Aventura at the Bay

Inspectors wroteBased on observation, record review, and interviews, the facility failed to 1) follow wound care orders for one resident (#5), and 2) conduct accurate skin assessments to identify skin integrity concerns for one resident (#11), out of three residents reviewed for wounds. These failures resulted in discomfort for Resident #5 and worsening of the wound and a failure to identify a sacral pressure injury in Resident #11.

Inspectors wroteBased on record review and interviews, the facility failed to provide adequate supervision and implement effective interventions to prevent falls for one (#11) out of three sampled residents. This resulted in Resident #11 experiencing eight unwitnessed falls and one witnessed fall over a 30 day period, and transfer to a higher level of care on two separate occasions.

Inspectors wroteBased on observation, record review, interviews, and photographic evidence, the facility failed to ensure sufficient nursing staff with appropriate competencies and skill sets to provide nursing services needed to meet Activity of Daily Living (ADL) needs for six (#4, 5, 7, 9, 16, 17, 18) of twenty one sampled residents. Applying a reasonable person's concept, the lack of sufficient nursing staff with appropriate competencies and skill sets to provide nursing services necessary to meet ADL needs, in order to attain or maintain physical, mental, and psychosocial well being, of Residents #4, 7, 9, 16, 17, and 18 experienced harm. Cross reference:

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment on one (200 hall - secured unit) of four units.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one (Resident #17) of three sampled residents from neglect and failed to ensure a safe, clean, and supervised environment. The facility failed to provide adequate supervision to prevent Resident #16, a male resident with severe cognitive impairment, from entering Resident #17's room; failed to maintain Resident #17's room in a sanitary condition as evidenced by a mattress with dried fecal material; failed to ensure Resident #17 received necessary bathing and hygiene services as evidenced by caked, dried fecal material on both feet; and failed to ensure Resident #17 received meaningful activities or room based engagement. These failures resulted in Resident #17 being exposed to an unsafe, unsanitary environment and placed her at risk for psychosocial harm and neglect.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to develop and implement person centered care plan interventions for three of three sampled residents (Residents #9, #16, and #17). Specifically: For Residents #9 and #16, the facility failed to develop care plan interventions for identified wandering behaviors, including entering other residents' rooms. For Resident #9, the facility failed to develop care plan interventions for defecation behaviors in other residents' rooms, failed to complete and document accurate skin assessments, failed to notify the physician of a new wound and obtain treatment orders, and failed to implement activities of daily living (ADL) care related to dressing, including ensuring shoes were worn correctly. For Resident #17, the facility failed to implement care and services related to bathing, hygiene, and skin assessments; [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the grievance process was followed for one (#5) out of 11 residents reviewed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure an allegation of resident to resident physical abuse was reported within 24 hours for two (#8 and #9) out of three sampled residents. This failure resulted in delayed notification to facility leadership and created the potential for unidentified injury and inadequate protection of the residents involved.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide proper catheter care for two (Resident #4 and Resident #20) out of three residents reviewed.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure: 1) resident food and beverage items were labeled and dated in two (100 and 300 wings) out of four nourishment rooms, 2) refrigerator and freezer temperatures were documented on two (100 and 400 wings) out of four nourishment rooms, 3) equipment in the kitchen and one (100 wing) out of four nourishment rooms were functioning appropriately, and 4) hand hygiene/infection control practices were followed in the kitchen.

Inspectors wroteBased on observations, interviews and record review, the facility failed to protect residents from the risk of accidents and hazards related to:1. Ensuring resident rooms were free from accident hazards, to include sharp objects and chemicals in one unit (memory/dementia) of four units toured, 2. Addressing smoking hazards for two residents (#138, and #68) of two residents sampled for smoking, and 3. Failed to eliminate potential hot liquid hazards related to coffee temperatures in four nourishment rooms (100, 200, 300 and 400) of four units observed.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure the medication error rate was below 5% for one resident (#31) out of six residents sampled for medication administration. This resulted in 8 errors out of 25 medication administration opportunities for a medication error rate of 32%.

