Aviata At University Hills

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to maintain resident call lights in 8 out of 67 rooms. (Rooms 101, 127, 151, 201, 204, 209, 231, and 252)The findings include: On 12/1/2025, a walkthrough of the building was performed with the Maintenance Director. Every resident's room was checked for functioning call lights in the beds and bathrooms. During the walkthrough, rooms 204A and B, 209A and B, 201A and B, 231A and B, 252A and B, 151A and B, 127A, and 101A and B were observed with nonfunctioning call lights.On 12/1/2025 at 10:30 am, Resident # 3 was interviewed. She stated she needs to have a bell at the bedside to make sure she can call the nurses but stated she cannot because the call light sometimes does not work.On 12/1/2025 at 10:40 am, Resident #1 was interviewed. She explained that, for a long time, her call light was not working, and the nurses gave her a bell to call for assistance. She stated the nursing aides appear irritated when she uses the bell and ask her why…

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 interview, and policy review, the facility failed to provide housekeeping and maintenance services neccessary to maintain a sanitary and orderly interior for 11 of 32 sampled rooms and 2 common areas observed. (Rooms 106, 110, 123, 129, 131, 208, 226, 227, 228, 232, 234, the unit one hallway, and the locked unit day room) The findings include: During a tour of the locked memory care unit with the Administrator and Employee B (Regional Maintenance Director) on 9/18/24 at 3:58 PM, the following was observed: room [ROOM NUMBER]B had blinds in disrepair. room [ROOM NUMBER] had a dark stain on the bathroom floor and an unlabeled wash basin on the back of the toilet. room [ROOM NUMBER] had two fire dampers bulging from the ceiling tile near the door. room [ROOM NUMBER] had one door that was missing from the armoire. room [ROOM NUMBER] had no curtains or blinds on the window and had a partially patched hole in the wall. The locked unit day room had a cove base missing from the wall near the…

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 upon interviews, observations, and record reviews the facility failed to implement the care plan to meet the nursing and physical needs to maintain the highest functional well-beingfor 1 of 22 residents reviewed for care plans. (Resident #95) The findings include: On 09/16/24 at approximately 01:30 PM Resident #95 was observed attempting to feed herself with her family present. Despite repeated attempts, she was unsuccessful using silverware and used her hands to feed herself, dropping much of the food in the process. On 09/17/24 at 12:36 PM, the resident was observed laying in bed with a bedside tray table positioned next to the bed with a lunch tray positioned on it with tray positioned at chin level. Resident #95 was observed having difficulty feeding herself. Resident #95's milk was not opened and Resident #95 was observed unsuccessfully attempting to open it. Resident #95 was observed with food debris down the front of her clothing and on her chin where she attempted to feed herself. On 09/18/24 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.

Based on observations, interviews, and review of the electronic medical records (EMR), the facility failed to provide necessary range of motion services for 1 of 4 residents sampled for range of motion. (Resident #68) The findings include: A review of Resident #68's medical record revealed an order dated 4/03/2024 stating Resident up to wheelchair every meal, every shift. Further review of the EMR revealed that staff had signed off on Resident #68 being up in her wheelchair for meals on 9/16/2024, 9/17/2024 (evening and night shift), 9/18/2024 and 9/19/2024 (day shift). However, on four separate observations on 09/16/24 at approximately 11:56 AM and 03:10 PM and on 09/17/2024 at approximately 08:35 AM and 03:59 PM, Resident #68 was observed to be in her bed. On 09/17/24 at approximately 12:45 PM, Resident #68 was observed semi-reclined in bed, leaning to the right side. The lunch tray was delivered by Staff Member P, a certified nursing assistant (CNA), who proceeded to reposition the resident and began to feed resident #68 her lunch. An interview was conducted with Staff Member P,…

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, record review, and the facilities' policy and procedures, the facility failed to maintain ongoing communication and collaboration with the dialysis center regarding dialysis care and services for 1 of 1 residents reviewed for dialysis care. (Resident #43) The findings include: A review of Resident #43's dialysis communication binder on 9/19/2024 revealed the last dialysis communication form was completed on 8/9/2024, even though Resident #43 had been receiving dialysis care from an outside facility every Monday, Wednesday, and Friday. On 09/18/24 at approximately 11:47 AM, the director of nursing (DON) indicated the residents have their own dialysis binders that are used to communicate with the dialysis center which should be kept at the nurses' station. The unit managers check the dialysis binders weekly to ensure the dialysis communication sheets are being completed. A concurrent interview with Staff C, unit manager, confirmed she did not follow up on these. On 09/18/24 at approximately 02:23 PM, during a follow-up interview with the DON, she stated that…

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 upon record review and interviews, the facility failed to provide scheduled medications for 1 of 20 residents reviewed for medication administration. (Resident #43) The findings include: A review of the medication administration record (MAR) for September 2024 revealed Resident #43 has not been receiving the following medications at 9:00 AM and 1:00 PM on Mondays, Wednesdays, and Fridays, as he is out of the facility at dialysis during those times, resulting in multiple missed doses: 1. Prostat (a protein supplement to aide in wound healing) 2. Vit D-Cholecalciferol Oral Capsule 50 MCG (2000 UT) Give 1 capsule by mouth one time a day for supplement 3. Ciclopirox External Solution 8 % (Ciclopirox) Apply to fingernails topically one time a day (to treat fungal infection of the nail bed) 4. Clopidogrel Bisulfate Oral Tablet 75 MG (Clopidogrel Bisulfate) Give 1 tablet by mouth one time a day (an antiplatelet drug to prevent blood clots) 5. Clotrimazole Mouth/Throat Troche 10 MG (Clotrimazole) Give 1 lozenge by…

