Palm Garden of Aventura

In the surveyor’s words

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

• Immediate jeopardy, isolatedF578Nov 25, 2024

  Based on record review and interview, the facility failed to ensure a Residents Advance Directive was honored for one (Resident #1) out of three residents sampled with a Do Not Resuscitate (DNR) order as evidenced by staff initiated Cardiopulmonary Resuscitation (CPR) on Resident #1. The facility's actions caused Resident #1 to have likely suffered serious psychological harm by the facility's attempt to be resuscitated against her wishes. Resident #1 could not express her reaction to this event; therefore, the reasonable person concept was applied. Additionally, there was a likelihood that Resident #1 experienced severe physical pain; broken ribs; broken sternum and bleeding in the chest area from the resuscitation efforts. […]

• Actual harm, isolatedF692Oct 28, 2022

  Based on records reviewed, observations and interviews, the facility failed to ensure an accurate nutritional assessment to increase nutrition and to address identified significant weight loss in a timely manner for 5 of 7 residents reviewed for nutrition (Resident #83, Resident #69, Resident #46, and Resident #58). The facility failed to provide nutritional interventions in a timely manner that resulted in significant weight loss and failed to provide protein supplements to aid with a newly developed stage 3 pressure ulcer wound for Resident #41. The findings included: The facility's policy titled: Baseline Weights, revised in September 2018, showed the following: An accurate baseline weight will be obtained upon admission. […]

• No harm, potential for more than minimal, isolatedF695Jul 24, 2026

  Based on observations, records reviewed and interviews, the facility failed to ensure oxygen was delivered at the prescribed rate for two (Resident #1 and Resident #5) out of two residents receiving oxygen. Observation of the oxygen flowmeters indicated Resident #1 whose oxygen orders were discontinued was receiving oxygen at 3 Liters Per Minute (LPM) and Resident #5 oxygen was being administered above the prescribed level. The findings included: Resident #5Observation on 07/24/2026 at 9:08 AM, revealed Resident # 5 awake in bed, chewing on the nasal cannula connected to the oxygen concentrator. […]

• No harm, potential for more than minimal, isolatedF761Jul 24, 2026

  Based on observations, records reviewed and interviews, the facility failed to ensure medications and biologicals are stored and secured in accordance with professional standards for four out of four sampled residents as evidenced by medications were left unattended in residents' rooms, and various ointments, lotions, shampoos, and other items were observed at residents' bedside. This practice significantly increases the risk of misuse and potential harm, which could result in severe adverse outcomes. […]

• No harm, potential for more than minimal, isolatedF880Jul 15, 2025

  Based on observations, interviews and records review, the facility failed to implement infection prevention and control practices in accordance with the facility's policy related to Enhanced Barrier Precautions (EBP) for one (Resident # 2) out of two sampled residents, as evidenced by staff failure to wear required Personal Protective Equipment (PPE) during central line care. There were two residents residing in the facility receiving IV therapy at the time of the survey. The findings included:On 7/15/25 at 2:06 PM, a medication administration observation for Resident #2 was completed with Staff A, Registered Nurse (RN) in the presence of the Risk Manager; Staff A, RN verified the physician orders, gathered supplies, entered room and explained procedure to the resident and provided… […]