Aviata At Shoal Creek

Based on record reviews and interview, the facility failed follow the physician orders for lab services for 1 of 5 residents sampled for medication review. (Resident #6)The findings include:On 1/6/25. a record review was conducted for Resident #6, who has diagnoses including Dementia, Major Depressive Disorder, and Schizophrenia. A physician order dated 11/6/24 included obtaining a fasting Depakote Level every May and November. A review of lab results in the electronic medical record (EMR) revealed there was no documentation of a Depakote level since 6/6/2025. (Photographic evidence obtained)On 1/7/25 at approximately 9:40 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the lab was not completed, and a stat fasting Depakote level was ordered today.

Based on observation, policy review, and interviews, the facility failed to discard spoiled foods and failed to store food in a sanitary manner that is in accordance with professional standards to prevent foodborne illness.The findings include:On 01/04/26 at approximately 10:45AM, during the initial kitchen tour, there was an unopened zip lock bag observed in the walk-in cooler on a shelf dated 12/21/26 containing chicken patties. There were bananas stored in their original produce box sitting directly on the walk-in cooler floor that had brown to black discoloration on the banana peels. There were also 9 medium size tomatoes that appeared wrinkled and shriveled loose in a worn and wet cardboard produce box.On 01/04/26 at 10:40 AM, an interview was conducted with Staff A, a Kitchen Aide. She reported she was not aware that food is not to be stored directly onto walk-in cooler floor and was not sure how to store food properly in the walk in cooler or freezer. A record review on 01/04/2026 revealed a facility policy, dated 4/2018, that indicated that all food items must be stored at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment for 7 of 26 sampled resident rooms. (Rooms 701, 703, 705, 706, 707, 708, and 710) The findings include: A tour of the 700 hall was conducted with the Director of Nursing (DON) on 8/28/24 at 3:12 PM. The following items were observed: Resident #42's wheelchair frame was heavily soiled with dust. room [ROOM NUMBER] had 5 wash basins under the sink on the floor in the bathroom stacked on top of each other. The basins were not labeled or bagged. Resident #20's left wheelchair arm was in disrepair with exposed inner foam. room [ROOM NUMBER]B's overbed table border was missing and the table had rough edges. room [ROOM NUMBER]'s bathroom had 2 wash basins not bagged or labeled and stacked on top of each other on a shelf. room [ROOM NUMBER]'s bathroom had a bedpan sitting in a wash basin on the floor that was not labeled or bagged. room [ROOM NUMBER] had basins on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, review of the electronic medical record (EMR), and review of the facilities policies and procedures for individual activities, the facility failed to provide recreational activities designed to meet the interests of and support the physical, mental, and psychosocial well-being for one of one resident sampled for activities. (Resident #4) The findings include: Observations: On 08/26/24 at approximately 01:23 PM, Resident #4 was seen sitting in a wheelchair at the nurses' station not engaged with any activities and with her eyes closed. On 08/27/24 at approximately 10:41 AM, Resident #4 was seen lying in bed with eyes closed. The resident does not have a TV but a radio/CD player is observed on the nightstand, but it is not on. On 08/27/24 at approximately 04:01 PM, Resident #4 was observed lying in bed with eyes closed, but the music was not on. On 08/28/24 at approximately 08:38 AM, Resident #4 was observed sitting in a reclining broda chair at the nurses station. Both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview, and policy review, the facility failed to ensure the provider documented a resident specific rationale for declination of a pharmacist's request for a gradual dose reduction for a psychotropic medication for 1 of 5 sampled residents reviewed for unnecessary medications. (Resident #25) The findings include: A review of Resident #25's medical record revealed a Consultant Pharmacist Medication Regimen Review dated 7/10/24. The physician recommendation stated the resident had been receiving Paxil (an anti-depressant) 40 mg, 1 tablet by mouth one time a day, starting in January 2024. This review states, If an anti-depressant is used for sleep or to manage behavior, stabilize mood, or treat a psychiatric disorder, it must be reviewed for a possible gradual dose reduction in an effort to find the lowest effective dose. If a dose reduction is deemed clinically contraindicated at this time, please state the rationale below and the risk versus benefit of continuing the drug at the current dose. The physician's response stated to continue the medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #2 On 5/15/23, a record review was conducted for Resident #2. The resident, admitted on [DATE], had diagnoses of major depressive disorder, general anxiety disorder and vascular dementia. The PASARR dated 