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, staff interviews, review of the electronic medical record (EMR), and review of the facility policies and procedures, the facility failed to provide safe and secure storage of medications for 1 of 1 residents. (Resident #108) The findings include: On 9/16/24 at approximately 11:45 am, Resident #108 was observed with a Spiriva inhaler (a medication used to prevent wheezing and shortness of breath) positioned at bed side. Resident #108 indicated that the inhaler at bedside was empty; however, another inhaler was visibly stored in a nearby open drawer. On 9/17/24 at approximately 10:00 am, during an interview with Resident #108, he stated the Spiriva inhaler still remains in his drawer. A follow up observation at 2:35 pm verified the Spiriva inhaler was still in an open nightstand drawer. On 9/18/24 at approximately 11:30 am, during an interview with Staff C, a licensed practical nurse (LPN), she stated that the inhaler should not be there. LPN C indicated that she was unaware the Spiriva inhaler was in the resident's possession. On 9/18/24 at approximately 12:00…

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 interviews, the facility failed to ensure the Resident Call lights were functional to allow residents to call for staff assistance for 1 of 32 rooms observed. (rooms [ROOM NUMBERS]) The findings include: room [ROOM NUMBER]: An observation of room [ROOM NUMBER] was conducted on 9/16/24 at 1:31 PM. The resident call system in the bathroom was not functional. A follow up observation of room [ROOM NUMBER] was conducted on 9/18/24 at 8:41 AM and the call system in the bathroom was still not functional. Employee L (Certified Nursing Assistant) confirmed the call system was not functioning. She stated the resident occupying the room toileted independently. Review of the facility policy for Communication Systems, Maintenance Inspection Testing and Safety (effective 11/30/14) revealed, .communication systems and components will be properly maintained to function reliably and ensure operator safety. In the event of systems or component failure the system operators will notify maintenance…

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 interview and record review, the facility failed to obtain a Level II screening for 3 of 6 residents reviewed for Preadmission Screening and Resident Review (PASARR). (Residents #25, #37, and #96) The findings include: Resident #96 A review of the PASARR form for Resident #96 (admitted on [DATE]) noted an identified diagnosis of Anxiety Disorder and a diagnosis of dementia. Per the PASARR form, the combination of a Serious Mental Disorder (SMI) diagnosis and Dementia or neurocognitive disorder would trigger the requirement for a Level II review. A review of the admission Diagnosis in the medical record noted a diagnosis of Major Depressive Disorder and Unspecified Dementia, Unspecified Severity with Psychotic Disturbance. A review of the Care Plan for Resident #96 noted that the resident was care planned for antipsychotic therapy for diagnosis of dementia with psychotic features, auditory and visual hallucinations, and antidepressant usage. A review of the physician's progress note dated 6/13/2023 noted…

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, record reviews, and interviews, the facility failed to implement the care plan for behavior monitoring for psychotropic medications for 1 of 5 residents sampled for unnecessary medication review. (Resident #86) The findings include: A record review was conducted of Resident #86's medical record, which revealed an order for Clonazepam 0.5mg (a medication used to treat anxiety). Further review of the medical record revealed a care plan dated 4/23/23 for monitoring of behavioral symptoms and side effects related to anti-anxiety medication. Review of the Medication Administration Record (MAR) revealed no monitoring for behaviors. On 6/13/23 at approximately 3:26 PM, an interview was conducted with Nurse D, a Registered Nurse (RN), concerning behavior monitoring for resident #86. Nurse D stated that the behavior monitoring is normally located on the MAR, but confirmed there was no behavior monitoring for Resident #86. On 6/13/23 at approximately 3:28 PM, an interview was conducted with the Director of Nursing (DON) concerning behavior monitoring for residents 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.

Based on observations, record reviews, and interviews, the facility failed to provide dietary services to meet the needs for 1 of 1 resident selected for food services. (Resident #22) The findings include: On 6/12/23 at approximately 8:30 AM, an observation was conducted of Resident #22's breakfast tray, which revealed one slice of French toast, 2 slices of bacon, a bowl of grits, 4 oz of apple juice, and a carton of milk. However, the accompanying dietary slip revealed the resident's diet to be regular, no added salt, with large portions. A further review of the dietary slip indicated the resident should have received 3 slices of French toast, 2 sausage patties, 6 oz of hot cereal, 4 oz of orange juice, and 8 oz of milk. On 6/14/23 at approximately 12:47 PM, an observation was made of Resident #22's lunch tray which revealed a ham sandwich, 1 scoop of potato salad, 1 plate of lettuce and tomato, and a glass of tea. A review of Resident #22's dietary slip indicated the resident should have received 1.5 ham sandwiches, 2/3 cup of potato salad, lettuce and tomato plate, and 1.5 cups…

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.