of Styrofoam plateware, and stated she had exhausted all avenues with management. The Administrator confirmed there was no tracking system to ensure food-related complaints raised through the Food Council were followed up and resolved. Individual residents reported being served burnt lasagna with an unrequested substitution of mashed potatoes and gravy, food sometimes being cold, lack of fresh bread, dissatisfaction with plastic silverware, tough food that was difficult to cut, too many sandwiches, and a snack cart that was inconsistently passed with no variety. Residents stated they attended Resident Council and Food Committee meetings to voice concerns but saw no changes, affecting 15 identified residents and potentially all residents receiving food from the kitchen.
Failure to Follow Posted Menu and Address Ongoing Food Quality Complaints
Penalty
Summary
The deficiency involves the facility’s failure to ensure food and drink were palatable, attractive, and served according to the planned and posted menu, as well as failure to provide meals in a manner consistent with residents’ nutritional needs. For one resident, admitted with multiple complex medical conditions including breast cancer history, diabetes with chronic kidney disease, hypertension, chronic kidney disease, and other comorbidities, the quarterly MDS showed she was not cognitively impaired and required setup or clean-up assistance for ADLs. A photograph dated 11/25/25 showed she was served burnt lasagna, mashed potatoes, and gray-green green beans instead of the planned lasagna, tossed salad, and mixed fruit. There was no documentation of any planned or approved menu substitution on the menu or substitution log for that date. The Ombudsman reported that this resident received burnt lasagna, mashed potatoes and gravy, and gray-colored green beans without requesting these substitutions, and also relayed broader resident complaints about food substitutions without notification and the use of Styrofoam plateware. The Ombudsman stated she had exhausted all avenues with management. The Dietary Manager confirmed that the posted menu was not followed for this resident’s lunch meal on 11/25/25, that no documentation of the substitution was completed, and that the photograph accurately showed burnt lasagna and mashed potatoes and gravy served instead of the planned tossed salad and mixed fruit. When shown the image, the Dietary Manager acknowledged he would not eat the burnt lasagna that had been served to the resident. The resident herself confirmed she was served a piece of burnt lasagna with mashed potatoes and gravy and had not ordered any substitutions. She also stated there was no fresh bread on site, that food was sometimes cold by the time it was served, and that she had raised these concerns in Resident Council and Food Committee meetings without improvement. A second resident, also not cognitively impaired and independent in ADLs, reported that the food “sucked,” that the facility did not listen to his concerns despite his attendance at Food Committee meetings, and that he was disgusted with the options and choices provided. He complained about plastic silverware, too many sandwiches, food sometimes being so tough he could not cut it, and an inconsistent snack cart with no variety. The Ombudsman corroborated multiple food complaints from several residents, including burnt lasagna, lack of fresh bread, unannounced food substitutions, and Styrofoam plateware. The Administrator confirmed there was no tracking system to ensure food-related complaints raised through Food Council were followed up and resolved.
Failure to Follow and Update Posted Dietary Menus
Penalty
Summary
The facility failed to ensure that dietary menus were followed as required, affecting at least one resident and potentially impacting all residents receiving meals from the kitchen. Observation of the breakfast meal service revealed that the food served did not match the posted menu; instead of the planned breakfast quiche, residents received scrambled eggs, yogurt, and donuts. The Dietary Manager acknowledged making last-minute changes to the menu, which were not updated on the master menu or communicated to residents. Review of the facility's policy confirmed that planned menus should be posted and any revisions made in a timely manner. A resident with diagnoses including diabetes, high cholesterol, arthritis, and chronic pain, who was cognitively intact and independent in eating, reported not being given a choice for breakfast and not knowing in advance what would be served. Minutes from a recent food committee meeting also documented resident concerns about inconsistencies between posted menus and actual meals served. The Administrator confirmed that the facility had issues with following posted menus and that changes should have been communicated to residents.
Infection Control Deficiencies in Medication Administration and Barrier Precautions
Penalty
Summary
The facility failed to ensure appropriate infection control procedures during medication administration, affecting three residents and potentially impacting all residents in the Northeast Hall. An LPN was observed preparing and administering medications without performing hand hygiene before or after handling medications and residents. The LPN handled medications with bare hands, including breaking tablets and placing them back into communal medication bottles, which were used by other residents. The LPN was unaware of the facility's hand hygiene policy and could not locate hand sanitizer on the medication cart or in resident rooms. Additionally, the facility did not implement an infection control program that included enhanced barrier precautions, which could affect all residents. Observations revealed that PPE carts were present but lacked signage indicating transmission-based precautions or directions for PPE use. Staff were observed not donning PPE when entering resident rooms, and wound care was provided without appropriate gowning. Interviews with staff confirmed a lack of awareness and implementation of enhanced barrier precautions, and the facility had not fully implemented an EBP program. The facility's policies on medication administration and standard precautions did not include enhanced barrier precautions, despite a memorandum from the Center for Clinical Standards and Quality/Quality, Safety & Oversight Group mandating EBP in long-term care facilities. The facility had residents with chronic wounds, indwelling medical devices, and a multidrug-resistant organism, yet there was no official policy or list of residents on enhanced barrier precautions.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to provide wound care according to physician orders for a resident with multiple health conditions, including chronic lymphedema and circulatory issues. The resident was admitted with diagnoses such as acute and chronic respiratory failure, congestive heart failure, and venous insufficiency. The care plan required specific wound care interventions, including the application of Dakin's solution, Neosporin ointment, and appropriate dressings from the feet to the knees. However, during an observation, it was noted that the Licensed Practical Nurse (LPN) did not follow these orders, as the dressings were applied only from the ankle to the calf, and Tubigrip stockings were used despite orders against compression until the wounds were closed. Interviews with the wound care physician and the Registered Nurse Unit Manager confirmed that the resident's wound care was not conducted as prescribed. The physician emphasized that no compression should be applied due to the risk of infection and the resident's history of blisters and open sores. The facility's policy required verification of physician orders and review of the care plan for wound care procedures, which was not adhered to in this case. This deficiency was identified during an investigation of a complaint.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an 11.4% error rate during a survey. This deficiency affected one resident, who was observed to have not received all prescribed medications. The resident, who had a complex medical history including acute and chronic respiratory failure, congestive heart failure, and glaucoma, was dependent on staff for medication administration. During the observation, it was noted that the resident refused a nasal spray but was given incorrect dosages of other medications, and some medications were not administered at all. The Licensed Practical Nurse (LPN) responsible for administering the medications confirmed that the resident did not receive all prescribed medications, including potassium, an inhaler, and eye drops. Additionally, the LPN admitted to marking the medication administration record (MAR) as if all medications had been given, despite some not being administered. The facility's policy required medications to be administered as prescribed and within one hour of the scheduled time, which was not adhered to in this instance. This deficiency was investigated under specific complaint numbers.
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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.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Briarfield At Ashley Circle | 0.7 mi | ★★★★★ | 6 | 0 |
| Briarfield Manor | 1.9 mi | ★★★★★ | 5 | 0 |
| Vista Center At The Ridge | 2.3 mi | ★★★★★ | 2 | 0 |
| Omni Manor Nursing Home | 3.6 mi | ★★★★★ | 1 | 0 |
| Austinwoods Rehab Health Care | 3.9 mi | ★★★★★ | 3 | 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.