9/18/20, did not list these diagnosis. The facility did not correct the PASARR upon admission and had not updated the form at the time of this survey. On 5/17/23 at approximately 3:49 PM, an interview was conducted with the DON who stated she does the PASARR if the resident comes from home or a hospice. If they come from the hospitals, they usually come in with a PASARR already completed. The DON stated that they always review to make sure the PASARRs are appropriate and completed and signed. The DON stated she doesn't know who was in charge of it back in 2020, so she can't say who missed it or why it was missed and verbally agreed the PASARR was not accurate and was missing the relevant diagnoses. Based on staff interview and record review, the facility failed to accurately complete the Level I…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and policy review, the facility failed to provide 6 of 7 residents sampled with palatable meals and snacks that took resident preferences into consideration (Residents #49, #8, #63, #278, #26, and #34). The findings include: Resident #49: On 05/15/2023 at approximately 11:20 AM, an interview with conducted with Resident #49 who talked about concerns regarding poor food quality and preparation. Resident #49 stated, the milk has been served curdled, there aren't enough snacks for the residents, we have several diabetics without any juice on the hall, they don't keep the nutrition room stocked, if I ask one of the Certified Nursing Assistants (CNA) for it, they try to bring it if they have them, but they usually don't have any. The food is ill prepared, the meat is too tough to cut much less chew. Residents are receiving the wrong diets, one (identified Resident #46) even choked on her food because they gave her regular food instead of pureed,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record reviews of temperature logs, maintenance logs, and policy review, the facility failed to maintain 1 of 2 ice machines and 2 of 2 nourishment room refrigerators located on A and B wing, in a sanitary and safe operating condition. The unsanitary condition of the ice machine represented a potential source of pathogen exposure to all residents served ice. Inadequate temperature control of residents' food during refrigeration indicates an unsafe food storage practice that can promote bacterial growth thereby increasing the nursing home residents' risk of food borne illness. The findings include: On 05/15/2023 at approximately 10:50 AM, an observation of the kitchen ice machine with District Dietary Manager F (District DM F) revealed an external surface that was unclean with unknown dark colored residue build-up and calcification present. The storage bin on the interior of the ice machine had the same type of residue as on the exterior surface. This residue appeared to be from an external leak, and, based on the amount of build-up, appeared to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, clinical record reviews, and review of facility investigations, the facility failed to submit federal immediate reports for 2 of 2 residents sampled for abuse reporting (Residents #46 and #76). The facility failed to report an allegation of neglect for Resident #46 in May 2023, and an allegation of resident to resident abuse for Resident #76 in January 2023. The findings include: Resident #46: On 05/18/2023 at approximately 12:36 PM, an interview was conducted with the Director of Nursing (DON) who stated that, on 05/06/2023, Resident #46 was in the independent dining room eating lunch and talking and chewing at the same time, that is kind of her normal behavior. One of the bites she took she started talking and got a piece of food stuck. The nurse in the dining room responded and performed the Heimlich and was able to get the food dislodged. The DON further stated that, during their investigation of the event, they identified that the resident was served a hamburger patty. The DON confirmed that Resident #46's diet at the time of the incident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, resident interviews, staff interviews, and record reviews, the facility failed to provide appropriate wound care and treatment for 1 of 1 residents sampled for non-pressure related skin conditions. (Resident #34) The findings include: On 05/15/2023 at approximately 11:00 AM, an observation was made of a dressing to Resident #34's left forearm. The dressing was not dated, timed, or initialed. When the resident was asked what the dressing was for, she stated, this wound has been there for 5 days and has only been changed once, I bumped my arm on the wall. On 05/16/2023 at approximately 1:49 PM, a second observation was made of a dressing to Resident #34's left forearm with no date, time, or initials. The dressing appeared to be the same dressing noted on the prior observation and was stained and lifted on one side. The resident confirmed that it was the same dressing and it had not been changed. When asked if staff assessed the area or offered to change it, the resident stated, no. A review of resident #34's electronic medical record (EMR) revealed no current…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.