Aventura at Oakwood Village

In the surveyor’s words

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

• Actual harm, isolatedF689May 20, 2025

  3. Review of medical record for Resident #32 revealed admission date of 11/12/24 with vascular dementia, chronic obstructive pulmonary disease, hypertension, diabetes mellitus. Review of the quarterly MDS dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. MDS revealed Resident #32 was dependent on staff for toileting, showering, dressing, and personal hygiene. Review of the care plan dated 11/13/24, revised 02/25/25, revealed Resident #32 had a potential for falls related to impaired cognition and weakness, interventions included evaluate medication regimen, fall risk assessment per protocol, hospice to supply Bariatric shower chair, keep environment clutter free, keep room well lighted, nonskid footwear at all… […]

• No harm, potential for more than minimal, widespreadF803Mar 13, 2026

  Based on record review, resident interview, staff interview, observation, and review of the facility policy, the facility failed to provide foods planned by the Registered Dietitian (RD) as listed on the dietary spreadsheet. This affected all of the residents in the facility who received food from the facility kitchen. The facility census was 109 residents. Findings Include: Review of the menu spreadsheets dated 02/28/26, 03/01/26 and 03/02/26 revealed residents on all types of diets should have received two ounces of scrambled eggs at breakfast. Residents on cardiac diets should receive an egg substitution product and no bacon. There was no notation on the spreadsheets of any food substitutions. Review of Temperature Guide dated 02/28/26 revealed no notation of any food substitutions. […]

• No harm, potential for more than minimal, widespreadF880May 20, 2025

  Based on observation, staff review, and policy review, the facility failed to ensure an implement their water management policy to prevent the presence of microorganisms in their water system including legionella. This had the potential to affect all 104 residents residing in the facility. Additionally, the facility failed to ensure staff handled food in an appropriate manner while assisting a resident with a meal. This affected one (#25) out of three residents reviewed for infection control. The facility census was 104. Findings include: Review of the facility's Chlorine Check off Sheet for TCU (transitional care unit) for 01/12/24 through 04/17/25 revealed water flow rate had not been tested since 10/31/24 and hot water temperatures ranged 106-117 degrees Fahrenheit. […]

• No harm, potential for more than minimal, widespreadF812Jul 27, 2023

  Based on observation, staff interview and policy review, the facility failed to ensure safe and sanitary storage of food and to ensure trash cans were covered when in the kitchen. This had the potential to affect all residents, excluding Resident #24 who does not eat food from the kitchen. Facility census was 105. Findings include: Observation on 07/24/23 from 9:37 A.M. to 10:18 A.M. revealed the following findings in the kitchen area. In the refrigerated areas there were the following items uncovered or not dated: over 10 pudding cups undated; two premade salads uncovered; two premade salads undated; over 10 cups of potato salad; six fruit parfait uncovered; over 20 cups of Jello uncovered; over 15 cups of mixed fruit uncovered; a block of cheese slices was uncovered and undated; a… […]

• No harm, potential for more than minimal, widespreadF880Jul 15, 2021

  Based on facility record review, staff interview, review of the facility's policy, review of the online resources from the Centers for Disease Control and Prevention (CDC), and memorandums from the centers for Medicare and Medicaid services (CMS), the facility failed to implement a water treatment program that followed the American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRA) industry standards and the CDC toolkit for prevention of Legionella. This had the potential to affect all 80 resident who resided in the facility. Findings included: During the facilities infection control log books and programs on 07/15/21 at 2:00 P.M. revealed the facility failed to implement an appropriate water treatment program to monitor and prevent the spread of Legionnaires Disease. […]