Aventura at Humility House

In the surveyor’s words

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

• Actual harm, isolatedF686Apr 3, 2025

  Based on record review, interview, review of hospital paperwork, and review of facility polices, the facility failed to implement an adequate and effective pressure ulcer prevention program for Resident #168. This affected one Resident #168 of two residents reviewed for pressure ulcers. The facility census was 68. Actual Harm occurred on 02/03/25 when Resident #168 developed an in-house acquired Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.) to the right leg from an Ace wrap and immobilizer brace. Resident #168 was admitted to the facility from the hospital on 01/23/25 with an Ace wrap and a knee immobilizer brace on his right leg. […]

• No harm, potential for more than minimal, widespreadF803Aug 15, 2025

  Based on observation, record review, interview, review of the food committee meeting minutes and review of the facility policy, the facility failed to ensure dietary menus were followed. This affected one (Resident #13) of three reviewed for dietary concerns and had the potential to affect all residents receiving meals from the kitchen. The facility identified one (Resident #45) who did not consume anything by mouth. The facility census was 66. Findings include:Review of the medical record for Resident #13 revealed an admission date of 09/08/23 with diagnoses including diabetes, high cholesterol, arthritis and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. […]

• No harm, potential for more than minimal, patternF684May 29, 2026

  Based on open and closed medical record review and staff interview, the facility failed to ensure physician ordered daily weights for the monitoring of medical conditions were obtained. This affected three (#30, #55, and #85) of three residents reviewed for daily weights. The facility census was 64. Findings include:1. Review of Resident #30's medical record revealed an admission date of 08/01/25. Diagnoses included Alzheimer's disease, dementia, diabetes, edema, and congestive heart failure (CHF).Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was moderately cognitively impaired.Review of a physician order dated 03/02/26 revealed daily weights every night shift.Review of the documented weights in Resident #30's medical record for March 2026 revealed no… […]

• No harm, potential for more than minimal, patternF565Jan 22, 2026

  Based on review of Food Committee minutes and interviews, the facility failed to investigate, address, and implement corrective actions related to repeated food service complaints raised through the Food Committee. This affected 15 residents (#216, #222, #225, #226, #228, #231, #242, #243, #244, #246, #249, #252, #253, #258, and #260) of 15 residents reviewed for resident rights and had the potential to affect all residents receiving food from the kitchen. The facility census was 65. Findings include:Review of Food Committee Minutes meeting minutes dated November 2025 through January 2026 revealed multiple documented complaints related to food quality, temperature, and menu variety. […]

• No harm, potential for more than minimal, patternF847Apr 3, 2025

  Based on review of the facility arbitration agreement and interview, the facility failed to clearly state that residents or their representatives could consult with local, state, or federal officials before signing or within thirty days of signing the agreement. This affected Residents #3, #12, #14, #16, #21, #24, #26, #29, #32, #35, #38, #41, #43, #45, #49, #50, #52, #53, #58, #61, #62, and #119 who signed the arbitration agreement. The facility census was 68. Findings include: Review of the arbitration agreement, undated, revealed that disputes not to be arbitrated include any communications with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representatives of the Office of the… […]