Regents Park At Aventura

F-F550 and staff standing over residents during dining in the last survey. This was resolved, and they do not have any QAPI regarding dignity during dining. She further stated that all department heads were responsible for monitoring dignity during dining and reporting to her. The Administrator reported that

she has identified medication at the bedside and that residents are ordering medications online. She has been doing her own monitoring and rounds with other staff members but was not able to provide this Surveyor with the QAPI paperwork regarding tracking and trending on any medications at the bedside or medication rooms not locked.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 27 105596 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105596 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Regents Park at Aventura 18905 NE 25th Ave Aventura, FL 33180

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41837 potential for actual harm Based on observations, interview and record review the facility failed to follow facility policy for 2 out of 31 Residents Affected - Few residents on Enhanced Barrier Precautions (EBP) Residents #177 and #69 as evidenced by no isolation gowns at the residents' doors and failed to ensure that food trash/soiled residents food trays are covered

during transportation.

The findings included:

Review of the facility's policy titled, Enhanced Barrier Precautions with a revised date of 04/01/24 included in part: EBP is intended for nursing homes to prevent the spread of novel or targeted Multi-Drug Resistant Organism (MDRO)s when resident have an infection or colonization with a MDRO or if the resident has a wound or indwelling medical device, regardless of MDRO infection or colonization.

Review of the Center for Disease Control (CDC) guidelines documented, in part, that for residents on EBPs that PPE (gowns and gloves) are to be located at the residents' doors. The CDC website is CDC_Implementation_Of_Personal_Protective_Equipment_(PPE _Use_In_Nursing_Homes_To_Prevent_Spread_Of_Multidrug-resistant_Organisms_(MDROs).

1) On 07/29/24 at 12:15 PM an observation was made of Resident #177 lying in bed, resident has EBP sign

on door and above her bed, there were no isolation gowns in the room.

On 07/29/24 at 3:50 PM a second observation was made of Resident # 177 lying in bed awake, resident has EBP sign on door and above her bed, there were no isolation gowns in the room.

During an interview conducted on 07/29/24 at 3:55 PM with Staff M Registered Nurse/Unit Manager (RN/UM)

in Resident #177's room, she acknowledged the resident was on EBP for a wound, when asked where the PPE is kept, specifically the gowns, she said they are right next to the inside of the door to the room and as

she pointed the area next to the door, she said they must have run out. When asked where additional isolation gowns are kept, she said they are at the nursing station. When asked to show surveyor the extra isolation gowns at the nursing station, she leads the surveyor to the nursing station at the other end of the hallway where they were out of gowns and handed the surveyor off to Staff H Registered Nurse (RN) who proceeded down another hallway almost to the very end across from room [] to an unlocked storage room with the extra isolation gowns. Staff H RN said the room is normally locked.

2) On 07/29/24 at 11:50 AM an observation was made of Resident #69 lying in bed with tube feeding bottle full and not infusing, the resident has EBP sign on door and above her bed, there was no isolation gowns in

the room.

3) On 07/30/24 at 9:55 AM an observation was made of an uncovered meal tray cart containing 10 dirty trays being pushed through the hallway on the 3rd floor by Staff I Dietary Aide.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 27 105596 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105596 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Regents Park at Aventura 18905 NE 25th Ave Aventura, FL 33180

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview conducted on 07/30/24 at 10:00 AM with Staff I Dietary Aide who reported she has worked at the facility for [AGE] years. When asked if she normally pushes a meal tray with dirty trays Level of Harm - Minimal harm or uncovered down the hall, she said no, but someone must have thrown the cover away. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 105596

F-F761 under Pharmacy Services, F 812 under Food and Nutrition Services, and

F-F812, the Administrator said that they had identified the condensation issue in the central kitchen but had yet to have a chance to start a QAPI. She discussed sanitation concerns and staff education completed by the kitchen manager but could not provide this Surveyor with any tracking and trending QAPI.

Continuing the interview on 08/01/24 at 10:00 AM with the facility's Administrator, she stated that they had issues regarding

F-F867 under Quality Assurance Performance Improvement.

During the QAPI review conducted with the Administrator on 08/01/24 at 9:20 AM, she stated that they meet monthly and review past deficiencies from prior surveys. They will start a QAPI and will reevaluate after the first three months. If a QAPI is not meeting its set goal, it will investigate the root cause analysis and change

the action plans until it meets the goal rate, usually at 100%. When asked about the repeated deficiency of