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
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
105452
Printed: 05/28/2026
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
105452
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/25/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Englewood
1111 Drury LN
Englewood, FL 34224
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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.
Event ID:
Facility ID:
105452
If continuation sheet
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