Aviata at University Hills

In the surveyor’s words

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

• Immediate jeopardy, isolatedF656Apr 6, 2023

  Based on observation, interviews, clinical record review and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 7 residents reviewed for elopement risk. (Resident #1) On 3/2/23, an elopement risk evaluation form identified Resident #1, a cognitively impaired vulnerable resident, as at risk for elopement, however, no care plan for elopement risk was initiated. Resident #1 subsequently eloped from the facility on 3/11/23 unbeknownst to staff, placing the resident at risk for serious injury, harm, or death. The situation resulted in a finding of Immediate Jeopardy at a scope and severity of J, isolated. The facility's Administrator and the Director of Nursing were notified of the findings of Immediate Jeopardy on 4/5/23 at 4:35 PM. […]

• Immediate jeopardy, isolatedF689Apr 6, 2023

  Based on observation, staff interviews, resident interview, responsible party interview, clinical record review and policy review, the facility failed to provide adequate supervision of a vulnerable resident and identify the resident as an elopement risk due to exit seeking and wandering behaviors for 1 of 7 residents sampled for accidents and supervision. (Resident #1) On 3/11/23, Resident #1, a cognitively impaired vulnerable resident, was able to exit the facility unbeknownst to staff. A facility staff member responded to a door alarm, looked out the window instead of exiting the facility and checking the surrounding grounds, shut the alarm off when no residents were observed, and returned to work. […]

• Immediate jeopardy, isolatedF867Apr 6, 2023

  Based on staff interviews, clinical record review, review of the quality assurance performance improvement plan, and policy review, the facility failed to implement their corrective action plan for monitoring of new admissions and re-admissions for elopement risk assessments for 6 of 20 residents reviewed. (Residents #6, 9, 12, 14, 19, and 20). On 3/11/23, Resident #1, a cognitively impaired vulnerable resident, was able to exit the facility unbeknownst to staff. The facility developed an implemented an immediate corrective action plan which included reviewing 100% of new admissions to ensure a complete and accurate elopement assessment and interventions initiated as indicated. […]

• Actual harm, isolatedF760Dec 22, 2022

  Based on interviews and record reviews the facility failed to ensure residents were free from significant medication errors for 2 of 3 residents sampled (resident #1 and # 2). Resident #1's blood sugar was not monitored per order which resulted in the resident becoming unresponsive and being transferred to the hospital with a blood sugar of 1711. Resident #2's INR (international normalized ratio) was not monitored daily as ordered which resulted in his blood clotting factor being below therapeutic range of 2-3. The findings include: Resident #1 On 12/21/22 a record review was conducted of resident # 1, which revealed that resident #1 had a history of being a brittle (severe) diabetic. […]

• Actual harm, isolatedF656Jan 14, 2021

  Based on observation, record reviews, and interviews the facility failed to implement the plan of care for 1 of 4 residents (#24) sampled for nutrition and for 1 of 1 resident sampled for skin condition other than pressure injuries (#77). The findings include: Resident #24 A record review was conducted for resident #24 which revealed a care plan, dated 8/27/20, for Nutritional problem or potential problem related to moderate protein calorie malnutrition with the goal Resident to comply with recommended diet daily and the interventions included RD (Registered Dietician) will evaluate and make diet changes to recommendations as needed and to provide and serve diet as ordered. A review of the physician orders [REDACTED]. […]