Inspectors wroteBased on interviews and record review, the facility failed to ensure voiced concerns from resident council meetings were documented as a grievance and acted upon during three meetings held on (12/10/2025, 1/16/2026, and 2/6/2026) out of seven resident council meeting minutes reviewed.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate related to diagnosis for three residents (#134, #211 and #226) of three residents reviewed for MDS assessments. Findings Included: 1. A review of Resident #134's admission record showed an original admission date of 3/1/2024 with a readmission date of 4/19/2024 with diagnoses to include but not limited to bipolar disorder, major depressive disorder, and anxiety disorder. A review of Resident #134's behavioral health progress note dated 11/6/2025 showed a diagnosis of Post Traumatic Stress Disorder (PTSD). A review of Resident #134's annual Minimum Data Set (MDS), dated [DATE], Section I, revealed PTSD was not marked. Review of Resident #134's care plan initiated, 3/20/2024 showed the following focus: [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure an accurate Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability review (PASARR) was completed for five residents (#2, #112, #9, #211, and #226) of six residents reviewed for PASARR.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the resident had assistive devices to maintain hearing abilities for one resident (#3) of two residents reviewed for communication and sensory problems.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to obtain physician orders for the percent of humidity to provide supplemental oxygen by tracheostomy according to professional standards of practice for one (#5) of two residents reviewed for respiratory care. Findings Included:On 03/02/2026 at 7:48 a.m. observed Resident #5's oxygen set to 3 L (Liters). Review of Resident #5's face sheet showed admission on [DATE] and readmission [DATE] with diagnoses to include acidosis, disorders of diaphragm, acute and chronic respiratory failure with hypoxia, pneumonitis and chronic respiratory failure. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to take a trauma-informed approach to deliver care that involves understanding, recognizing and responding to the effects of a specific trauma Post Traumatic Stress Disorder (PTSD) for one resident (#6) of five residents reviewed with PTSD.

Inspectors wroteBased on observation and interviews facility did not ensure medications were stored properly related to 1) an unlocked treatment cart; 2) expired medications on one unit (C-Wing) out of two units observed for medication storage.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure the physician was notified of missed doses of pain medications for one resident (#3) out of three residents sampled.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure to advise physicians or family representatives of missed scheduled pain medications for one resident (#3) out of three residents reviewed and sampled.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure adequate supervision and interventions were provided 1) to prevent major injuries for two residents (#213 and #81); and 2) to maintain a hazard free environment for one resident (#55) out of six residents sampled for falls and hazards.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure food allergies and preferences were honored for four residents (#169, #71, #171, #172) out of six sampled for dietary concerns.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure 1) A clean and sanitary kitchen where food is prepared and served; and 2) an operating dish washing machine on a consistent manner observed during the four days of survey in the facility kitchen.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the large outside trash compactor area was free from refuse and trash debris during one of one days observed (8/25/2025).

Inspectors wroteBased on interviews and record review the facility failed to ensure the residents or their representatives acknowledged understanding of the binding arbitration agreement and the agreement is not required as a condition of admission or as a requirement to continue to, receive care for three residents (#19, #117 and #215) of three residents sampled.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the arbitration agreement provided for the selection of a neutral arbitrator agreed upon by both parties for three (#19, #117 and #215) of three residents sampled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure an effective infection control program was implemented related to: a) improper use of Personal Protective Equipment (PPE); b) contact/isolation signs not posted and precautions not followed by staff; and c) hand hygiene practices were not conducted properly in four of four wings observed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure clean and sanitary resident spaces, to include resident rooms and bathrooms and clean and safe resident equipment, during three of four days observed (8/25/2025, 8/26/2025, and 8/28/2025) and in four of four units (A, B Memory Unit, C, and D).

Inspectors wroteBased on interviews and record review, the facility did not ensure grievances were documented and/or resolved for the Resident Council, the Food Committee, and six residents (#8, #171, #172, #213, #169, #125) out of thirty-eight residents sampled.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure oxygen was administered per physician orders for four residents (#179, #117, #65, and #6) out of six reviewed for oxygen therapy.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure medications were stored and secured in accordance with guidelines related to 1) medications improperly labeled and stored in resident rooms (#316 and #416); 2) medications left out in an unlocked office; 3) glucose test strips undated in a medication cart; 4) personal items stored with medications; and 5) improper disposal of a medication observed during three of four days of survey.

Inspectors wroteBased on interviews and record review, the facility failed to offer a nourishing evening snack for seven residents (Resident #3, #131, #33, #181, #108, #60, and #10) out of seven residents sampled for dining.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective Action Plan to improve findings of deficient practice on the recertification survey conducted 8/25/25 -8/28/25 regarding medication storage, infection control, food safety and sanitation, and arbitration agreements.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a functioning call light system for four residents (#169, #125, #147, and #84) out of four residents sampled for call lights.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure dignity was maintained for residents during dining related to serving residents at a single table meals at the same time in one out of four dining rooms observed.

