Health inspection·November 19, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, resident and staff interviews, the facility failed to ensure staff provided incontinence care in accordance with accepted standards of care to meet the needs of 1 (Resident #800) of 3 residents reviewed.The findings included:On 10/15/25 at 9:24 a.m., Resident #800 was observed in bed in her room. In an interview Resident #800 said staff put two incontinent briefs and a towel on her because she was a heavy wetter. With the resident's permission, the incontinent briefs were observed. Resident #800 was wearing two incontinent briefs. A folded towel was placed inside the briefs. Resident #800 said it took 2 to 3 staff to provide incontinent care and change her briefs. She said the other day Certified Nursing Assistant (CNA) Staff A came in to change her. She tried to explain to the CNA how they did her care and that it took 2 to 3 staff to change her. The resident said that CNA Staff A did not explain what she was going to do and did not listen to her. She reported the incident.Review of the clinical record revealed Resident #800 had an admission date of 9/23/25. Diagnoses included severe morbid obesity, lymphedema (swelling caused by buildup of lymph fluid in body tissues), and chronic pain.Review of the admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 9/30/25 documented Resident #800 was dependent on staff for toileting, bathing and dressing. The MDS noted the resident scored 15 on the Brief Interview for Mental Status, indicating the resident's cognitive skills for daily decision making were intact.Review of the care plan for Resident #800 revealed:Resident #800 had non-blanchable redness to the buttocks, actual impairment to skin integrity of the medial thighs and groin secondary to fungus.Resident #800 was incontinent of bladder and bowel (Date initiated: 10/3/25). The goal was for the resident to remain free from skin breakdown due to incontinence and brief use.The interventions included: Clean the peri-area with each incontinence episode. Check for incontinence. Wash and dry perineum. Change clothing as needed after incontinence episode.Resident #800 had Alteration in usual functional performance in self-care related to lymphedema, Diabetes Mellitus, morbid obesity, Congestive Heart Failure, chronic pain and osteoarthritis.The interventions as of 10/3/25 noted:The resident used disposable briefs and was dependent on 3 staff assist for bed mobility (includes rolling from side to side and side to back).Resident #800 was dependent with 3 staff assist for Toilet Hygiene. Staff was to use disposable briefs, and clean peri-area with each incontinence episode. The care plan specified Resident performance: Bed mobility (includes rolling from side to side and side to back) - Dependent with 3 (three) staff assist.On 10/15/25 at 1:30 p.m., in an interview the Director of Nursing (DON) said the practice of putting 2 briefs on incontinent residents was not consistent with the facility's expectations. The DON said the facility's investigation verified that CNAs have been double briefing Resident #800 and other residents who were heavy wetter. She said after the incident, she addressed it in a staff meeting. She provided in-services dated 9/22/25, 9/23/25 and 9/26/25 on abuse, neglect and exploitation. 18 CNAs attended the in-services. The in-services provided did not address the practice of double Residents Affected - Few Page 1 of 2 105588 105588 11/19/2025 Aviata at Santa Barbara 216 Santa Barbara Blvd Cape Coral, FL 33991

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few briefing incontinent residents.Review of the facility provided incident investigation revealed that Resident #800 reported that on 10/5/25 CNA Staff A entered her room between 1:00 a.m. - 3:00 a.m. The resident tried to explain that it usually takes more than one person to help her with care, but the CNA did not listen. The facility's investigation documented Resident #800 was a heavy wetter. CNAs have been putting two disposable incontinent briefs and a wadded towel in front of her personal area.On 10/15/25 at 2:00 p.m., in an interview the Administrator said CNA Staff A did not provide quality of care as expected to Resident #800. 105588 Page 2 of 2