Health inspection·November 25, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff and resident interviews, the facility failed to follow Infection Control measures to prevent a potential outbreak of scabies.The findings included:Review of the facility policy titled, Infection Prevention and Control revised October 2018, revealed an infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Outbreak management includes a process that consists of: determining the presence of an outbreak; managing the affected residents; preventing the spread to other residents; documenting information about the outbreak; reporting the information to appropriate public health authorities; educating the staff and the public; monitoring for recurrences and reviewing the care after the outbreak has subsided; and recommending new or revised policies to handle similar events in the future.Review of the clinical record for Resident #1 revealed an admission date of 6/10/25. Diagnoses included Cerebral infarction (stroke), Spinal lesion, Failure to Thrive, Diabetes and Kidney failure.Review of the Quarterly Minimum Data Set (MDS) Assessment with a target date of 9/19/25 noted the resident scored 15 on the Brief Interview for Mental Status (BIMS), indicative of intact cognition.Review of the progress notes revealed on 10/17/25, the Advanced Practice Registered Nurse (APRN) assessed Resident #1 for a complaint of a rash underneath his thighs.Review of the Medication Administration Record (MAR) for October 2025 revealed a physician's order to apply Permethrin 5% external cream (used to treat scabies infections) to the body topically one time a day for rash. The MAR showed documentation Resident #1 was treated with the Permethrin as ordered on 10/22/25.Review of the care plan initiated on 10/28/25 revealed Resident #1 has a Rash/Scabies.The goal was for the resident to verbalize an acceptable level of comfort from itching and will follow the recommended treatment for the alleviation of scabies.On 11/4/2025 at 3:30 p.m., Resident #1 was observed on the patio. He had noticeable bites marks to his arms and legs. In an interview, the resident said he's had the rash for a month. Resident #1 said he received treatment for scabies since he first mentioned it but did not want to go through it again as it burned his skin. The resident said the rash was better since it was treated but he was still itching and needed to see a dermatologist. He said, They need to do something about this itching!. Resident #1 was observed constantly scratching his arms and legs during the interview.Review of the clinical record for Resident #2 revealed an admission date of 2/2/24. Diagnoses included Chronic Obstructive Pulmonary disease, heart disease, and chronic pain syndrome.Review of the Quarterly MDS with a target date of 8/9/25 revealed Resident #2 scored 15 on the BIMS, indicating intact cognition.Review of the progress notes revealed the APRN saw Resident #2 on 10/18/25 for vesicular lesions, some open, around and on her lips. The APRN documented on 10/24/25 Resident #2 was seen for a rash on her arms, hands, face and neck. The areas appear to be a bite in nature but it was less likely scabies since the rash was not disseminated. It did itch but was not painful. The APRN documented the resident received one treatment of Permethrin but no improvement. Resident #2 was using hydrocortisone which seems to Residents Affected - Some Page 1 of 2 105452 105452 11/25/2025 Aviata at Englewood 1111 Drury LN Englewood, FL 34224

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some help.Review of the care plan initiated on 10/31/25 revealed Resident #2 had a rash/scabies. The goal was for the resident to verbalize an acceptable level of comfort from itching and follow recommended treatment for the alleviation of scabies.On 11/4/2025 at 2:50 p.m., in an interview with Resident #2 said she has been itching for about a month now. She said she was treated for scabies. It was better but she was still itching. She said she has asked multiple staff members to see a dermatologist. She said the cream they give her does not help the itching for long. During the interview, Resident #2 was scratching her right inner forearm where a rash was observed.Review of the clinical record for Resident #3 revealed an admission date of 12/17/22. Diagnoses included Dementia, Cerebral Infarction and Osteoarthritis.Review of the Quarterly MDS with a target date of 8/22/25 revealed Resident #3's BIMS was 08 which indicated moderate cognitive impairment.Review of the progress notes revealed on 10/21/25 the APRN documented Resident #3 had an extensive ongoing rash to the hands, arms, trunk and chest that was consistent with eczema/psoriasis versus fungal infection. She documented it was not responding to treatment. Had failed Triamcinolone (corticosteroid), oral Diflucan (antifungal), over the counter antifungals, Prednisone (corticosteroid). The resident was currently on Methotrexate (used to treat severe psoriasis) and Clobetasol (topical steroid), it does itch less.Review of the care plan initiated on 10/29/25 revealed Resident #3 has a rash/scabies. The goal was to verbalize an acceptable level of comfort from itching and follow recommended treatment for the alleviation of scabies.Review of the MAR for October 2025 revealed a physician's order with a start date of 10/29/25 for, Permethrin External Cream 5% apply to head to toe topically one time only for dry, scaley skin for 1 day. Apply to head to toe topically for rash for 1 day. Wash thoroughly after 8 hours.Further review of the clinical record revealed that on 11/3/25, Resident #3 was seen by the dermatologist. The dermatologist documented that the resident is a new patient who is being seen for a chief complaint of rash located on the arms, face, feet, hands and trunk. The rash is flaking itchy and painful and severe in severity. The rash has been present for months. The impression was dermatitis. Discussed biopsy but unable to perform biopsy due to unable to obtain consent for a procedure from healthcare proxy. Patient will return for follow up will consider biopsy at that time. Advised caregiver to bring necessary paperwork regarding healthcare proxy.On 11/4/2025 at 3:15 p.m., in an interview the APRN said he treated the residents even when their symptoms first started. He said he still did not feel that any of the cases were scabies but he could not prove it because the skin test was not available. He said he agreed that when the first 2 residents were treated for scabies it would have been good practice for the facility to do a full skin sweep of all the residents and interview staff.On 11/4/2025 at 11:58 a.m., an interview was held with the Infection Preventionist and the Director of Nursing (DON) related to onset of rashes, documented scabies and interventions implemented to minimize the risk of spreading potential scabies.The DON said they did not do skin sweeps or isolate residents with symptoms until 10/28/25 when an investigator showed up to investigate a complaint of possible scabies in the facility. The infection preventionist said a total of 29 residents and 15 staff members were treated for scabies. 11 of the 29 residents were treated prophylactically due to being the roommate of a resident with symptoms. She said 7 residents were still symptomatic and would be retreated. 105452 Page 2 of 2