Inspectors wroteBased on interviews and record review the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were accurate and failed to submit a Level II PASRR for one resident (#8) out of three residents sampled.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the revision and/or implementation of a comprehensive care plan was completed for one resident (#213) out of five residents sampled for falls.

Inspectors wroteBased on interviews and record review, the facility failed to 1) provide adequate catheter care for Resident # 10, and 2) ensure documentation of catheter care was completed for Resident #125, out of three residents sampled for catheter care. Findings Included: 1) During an interview with Resident #10 on 08/25/2025 at 9:45a.m., the resident voiced concerns regarding lack of care for her suprapubic catheter. The resident stated no one had cleaned the site or changed the dressing on her catheter for three days. Resident #10 voiced a concern of her catheter care not being done correctly since a nurse who previously did most of her care resigned from the facility. A follow-up interview was conducted on 08/26/2025 at 10:20 a.m. where the resident stated she had still not received care for her catheter. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide effective pain management in a timely manner for one resident (#179) out of one resident sampled for pain management.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure sufficient staff were available to meet the needs of the residents on four units (A, B, C and D) out of four units in the facility.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure two residents (#23, #90) were offered the COVID-19 vaccine out of 5 residents sampled for COVID-19 immunizations.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for six employees (Staff C, Licensed Practical Nurse and Unit Manager, Staff G, Registered Nurse, Staff H, Certified Nursing Assistant, Staff I, Certified Nursing Assistance, Staff J, Licensed Practical Nurse, and Staff K, Certified Nursing Assistant) of six employee files reviewed.

Inspectors wroteBased on interviews and record review, the facility did not ensure preferences were honored and dignity maintained for one resident (#8) out of eight sampled residents.

Inspectors wroteBased on interviews and record review, the facility failed to act upon resident's concerns and grievances for two residents (#3 and #8) of seven residents reviewed for grievances.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure care and treatment was provided in accordance with professional standard of practice related to 1. Failure to ensure repositioning, skin integrity checks, and incontinence care was provided timely for one resident (#3) of three residents sampled, 2. Failure to ensure a lift transfer was conducted per facility protocol for one resident (#3) of three residents sampled, 3. Failure to ensure a call light was within reach for one resident (#7) of seven residents sampled, and 4. Failure to ensure medications were administered per physician orders for one resident (#3) of three residents sampled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure sufficient nursing staff, with the appropriate competencies and skill sets, provided nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident on four out of four resident units in the facility. This failure resulted in a fracture of unknown origin, falls with major injury, lack of wound care according to physician orders, lack of medication administration according to physician orders, missed laboratory orders, lack of follow-up for critical diagnostic results, and Activities of Daily Living (ADL) care not being provided to residents per care plans. [...]

Inspectors wroteBased on interview and record review the administration of the facility failed to update their emergency plan as changes occurred and failed to plan and carry out a safe evacuation. There was a complete disregard for patient safety and quality of care to be maintained during a natural disaster that required an evacuation. Additionally, after one failed evacuation the facility did not secure a location for a second natural disaster that occurred shortly after the first one. The facility maintained an evacuation agreement with a local church that began in 2018. In February 2024 the church informed the facility that the agreement was to be terminated effective May 31, 2024. No alternative evacuation location was arranged. In September of 2024 when evacuation was ordered for hurricane [NAME] the facility staff moved 226 residents to a local church. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain a Governing Body that was aware of the facility emergency plans. The Governing body was not aware the facility did not update their emergency plan as changes occurred. The facility failed to address the needs of their patient population during an emergency and failed to provide for continuity of operations during a natural disaster, a hurricane. The facility maintained an evacuation agreement with a local church that began in 2018. In February 2024 the church informed the facility that the agreement was to be terminated effective May 31, 2024. No alternative evacuation location was arranged. In September of 2024 when evacuation was ordered for hurricane [NAME] the facility staff moved 226 residents to a local church. Family members of the residents called the police and emergency medical services to report conditions. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to protect the resident(s') right to be free from neglect when it failed: 1) to provide a hazard free environment and supervision for three residents (#3, #8, and #12) of three reviewed for falls with injuries; 2) to provide follow-up notification for critical radiology results for one resident (#9) of one reviewed for imaging; 3) to provide proper wound care to prevent the development of complications for four residents (#19, #21, #22, and #20) of four reviewed for wound care; 4) to provide medication administration per physician orders for three residents (#1, #13, #15) of three reviewed for medications; [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide a hazard free environment and adequate supervision for three residents (#3, #8, and #12) of three reviewed for falls with injuries, resulting in the need for transfer to a higher level of care for evaluation and treatment. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Residents #3, #8, and #12 and resulted in the determination of Immediate Jeopardy on 6/22/24. The findings of Immediate Jeopardy were determined to be removed on 10/28/04 and the severity and scope was reduced to a E.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a safe, clean, and homelike environment was maintained, to include resident rooms, resident bathrooms, and doors, on four of four resident units, during five of five days observed during survey.

