Aviata at the Bay

Inspectors wroteBased on interviews and records review the facility failed to protect the resident's right to be free from neglect related to elopement for one resident (#5) out of three residents reviewed for elopement risk. On 8/30/25 Resident #5 exited the facility at approximately 4:15 p.m., unnoticed by staff. Resident #5 had severely impaired cognition, ambulated independently, had wandering behaviors, and did not have an electronic monitoring device on. Resident #5 was able to get from the fourth floor to the first floor, access a stairwell door that should have been locked, and then exit the facility. Another resident observed Resident #5 walking around the west side of the building to the front parking lot and directed her back to the building. Staff did not know Resident #5 was off the fourth floor. [...]

Inspectors wroteBased on interviews and records review the facility failed to provide supervision to prevent elopement for one resident (#5) out of three residents reviewed for elopement risk. On 8/30/25 Resident #5 exited the facility at approximately 4:15 p.m., unnoticed by staff. Resident #5 had severely impaired cognition, ambulated independently, had wandering behaviors, and did not have an electronic monitoring device on. Resident #5 was able to get from the fourth floor to the first floor, access a stairwell door that should have been locked, and then exit the facility. Another resident observed Resident #5 walking around the west side of the building to the front parking lot and directed her back to the building. Staff did not know Resident #5 was off the fourth floor. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to serve Dinner meals in a timely manner and per the daily meal service timeframe for fourteen of seventeen meals reviewed (days 1/10/26, 1/11/26, 1/12/26, 1/13/26, 1/14/26, 1/15/26, 1/18/26, 1/19/26, 1/20/26, 1/21/26, 1/22/26, 1/23/26, 1/25/26, and 1/26/26).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect the resident's right to be free from neglect for four residents (#47, #114, #124, #126) out of thirty-one sampled residents related to no access to wheelchairs, no assistance getting out of bed, and residents not receiving proper ADL (activities of daily living) care including hair care and dressing.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure the kitchen was clean and free of expired food(s) of one kitchen.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe and homelike environment on three units of three units and one shower room (3rd Floor) out of three shower rooms related to soiled privacy curtains, unpainted/unfinished wall repairs, foul odors, unclean bathroom, disrepair of closets, furniture and light fixture, and a shower chair.

Inspectors wroteBased on record review and staff interview, the facility failed ensure the Level I Preadmission Screening and Resident Review (PASRR) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses were accurate for six residents (#394, #135, #122, #75, #114, and #53), and failed to initiate a Level II PASRR for one resident #53 of 31 residents sampled.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide life-enriching activities for three residents (#79, #57, and #124) out of 53 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents with limited mobility received restorative services to maintain or improve mobility and/or range of motion (ROM) for three (#129, #31 and #102) of four residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure medication was stored properly for three residents (#129, #141 and #142) related to medications in resident rooms and medications on the floor, and in three medication carts (400 Low, 300 High and 200 Low) out of four medication carts audited related to undated insulin, and an unlocked medication cart.

Inspectors wroteBased on observation, interview, and facility policy review, the facility did not ensure the confidentiality of Protected Health Information (PHI) was maintained for one resident (#395) of 42 residents on the 200 Unit.

Inspectors wroteBased on interview and record review the facility failed to act upon a resident's grievance for one (#394) resident out of 42 residents on the 200 Unit.

Inspectors wroteBased on observation, record review, and interview the facility failed to develop and/or implement an effective care plan for three (#57, #75, and #114) out of 53 sampled residents.

Inspectors wroteBased on observation, record review and interview the facility failed to implement an effective discharge planning process to assist one resident (#72) with a discharge to another facility out of eight residents sampled.

Inspectors wroteBased on observation, interview and record review the facility did not ensure a functional communication system implemented for two (#393 and #97) of three residents sampled.

Inspectors wroteBased on observation, record review and interview the facility did not ensure activities of daily living (ADLs) were completed and maintained for two (#126 and #97) out of two residents sampled.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure trauma informed care was provided for one (#114) out of three residents with post-traumatic stress disorder (PTSD).

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered for one resident (#393) of 42 residents on the 200 Unit.

Inspectors wroteBased on record review and interview, the facility failed to ensure critical labs were reported to the ordering physician in a timely manner for one resident (#393) of 53 residents sampled.

