Aventura at Prospect

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 2, 2024

  Based on review of clinical records, interview with resident and staff, and review of facility policies, it was determined that the facility failed to adequately supervise one of six residents reviewed (Resident R2), who was able to board a bus and train and elope from the facility. This failure placed Resident R2 at high risk for injury and resulted in an Immediate Jeopardy situation. (Resident R2) Findings include: Review of the facility's policy title Elopement/ Missing Resident revealed that it is goal of the facility to provide a safe environment and to identify residents who are at risk for elopement. It strives to prevent harm while maintaining the least restrictive environment for residents. […]

• Immediate jeopardy, isolatedF660Mar 9, 2024

  Based on clinical record reviews, interviews with staff, review of hospital records and review of policy and procedure, it was determined that the facility failed to properly discharge Resident Cl1 who was assessed by the facility as requiring guidance for safety awareness and problems with short term memory for one of three closed records reviewed. (Resident Cl1) This failure resulted in an Immediate Jeopardy situation for Resident Cl1 whose safety device was removed by facility staff allowing the resident to exit the building, discharging the resident against medical advice to an unknown location and without returning resident's identification documents. Further the facility failed to notify the required State authorities and resident's family of the resident's discharge. […]

• Immediate jeopardy, isolatedF689Nov 9, 2022

  Based on clinical record review, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that the resident environment remained free of accident hazards by failing to monitor the temperature of hot water beverages served to residents. This failure resulted in Immediate Jeopardy situation to Resident R1 who spilled a hot water beverage on his leg and developed a second degree thermal burn, for one of six residents reviewed. (Resident R1) Findings include: Review of Resident R1's quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 4, 2022, revealed that the resident was admitted to the facility February 19, 2021, and had diagnoses including paraplegia and immunodeficiency disease. […]

• Actual harm, isolatedF689May 8, 2025

  Based on observations, review of facility documentation and clinical records, and staff and resident interviews, it was determined the facility failed to ensure that one of four residents reviewed (Resident R51) was adequately secured during transportation in the facility's van. This failure resulted in actual harm to Resident R51 who sustained a fracture of the right knee after sliding out of the wheelchair on the way to an appointment. (Resident R51) Findings Include: Review of Resident R51's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 5, 2025, revealed the resident had diagnoses of muscle weakness, lack of coordination, Aphasia (communication disorder), Cerebrovascular Accident (CVA - stoke; loss of blood flow to part of… […]

• No harm, potential for more than minimal, widespreadF812May 8, 2025

  Based on review of facility policy, observations, and interviews with staff and residents, it was determined that the facility did not ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. Findings Include: Review of facility policy Dishwashing Machine Use revised March 2010 revealed dishwashing machine chemical sanitizer for use of chlorine solution, the minimum concentration should be 50-100 ppm (parts-per-million) for a contact time of 10 seconds. A tour of the main kitchen conducted on May 5, 2025, 9:30 a.m. […]