Aviata At The Bay

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

neglect and they did not accept the case. On 9/2/2025 Resident #5 was seen by psych services. She was alert with confusion, denied any distress, or intent to harm herself or others with no injuries with no complaints from the event. On 9/12/2025 Identified resident #5 discharged to a memory care unit as planned with IDT [Interdisciplinary Team], Family and Medical Director On 8/30/2025 Door guard was placed at door by NHA to ensure no one was able to leave from facility until screamers were installed. On 8/31/2025-9/7/2025 Elopement drills were completed every day, 3 times a day randomly. On 9/8/2025-9/30 Elopement drills were completed 1 time a week on random days. Monthly Drills have been completed monthly from October 2025- Current on random shifts and days. Results have been reviewed with QAPI Team. On 9/3/2025 Screamers were shipped from manufacturing company verified by Maintenance Director On 9/23/2025 a contractor came to facility to install cameras and new secure care boxes.

Maintenance Director completed door checks to ensure they are functioning properly. On 9/23/2025 IDT & Clinical Consultant met to discuss removal of Door Guard. All agree On 9/23/2025 Security company came to facility to access possible amber alarm system and they were installed 10/7/2025 Security cameras were set up in the facility with main station located in NHA office. On 8/30/2025, 9/12/2025, 9/19/2025, and 9/26/2025 IDT including Medical Director met to review ADHOC [for this specific purpose] /QAPI plan with no negative findings. Medical Director reviewed and recommended no changes. On 8/30/2025 Education was initiated via phone [telephone] and in person with 100% of staff to include contract employees related to abuse & neglect, missing persons policy, elopement policy that included care plans and KARDEX for those at risk for wandering/elopement, and staff response to door alarms by ED and Designee. Completed

on 8/31/2025 On 8/30/2025 elopement drills were initiated for 100% of staff to include contracted employees by DON and Designee. Verification of the facility's removal plan was conducted by the survey team on 1/28 and 1/29/26. - Interviews were conducted with forty staff members, who worked across all shifts, including housekeeping, dietary, administrative/clerical, therapy, social services, CNA's, licensed nurses. The staff members were able to state that they had been trained and were knowledgeable about

the new policies and procedures initiated by the facility. - A tour of the facility with the Director of Maintenance (DOM) and staff interviews confirmed alarms and cameras had been installed and were functioning - A review of in-service documentation revealed 100% of staff had acknowledged education and training related to abuse, neglect, and exploitation, resident supervision, elopement protocols, and following care plans. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be corrected on 9/3/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at the Bay

2916 Habana Way Tampa, FL 33614

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

residents' demographics were found in each resident elopement binder at nurse station, receptionist and therapy gym. On 8/30/2025 Resident #5 demographics and picture was added to the elopement binder by DON. On 8/30/2025 Door checks were completed by NHA to ensure all doors worked properly with no negative findings. On 8/30/2025 a 100% head count was completed by Weekend supervisor to ensure all residents were in facility with no negative findings. On 8/30/2025 100% of residents were re-assessed for elopement risk by DON and Designee. No new residents were identified. On 8/30/2025 an initial Elopement drill was complete on 8/30/2025 by NHA & Designee reviewed results and documented them on Elopement Drill QAPI [Quality Assurance Performance Improvement] Worksheet with no negative findings. On 8/30/2025 ED and DON gathered witness statements from residents and staff. On 8/31/2025 DON notified DCF [Department of Children and Families] & police of allegation of neglect and they did not accept the case. On 9/2/2025 Resident #5 was seen by psych services. She was alert with confusion, denied any distress, or intent to harm herself or others with no injuries with no complaints from the event. On 9/12/2025 Identified resident #5 discharged to a memory care unit as planned with IDT [Interdisciplinary Team], Family and Medical Director On 8/30/2025 Door guard was placed at door by NHA to ensure no one was able to leave from facility until screamers were installed. On 8/31/2025-9/7/2025 Elopement drills were completed every day, 3 times a day randomly. On 9/8/2025-9/30 Elopement drills were completed 1 time a week on random days. Monthly Drills have been completed monthly from October 2025- Current on random shifts and days. Results have been reviewed with QAPI Team. On 9/3/2025 Screamers were shipped from manufacturing company verified by Maintenance Director On 9/23/2025 a contractor came to facility to install cameras and new secure care boxes. Maintenance Director completed door checks to ensure they are functioning properly. On 9/23/2025 IDT & Clinical Consultant met to discuss removal of Door Guard. All agree On 9/23/2025 Security company came to facility to access possible amber alarm system and they were installed 10/7/2025 Security cameras were set up in the facility with main station located in NHA office. On 8/30/2025, 9/12/2025, 9/19/2025, and 9/26/2025 IDT including Medical Director met to review ADHOC [for this specific purpose] /QAPI plan with no negative findings. Medical Director reviewed and recommended no changes. On 8/30/2025 Education was initiated via phone [telephone] and in person with 100% of staff to include contract employees related to abuse & neglect, missing persons policy, elopement policy that included care plans and KARDEX for those at risk for wandering/elopement, and staff response to door alarms by NHA and Designee. Completed on 8/31/2025 On 8/30/2025 elopement drills were initiated for 100% of staff to include contracted employees by DON and Designee. Verification of the facility's removal plan was conducted by the survey team on 1/28 and 1/29/26. - Interviews were conducted with forty staff members, who worked across all shifts, including housekeeping, dietary, administrative/clerical, therapy, social services, CNA's, licensed nurses. The staff members were able to state that they had been trained and were knowledgeable about the new policies and procedures initiated by the facility. - A tour of the facility with the Director of Maintenance (DOM) and staff interviews confirmed alarms and cameras had been installed and were functioning - A review of in-service documentation revealed 100% of staff had acknowledged education and training related to abuse, neglect, and exploitation, resident supervision, elopement protocols, and following care plans. Based on verification of

the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be corrected on 9/3/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at the Bay

2916 Habana Way Tampa, FL 33614

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809

to receive their meals timely, and per the meal service schedule.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet