F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews and record review, the facility failed to prevent verbal abuse from staff for 2 of 3
residents reviewed. (Patient #1 and Patient #2)The findings included: Review of the facility Abuse, Neglect,
Exploitation & Misappropriation policy (last revised on 11/16/2022) says that residents should be afforded
basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or
misappropriation of property. The policy further noted no employee may at any time commit an act of
physical, psychological, or emotional abuse. The policy defines abuse as the willful infliction of injury,
unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental
anguish. The policy defines mental abuse as the use of verbal or nonverbal conduct which causes or has
the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or
degradation. The policy defines verbal abuse as the use of oral, written, or gestured communication, or
sounds, to residents within hearing distance regardless of age ability to comprehend or disability. The policy
noted examples of mental and verbal abuse to include mocking, insulting, ridiculing and yelling or hovering
over a resident, with the intent of intimidate. Record review for Resident #1 showed the resident was
admitted on [DATE] with a diagnosis of Parkinsons Disease. Resident #1's most recent (10/20/25) Brief
Interview for Mental Status (BIMS) was a score of 15 indicating intact cognition.Review of a Patient #1
psychiatric progress note (completed on 12/31/25) stated patient was seen today as staff request for
psychiatric evaluation following a reportable incident. Patient reports feeling emotional discomfort following
an interaction with a staff member on 12/25/25.During an interview on 1/13/26 at 11:16 a.m., Resident #1
said she was abused by a staff member around Christmas. She said CNA (Certified Nursing Assistant)
Staff A came in to change her brief due to an episode of incontinence. She said she has Parkinsons
Disease (a neurological disorder that affects movement) causing her to move very slowly and deliberately.
Resident #1 said she told CNA Staff A to slow down prior to turning her. Resident #1 said CNA Staff A was
yelling at me the whole time and not listening. Resident #1 said CNA Staff A was yelling at me with a tone
and attitude of I have to get this done as fast as possible. Resident #1 said CNA Staff A grabbed the sheet
and whipped me to the side. Resident #1 said she caught the windowsill which prevented her from hitting
the floor. Resident #1 said CNA Staff A not listening to me and moving me rough like that made me feel
inconsequential, like I don't matter to her.Review of the facility complaint/grievance reported on 12/25/25
from Resident #1 stated, CNA Staff A was verbally abusive by calling her ‘heavy' and stating ‘I don't get
paid enough to do this. My back hurts'. Resident stated CNA ‘bitched at me for not being able to get into my
wheelchair'. Resident stated CNA rolled her over onto her right side ‘so rough using the pad, I thought I was
going to fall onto the floor'. Resident stated she overheard CNA yelling to night nurse about her.Review of a
statement on 12/25/25 by LPN (Licensed Practical Nurse) Staff B said Resident #1 had turned on her call
(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
01/14/2026
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 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
light, the CNA (Staff A) had just been in there and said out loud like what she wants now or something to
that effect. LPN Staff B said CNA Staff A likes to talk loudly, so even though she was having a conversation
with me and venting about the job, she was loud enough that Resident #1 could hear her through a shut
door. In fact, Resident #1 actually called the nurses station and told me that if she has got time to talk, then
she has time to change her.Review of a witness statement on 12/25/25 by Resident #2 (Resident #1's
roommate) said the CNA was very loud and mean talking to Resident #1. She told Resident #1 she could
break her back changing her.Record review for Resident #2 showed a most recent BIMS score of 13, dated
7/25/25, indicating intact cognition.During an interview on 1/13/26 at 12:01 p.m., Resident #2 said CNA
Staff A treated Resident #1 very badly that night around Christmas. Resident #2 said, I have never seen
anyone treat anybody the way she did. Resident #2 said CNA Staff A was yelling at Resident #1 while
changing her brief. Resident #2 said, I was so nervous because of what was going on. Resident #2 said, it
made me scared and I covered my face and hid under my blanket. Resident #2 said, I was scared of the
woman and was scared of what she would do to me if I spoke up. I did not get involved due to this. I just
hid.During an interview on 1/13/26 at 12:36 p.m., Resident #3 said CNA Staff A would come into my room
in the middle of the night, slam on the lights and not explain anything. Resident #3 said you had to do it her
way. Resident #3 said CNA Staff A used to yell at me all of the time. She would be nasty to my roommate
as well. I feel bad for my roommate because he is very old and not with it sometimes. She would come in
and yell at him. I always felt bad for him. She would always talk down to both of us as though she was
entitled. Resident #3 said CNA Staff A was eventually not allowed in his room anymore. During an interview
on 1/13/26 at 2:12 p.m., the Administrator said she came into the facility on Christmas due to an allegation
of abuse. The Administrator said she collected statements, including statements from Resident #1 and
Resident #2. The Administrator said both residents have a BIMS of 15 (indicating intact cognition). The
Administrator said they did substantiate the allegation of abuse when the investigation was complete.
Event ID:
Facility ID:
105588
If continuation sheet
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