Inspectors wroteBased on observation, record review, and interview the facility failed to promptly provide dental services for one (#79) out of one sampled resident complaining of chewing difficulties related to tooth pain.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure the medical record of one (#90) out of fifty-three sampled residents was accurate related to the application and removal of an orthotic device.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to post correct infection control signage in resident rooms on 2 (3rd and 4th) of 3 facility floors including for Residents #37, #77 related to not correctly informing staff necessary precautions to take to prevent cross contamination of infections between residents.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide a pest-free environment on two of four residential units (Hall 200 and Hall 300) and the kitchen of the facility.

Inspectors wroteBased on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the resident's primary care physician, and review of the resident's medical record and facility policies, the facility failed to protect the resident's right to be free from neglect by not ensuring one resident (#1) of 10 residents at risk for elopement, was provided with supervision and services related to the resident's cognitive deficits and history of dementia, epilepsy, and confusion before admission to the facility. In addition, the facility failed to provide meals, shelter and ordered medical treatment during Resident #1's absence. The facility staff failed to ensure the medical care and safety of Resident #1; [...]

Inspectors wroteBased on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the resident's primary care physician, and review of the resident's medical record and facility policies, the facility failed to ensure one resident (#1) of 10 residents at risk for elopement, was provided with supervision and services related to the resident's cognitive deficits and history of dementia, epilepsy, and confusion before admission to the facility. The facility staff failed to ensure the safety of Resident #1; on 12/31/2023 at approximately 2:30 PM, Resident #1 ambulated from the second floor of the facility, entered the facility elevator, and rode the elevator down to the first floor of the facility. [...]

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure weight loss was monitored and assessed timely, as evidenced by lack of weekly weights and lack of food consumption documentation, which resulted in a significant weight loss for one (Resident #67) out of seven residents sampled for nutrition.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide necessary respiratory care and services, related to storage of oxygen, and nebulizer tubing's and supplies, consistent with professional standards of practice for six residents (#56, #69, #95, #178, #378, #381) of ten facility residents receiving respiratory treatments.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure proper storage of drugs and biologicals as evidenced by: 1) not maintaining refrigerator temperatures within reference range for three of three medication refrigerators, and 2) not storing four vials of Lorazepam 2 mg (milligrams)/ml (milliliter), a Schedule IV medication, in a permanently affixed compartment in the refrigerator for one of three medication storage rooms.

Inspectors wroteBased on record review and interviews, the facility failed to allow a resident's guardian to participate in the care planning process for one resident (Resident #329) out of 27 residents reviewed for care plans.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to review and revise the Resident Centered Care Plan related to 1) adding interventions after a fall for one (Resident #50) of three residents sampled for falls, and 2) adding a focus area with interventions implemented for range of motion for one (Resident #50) of three residents sampled for range of motion.

Inspectors wroteBased on observations, interviews, and policy reviews the facility failed to ensure proper care for activities of daily living (ADLs) related to nail care and incontinence care for two (Resident #95 and Resident #63) out of four residents sampled for activities of daily living.

Inspectors wroteBased on observation, record review, interviews, policy review, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance Committee. The facility was actively involved in the effective creation, implementation, and monitoring of the POC for deficient practice during a recertification survey that was conducted on 03/29/2022 through 04/01/2022 and was cited F692 and F761. On 05/18/2022 the facility was recited for F692 and F761. The facility had developed a POC with a compliance date of 05/01/2022.

Inspectors wroteBased on observations, interview and review of policy and maintenance logs, the facility did not ensure the transportation services were adequate related to the air conditioning not cooling residents during transport in the facility's van for two residents (Resident #380 and Resident #77) of two residents transported in the facility's only van during the week of March 28, 2022.

Inspectors wroteBased on observations, interviews and record review the facility failed to maintain drugs and biological's used in the facility in a safe, secure, and orderly manner in three of five inspected medication carts and one of two inspected medication storage rooms.

Inspectors wroteBased on interview and record review the facility failed to provide required written beneficiary notifications (Skilled Nursing Facility Advance Beneficiary Notice Form Centers for Medicare and Medicaid Services 10055 [SNF ABN Form CMS-10055]) to three (Resident #7, Resident #68 and Resident # 83) of three sampled residents.

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure that the confidential medical information for one (Resident # 109) of six residents reviewed during the facility task of Medication Administration, was secured when he left the computer screen displaying Resident #109's record unattended on his cart on multiple occasions during a medication pass.