The resident, identified as Resident #213 in the August inspection report, experienced multiple falls between May and July. After a May 25 fall that caused a right wrist skin tear, abrasion to the right elbow and forearm, bruising to the left upper back, and pain to the right side, staff implemented a care plan intervention on May 26 that was identical to interventions from May 14, 2024, and December 24, 2024.
No new intervention was created.
The pattern continued through the summer. On May 27, inspectors found no injury noted but discovered no new care plan intervention had been added and no documentation showing the care plan had been reviewed. When the resident was sent to the emergency room on June 28, staff implemented a care plan intervention on June 30 "to offer and assist to bed after family visit." After another incident on July 1, again no new intervention was added and no care plan review was documented.
Staff GG, a Licensed Practical Nurse and Minimum Data Set Coordinator, told inspectors during an August 28 interview that she was responsible for ensuring assessments were complete and assisting with care plan coordination. As a new employee, Staff GG said she believed the floor nurse would initiate an intervention after a fall, and the Interdisciplinary Team would review the incident the following work day to ensure care plan updates were completed accurately.
"Although, I am not sure of how exactly care plans are updated in between assessments," Staff GG said, referring inspectors to the Assistant Director of Nursing.
The Assistant Director of Nursing stated during her interview that the Interdisciplinary Team discussed incidents during morning clinical meetings and ensured interventions were added. But she said the entire care plan was not reviewed.
The facility's Risk Manager provided more detail about the process during her interview. She said the Interdisciplinary Team met the morning after an incident occurred, reviewed it, and updated the care plan "to reflect the current situation." She explained that residents who had fallen were added to the facility's weekly Standard of Care meeting for review and continued follow-up for four weeks, when the care plan should be reviewed to ensure interventions were appropriate.
But when the Risk Manager reviewed Resident #213's care plan and fall history, she verified that interventions were not added to the resident's fall care plan after each fall. Several of the interventions that were added were duplicates of prior interventions.
The Risk Manager confirmed this could mean no new intervention was actually added.
The facility's policy on care plans, which was undated, states that care plans must be "reviewed no less than once every 3 months" and "reviewed promptly after a significant change." The policy defines significant change as needing "to stop a form of treatment because of adverse consequences" or "commence a new form of treatment to deal with a problem in the resident's physical or mental condition."
The policy requires care plans to be "revised as appropriate to assure the continued accuracy of the assessment" and states they must "describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and social wellbeing."
Federal inspectors found the facility failed to follow its own policy. Despite multiple falls resulting in documented injuries, staff repeatedly used identical interventions from months earlier instead of analyzing why the resident continued falling and developing new prevention strategies.
The inspection, conducted in response to a complaint, found the facility's approach put residents at risk for continued falls and injuries. When care plans are not updated after incidents, facilities miss opportunities to identify underlying causes and implement targeted interventions that could prevent future harm.
For Resident #213, the cycle of falls continued through the summer months, with each incident followed by the same inadequate response from staff who appeared more focused on checking procedural boxes than addressing the resident's actual fall risk factors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aventura At the Bay from 2025-08-28 including all violations, facility responses, and corrective action plans.