Aviata at Shoal Creek

In the surveyor’s words

From the most serious findings on record at Aviata at Shoal Creek, in the surveyor’s own words.

• Immediate jeopardy, isolatedF802May 19, 2023

  Based on observations, interviews, record review, diet manual review and facility policy review, the facility failed to ensure sufficient food and nutrition services support staff that had the appropriate competencies and skill sets to accurately prepare, plate and serve modified consistency diets for 2 of 5 residents sampled for mechanically altered diets (Resident #46 and Resident #278). This failure resulted on a choking incident on 05/06/2023 for Resident #46 when she was served an intact meat patty instead of the ground or pureed meat that she was ordered to receive. On Sunday 05/14/2023, the facility contracted Dietary Manager (Dining Services Director) was removed from the position and the rest of the food and nutrition services staff resigned at the same time. […]

• Immediate jeopardy, isolatedF803May 19, 2023

  Based on observations, staff interviews, clinical record review, menu review, diet manual review, and policy review, the facility food and nutrition services staff failed to follow the Dysphagia (difficulty swallowing) Advanced Texture and Dysphagia Mechanically Altered diets for 2 of 5 residents sampled for mechanically altered diets (Resident #46 and Resident #278). On 05/06/2023 Resident #46 was served the incorrect diet texture during the lunch meal which resulted in the resident choking on a meat patty necessitating the immediate medical intervention of abdominal thrusts by a Registered Nurse (RN) to clear the meat from the resident's airway. […]

• Immediate jeopardy, isolatedF805May 19, 2023

  Based on meal observation, staff interview, resident interview, clinical record review, review of the diet manual, and policy review, the facility failed to prepare and serve food designed to meet individual needs for 2 of 2 residents sampled who required mechanically altered diets (Residents #46 and #278). Resident #46 had diet orders for ground meat due to dysphagia (difficulty swallowing). On 05/06/2023, Resident #46 was served a whole hamburger patty and had a subsequent choking event requiring abdominal thrusts to remove airway blockage. Resident #46 had diet orders for a Dysphagia Advanced diet which required all meats to be mechanically altered by chopping or grinding methods. On the evening of 05/17/2023, Resident #278 was served a sandwich with whole slices of bread for dinner. […]

• Immediate jeopardy, isolatedF867May 19, 2023

  Based on observations, staff interviews, clinical record review, review of the quality assurance performance plan, and policy review, the facility failed to implement their corrective action plan for educating staff on ensuring the residents were served the correct diets as ordered for 2 of 5 residents selected for modified texture diets. (Resident #46 and #278). On 05/6/2023, Resident #46 was served the incorrect diet texture during the lunch meal that resulted in the resident choking on a meat patty, necessitating the Heimlich Maneuver (abdominal thrusts) by Registered Nurse (RN) D in order to clear the meat from the resident's airway. […]

• No harm, potential for more than minimal, widespreadF585Jun 1, 2022

  Based on observation, interviews and record review, the facility failed to ensure prompt effective efforts to ensure resolution and monitoring of grievances related to food and dietary services. This has the potential to affect all 105 residents who receive dietary services in the form of cooked meals provided by the facility. The findings include: On 5/31/22 at approximately 11:50 AM, an interview was conducted with Resident #1 who stated the facility changed the menu recently. She was unable to recall the date, but reported the food had gotten worse since the change. Resident #1 stated she filed grievances, but nothing changed, and the food continues to become worse and worse. […]