Inspectors wroteBased on interviews and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported immediately, but not later than two hours after the allegation was made, to the administrator of the facility and required state agencies in accordance with state law through established procedures for three residents (#3, #8, and #12) of three sampled residents. Findings Include: Review of Resident #3's progress note, dated 6/22/24 at 9:48 a.m., authored by Staff M, Licensed Practical Nurse (LPN) showed the following: Upon arriving on the unit and doing rounds the resident was observed sitting in wheelchair by resident's room door chanting but not outside of her normal behavior. Another nurse came and informed the nurse that the resident posture was not looking normal and if I would assess her. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide assistance with Activities of Daily Living (ADL's) related to showers, incontinence care, and assistance with meals for six residents (#16, #18, #7, #17, #24, and #25) out of six reviewed for Activities of Daily Living.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide proper wound care to prevent the development of complications for four residents (#19, #21, #22, and #20) of four reviewed for wound care.

Inspectors wroteBased on interviews and record review, the facility failed to provide medication administration per physician orders for three residents (#1, #13, #15) of three reviewed for medication administration.

Inspectors wroteBased on interview, record review, and policy review the facility failed to provide laboratory services as ordered for three residents (#14, #13, and #10) out of three reviewed for laboratory orders.

Inspectors wroteBased on interviews and record review, the facility failed to provide follow-up notification for critical radiology results for one resident (#9) of one reviewed for imaging.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure infection control practices were implemented to provide a safe, sanitary, and comfortable environment for residents on three out of four units in the facility related to hand hygiene, soiled linens, housekeeping carts during mealtime, personal protective equipment (PPE) carts, and isolation precautions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store medications properly on one out of four units and in three out of four medication carts.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services in a timely manner in relation to call lights for three residents (#173, #57, and #117) out of 53 sampled residents with the potential to affect all residents in the faciltiy.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the environment was maintained in a clean and comfortable manner in two hallways (100 hall and 200 hall) out of four hallways in the facility serving as resident living areas.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to review and revise a care plan to reflect the nonuse of a secure door safety banner stop sign for one resident (# 54) out of ten residents sampled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide two residents (#3 and #9), who were dependent for Activities of Daily Living (ADLs), personal grooming related to shaving and nail care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice related to unlabeled dressings for one resident (#294) out of two residents sampled for skin conditions.

Inspectors wroteBased on observations, interviews, and record review the facility 1) failed to ensure a resident who cares for his laryngectomy tube was assessed and deemed competent, 2) failed to ensure necessary supplies were available, and 3) failed to ensure follow-up with a specialty physician related to his laryngectomy tube was coordinated for one resident (#154) out of one resident sampled with a laryngectomy tube.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the drug regimen review was completed monthly, the pharmacist's report was documented in the medical record, and the pharmacist's recommendations were acted upon for one resident (#135) of nine residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effect pest control program for two units out of four units in the facility.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure Narcotic Cards/ Bottles Reconciliation logs were completed on 4 out 4 resident wings (A, B, C, D) and failed to document controlled narcotics in sufficient detail to enable an accurate reconciliation for 3 residents (Resident #5, Resident #6, and Resident# 11) of 3 residents reviewed on Wing B, for 2 of 2 medication carts located on Wing B.

Inspectors wroteBased on observation, interview, and record review the facility failed to submit a timely report to the required state agencies for 1 resident (#6) out of 3 residents reviewed. The facility failed to submit a timely report to the required state agencies for misappropriation of Resident #6's missing narcotic medication.

Inspectors wroteBased on interviews and review of facility and resident's record, the facility did not ensure supervision was provided to prevent a fall for 1 of 3 residents reviewed, Resident #3 and the facility did not ensure documentation and follow up were completed after the fall.