Aventura at Assumption Village

In the surveyor’s words

From the most serious findings on record at Aventura at Assumption Village, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684May 20, 2026

  Based on closed record review, review of emergency medical services (EMS) records, review of hospital documentation, facility policy review and interview, the facility failed to recognize and respond timely and appropriately to an acute significant change in condition for Resident #108 to ensure prompt and necessary medical intervention was provided. This resulted in Immediate Jeopardy and Actual Harm with subsequent death beginning on 03/09/26 at 1:38 A.M. when Resident #108 was documented to have respiratory distress and abdominal pain. The resident's oxygen saturation was 84% (with oxygen increased to 6 liters per minute (L) nasal cannula). However, record review revealed no evidence of monitoring or comprehensive re-assessment of the resident until 6:14 A.M. […]

• Actual harm, isolatedF686May 20, 2026

  Based on observation, review of medical records, interviews with staff, review of hospital records, review of the National Pressure Injury Advisory Panel (NPIAP) and review of the facility policy, facility failed to provide the necessary care and services to prevent the development, worsening, and to promote the healing of a facility acquired pressure ulcer for Resident #14. This affected one resident (#14) of three residents reviewed for pressure ulcers. The facility census was 107.Actual harm occurred on 12/23/25, when documentation first identified that the wound had progressed from Stage II to Stage III, with deeper tissue involvement and worsening characteristics because the facility failed to ensure consistent wound assessments, adherence to physician ordered treatments, proper… […]

• Actual harm, isolatedF689Sep 5, 2023

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of an incident investigation, and interview, the facility failed to ensure Resident #100 received adequate and proper assistance during a transfer to prevent an injury. Actual harm occurred to Resident #100 on 07/11/23 when State tested Nursing Assistant (STNA) #185 transferred the resident without the assistance of a second staff person and mechanical lift (as required/ordered) resulting in pain and fractures to the resident's tibia and fibula. This affected one resident (#100) of four residents reviewed for quality of care. […]

• Actual harm, isolatedF686Sep 26, 2022

  Based on observation, record review, facility policy and procedure review and interview the facility failed to implement an effective pressure ulcer prevention program to prevent the development of an unstageable pressure ulcer to Resident #101's buttock/coccyx area. Actual Harm occurred on 09/13/22 when Resident #101, who was severely cognitively impaired, at risk for skin breakdown and required staff assistance for bed mobility, transfers and hygiene was assessed to have an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the buttocks/coccyx. […]

• No harm, potential for more than minimal, widespreadF565May 20, 2026

  Based on review of resident council minutes, and staff and resident interviews, the facility failed to ensure concerns raised by the resident council were thoroughly documented, effectively addressed, and resolved. The facility also failed to ensure consistent follow up for repeated concerns voiced across multiple council meetings from 05/02/25 through 04/03/26. This had the potential to affect all 107 residents residing in the facility.Findings include:Review of the monthly resident council minutes from 05/02/25 through 04/03/26 revealed the following concerns:-05/02/25 residents expressed dietary concerns (nothing specific was documented). […]