Health inspection·September 14, 2023

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, review of facility policy and procedure, clinical record review and staff interviews, the facility failed to provide appropriate services and interventions to maintain function and prevent the decline in range of motion for 2(Resident #19 and #24) of 3 residents sampled with a limitation in range of motion (ROM). The findings included: The facility policy N-904, Contractures, Prevention (revised 8/22/17) documented To prevent contracture of extremities for those residents who no longer have full use of their extremities . Each resident must be evaluated for need of contracture prevention procedures on admission, readmission and as needed. Residents with inactive extremities should have ROM exercises done to those extremities as part of their daily care . Hand rolls may be placed in any hand that the resident cannot move. These can be commercial rolls or wash cloths rolled up and should be removed daily during care . Some residents may have braces or splints to prevent or help release contractures, so be sure to follow physician's order regarding schedule of when to put these on and when to remove them . 1. Review of the clinical record revealed Resident #19 had an admission date of 2/28/19 with diagnoses including muscle weakness, morbid obesity and nonverbal. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 8/9/23 documented Resident #19 was dependent with assistance of two persons for bed mobility, toileting, transfers, and required extensive assistance with eating. The MDS documented Resident #19 had functional limitation in ROM on both sides of the upper and lower body. The MDS noted Resident #19's cognitive skills for daily decision making were severely impaired. The clinical record revealed a physician order dated 8/16/23 and instructed staff to place a rolled washcloth in bilateral (B/L) palms for comfort and contracture prevention every 12 hours as needed. On 9/11/23 at 3:24 p.m., and 9/13/23 at 8:45 a.m., Resident #19 was observed in her bed with her hands in tightly closed fists. The resident was not able to follow cues to open her hands. There were no splints or rolled washcloths in her hands. On 9/12/23 at 3:05 p.m., the Therapy Director (TD) said Resident #19 was able to open both of her hands and was not receiving restorative therapy or occupational therapy for hand contractures. The TD said Resident #19 had a decline after a recent hospital admission and was at her optimal level of function. On 9/12/23 at 3:52 p.m., the Director of Nursing (DON) said Resident #19 was able to open both of her hands and was now on hospice services. On 9/13/23 at 9:55 a.m., Restorative Certified Nursing Assistant (CNA) Staff E said she sees patients on Tuesdays and Thursdays and the average visit is 15 minutes. Staff E said therapy screens (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105588 If continuation sheet Page 2 of 6 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 105588 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Santa Barbara 216 Santa Barbara Blvd Cape Coral, FL 33991 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents every three months, write programs for restorative, and they give it to her, and they go over it with her. Staff E confirmed Resident #19 was not on a restorative program and did not receive any splints or rolled wash cloth in her hands for contractures. On 9/13/23 at 10:35 a.m., the DON said she was unaware Resident #19 had an order for rolled wash cloths in her hands and said the nurse would be responsible to assess the need for the rolled washcloths to be placed. The DON said the CNAs provide the actual placement of the rolled washcloths in the patient's palms. The DON said Resident #19 was able to open her hands and would remove the washcloths when placed. On 9/13/23 at 10:49 a.m., the DON said she reviewed Resident #19's clinical record and found no documentation the resident refused care for the contractures. The DON said she reviewed the order for the rolled washcloths to be placed as needed to B/L hands and said she did not know why the order was written as needed. The DON said the staff place the rolled washcloths and Resident #19 pulls them out, but there is nothing documented. The DON said, all I can do is have therapy screen her and see what they can do if anything. On 9/14/23 at 9:28 a.m., CNA Staff G said Resident #19 was not able to open her hands and she did not have splints, or anything placed in her hands that she was aware of. Staff G said she will try and open the Resident's hands to clean her hands when she was assigned to care for Resident #19. Staff G said if there was an order for anything for her hands that said as needed, she would ask the nurse. Staff G said she had not seen any rolled washcloths or anything in the resident's hands and said, no one told me to put one in her hands but if she needs it I can do it. On 9/14/23 at 9:41 a.m., Resident #19's hands were observed with CNA Staff G and the Registered Nurse, Infection Preventionist. The Infection Preventionist was able to use gentle touch to open Resident #19's right hand halfway. Resident #19 was yelling and attempted to strike the nurse and was tearful during the observation. The RN said the left hand was more rigid and said Resident #19 was resisting. The left hand was partially opened by the RN. On 9/14/23 at 10:14 a.m., CNA Staff G said she works with Resident #19 every day, and she can't open her hands. She said, She is not able to open her hands and she keeps them in a tight fist all day long. She will scream if you try to open her hands, you saw that. On 9/14/23 at 10:25 a.m., the Therapy Director said therapy screens did not document hand assessments, ROM, or contractures. The Therapy Directory said, We look at the residents we don't actually touch them when we are doing a screen. The Director said, You do know Resident #19 is on hospice services, don't you? On 9/14/23 at 11:44 a.m., the Regional Nurse Consultant (RNC) said she reviewed Resident #19's clinical record and verified Resident #19 was not receiving hospice services. On 9/14/23 at 8:16 a.m., the Therapy Director said Resident #19 did not have a contracture and was screened quarterly. She said, we don't place anything in her hands because there is no need. The Therapy Director confirmed there were no interventions in place for the residents hands. 