Health inspection·April 25, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record reviews the facility failed to follow Physician orders to ensure the health and safety of one resident, Resident #1, of 4 residents reviewed for significant medication errors. Residents Affected - Few The findings included: Administering Medications Policy dated 2001 and Revised April 2019 states, Medications are administered in a safe and timely manner, and as prescribed. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration record space provided for that drug and dose. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: The date and time the medications was administered; the dosage; the route of administration; the injection site; Any complaints or symptoms for which the drug was administered; Any results achieved and when those results were observed; and the signature and title of the person administering the drug. Medical record review for Resident #1 show he was admitted to the facility on [DATE] for post Cerebrovascular Accident (CVA) causing left upper and lower paralysis. He also had a history of diabetes. His cognition was evaluated using the BIMS (Brief Interview for Mental Status) and had a score of 15 out of 15 which indicates intact cognition. The care plan initiated 4/10/24 identified resident #1 had Diabetes Mellitus and implemented goals and interventions that included medications as ordered by doctor and fasting serum blood sugar as ordered by doctor. The original physician order/start date written on 3/28/24 by the Physician Assistant with an end date of 4/22/24 read Insulin Lispro Injection Solution Lispro Insulin inject subcutaneously before meals & at bedtime per sliding scale PRN (as needed), inject as per sliding scale; if 151-299 = 2 units into skin as per sliding scale; less than 151 = 0 units; 201-250 = 4 units; 251-300 = 6 units; 30-350 = 9 units; 351-400 = 11 units; greater than 400 give 12 units and call MD, subcutaneously as needed for DM (Diabetes Mellitus) AC/HS (before meals and Hour of sleep). Review of the MAR/TAR (Medication Administration Record/Treatment Administration Record) for the month of April 2024 had the order listed but there were no documented blood sugar results recorded or (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 3 Event ID: 105507 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 105507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903 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)