Health inspection·July 11, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's policy and procedure review, and staff interviews, the facility failed to report an injury of unknown source and serious bodily injury was reported to the State Survey Agency within the prescribed timeframe for 1 (Resident #1) of 1 resident reviewed. The findings included: Review of the facility's policy and procedure for Abuse, Neglect, Exploitation and Misappropriation with a revision date of 11/16/22 noted, Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source . to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law . Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included senile degeneration, moderate dementia with behavioral disturbance. Review of the facility's incident investigations revealed on 5/28/24 at approximately 8:55 p.m., staff noticed bruising to Resident #1's left hip, thigh and groin area. Resident #1 was not able to state, what happened if anything to staff. Diagnostic studies identified an acute left femoral fracture. The incident investigation noted, It appears that some time 5/28/24 in the evening is when the bruising was identified based on all the statements obtained. Due to her history, it is no unlikely that maybe she attempted to get out of bed unassisted and possible injury occurred that staff were not made aware to due to the cognitive impairment of the resident . On 7/11/24 at 2:54 p.m., in an interview Licensed Practical Nurse Staff A said the Certified Nurse Assistant Staff B notified him of the bruising on Resident #1's left thigh on 5/28/24 at 8:55 p.m. He assessed the resident and notified Power of Attorney (POA) (for the resident), MD (Doctor of Medicine), Hospice, and Assistant Director of Nursing (ADON). He said he got witness statements done. He placed a progress note in the electronic medical record at 3:00 a.m. The record showed that he received no new orders from the MD and Hospice would send out a nurse to evaluate Resident #1. He got the witness statement from the CNA before her shift ended at 10:00 p.m. He said, I am almost certain that I did the calls within that hour. (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: 105588 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 07/11/2024 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)