2. Review of the clinical record revealed Resident #24 had an admission date of 1/15/20 with diagnoses including Alzheimer's disease, cardiac pacemaker, anxiety, osteoarthritis, and dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105588 If continuation sheet Page 3 of 6 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 105588 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Santa Barbara 216 Santa Barbara Blvd Cape Coral, FL 33991 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 0688 Level of Harm - Minimal harm or potential for actual harm The Quarterly Minimum Data Set with an assessment reference date of 8/7/23 documented Resident #24 was dependent with assistance of two for activities of daily living (ADLs). The MDS documented Resident #24 had limitation in ROM on both sides of the upper and lower body. The MDS noted Resident #24's cognitive skills for daily decision making were severely impaired. Residents Affected - Some On 9/11/23 at 10:12 a.m., and 1:13 p.m., and on 9/12/23 at 9:36 a.m., Resident #24 was observed in her room in bed. The resident's fingers in both hands were curled in tightly closed fists. Her elbows were flexed with her hands resting on her shoulders. No splints or rolled washcloth were in the palms of her hands. 9/11/23 at 1:30 p.m., RN Staff H said Resident #24 would hold a cup at times with her hands despite the contractures. RN Staff H said Resident #24 did not have splints or devices for her hands. On 9/13/23 at 9:55 a.m., CNA Staff E said Resident #24 was not on a restorative program and did not receive any splints or rolled wash cloth in her hands for contractures. Staff E said, Since you brought it up, Resident #24 could use something in her hands. On 9/13/23 at 2:07 p.m., CNA Staff F said Resident #24's arms and legs are very stiff and she will try and punch you and screams during any care. CNA Staff F said Resident #24 did not really speak more than a few words and was dependent for all care needs. The CNA said Resident #24 was not able to open her hands and said, when I try and clean her it is very difficult to get a washcloth in there to clean her hand. The CNA said she did not place any splints or wash cloths in her hands because she is not able to get the washcloth in her hands. On 9/14/23 at 9:16 a.m., CNA Staff G said Resident #24 can use her hands at times to hold a cup and drink but was total care for ADL's. The CNA said the resident does not let you touch her hands, she will scream and try to punch you if you even try. I know when I clean her hands she fights and screams. I try to wash her hands as best I can, but she won't let you put anything in her hands. I have not seen anything placed in her hands. On 9/14/23 at 8:57 a.m., the Therapy Director said Resident #24 does not allow anyone to touch her hands. She will punch and scream the minute you touch her hand. The Therapy Director said Resident #24 did have a carrot (a soft positioning device for hands) previously, but she would not allow anyone to place it in her hands and it was discontinued. The Therapy Director confirmed there were no current interventions in place to prevent the worsening of Resident #24's contractures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105588 If continuation sheet Page 4 of 6 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 105588 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Santa Barbara 216 Santa Barbara Blvd Cape Coral, FL 33991 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, review of facility policy and procedures and staff interviews, the facility failed to ensure insulin pens were properly labeled and dated when opened in 2 (Cart #4 and #5) of 3 medication carts reviewed. This had the potential for residents to receive medications that could create hazardous health consequences. The findings included: The facility policy 5.3 Storage and Expiration Dating of Medications, Biologicals, documented, Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. 1. On 9/11/23 at 10:06 a.m., observation of medication cart #4 with Registered Nurse (RN) Staff H revealed: One opened Glargine insulin 100-unit Pen for Resident #19 with no date of when it was opened. The Pharmacy label specified to discard unused medication after 28 days. Photographic evidence obtained. One opened insulin Aspart 100 unit/milliliter(ml) Pen for Resident #1 with no date of when it was opened. One opened Novolog Mix 70/30 insulin flex pen for Resident #1 with no date of when it was opened. The Pharmacy label specified to discard unused medication after 28 days. Photographic evidence obtained. One opened Lantus Solostar insulin pen for Resident #14 with no date of when it was opened. The Pharmacy label specified to discard unused medication after 28 days. Photographic evidence obtained. The findings in medication cart #4 were confirmed with RN Staff H. 2. On 9/11/23 at 10:26 a.m., observation of Medication Cart #5 with RN Staff J, revealed: One opened Glargine insulin pen. The insulin pen had no pharmacy label, resident's name, or date opened. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105588 If continuation sheet Page 5 of 6 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 105588 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Santa Barbara 216 Santa Barbara Blvd Cape Coral, FL 33991 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 0761 Photographic evidence obtained. Level of Harm - Minimal harm or potential for actual harm One opened Novolog(Aspart) 100 units per milliliter (ml) insulin pen, and one opened Glargine 100 units/3 ml. insulin pen were stored in a clear plastic zip log bag. The zip log bag did not have a label. The opened insulin pens were not labeled and had no date opened. Residents Affected - Some RN Staff J verified the clear plastic bag, and the insulin pens were not labeled. She verified the insulin pens were opened but not dated. She said the insulin pens belonged to Resident #35. Photographic evidence obtained. One open insulin Aspart 100 units/ml pen for Resident #49 with no opened date. The Pharmacy label specified to discard unused medication after 28 days. Photographic evidence obtained. One opened Basaglar 100 units/ml Kwik pen for Resident #20 with no date opened. The findings in medication cart #5 were confirmed with RN Staff J who verified without a date indicating when the insulin pens were opened, it was impossible to determine when to discard the unused medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105588 If continuation sheet Page 6 of 6