Aviata at the Bay

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jan 29, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689Jan 29, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF600Jan 12, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689Jan 12, 2024

  Based 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. […]

• Actual harm, patternF600Jun 28, 2024

  Based 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. Findings included: 1. An interview was conducted on 6/26/24 at 2:17 p.m. with a family member for Resident #114. He said when he brought the resident to this facility, he was looking for a place with more interaction. He said she was only staying in her bed. He said he brought Resident #114's custom wheelchair to the facility for them to use. […]