Health inspection·August 17, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm cognitively impaired, had continual signs and symptoms of delirium with disorganized thinking, and disruptive behavior directed at himself for 1-3 days. The Functional Status noted he required extensive assistance provided by two staff to complete Activities of Daily Living (ADL). Urinary and Bowel function was shown as always incontinent. Nutritional status was noted with excess weight loss, and the resident received antidepressant medication for 7 out of 7 days during the look back period. Residents Affected - Few The Level I Pre-admission Screen and Resident Review form DH: PASRR (11/11) dated 9/12/13 and completed by a hospital noted there was no Mental Illness (MI) or difficulty present with interpersonal functioning or concentration that required assistance. The Electronic Health Record (EHR) showed diagnoses of bipolar disorder on 10/19/16, and vascular dementia on 3/12/17 were included in the resident's plan of care. The Comprehensive Care Plan noted the resident exhibited behaviors related to dementia, depression and anxiety with a disorganized thought process and decision making deficits, was dependent on staff to meet his emotional, physical, and social needs, had limited physical mobility, and deficits that required staff to complete ADLs. The psychology Progress Notes dated 4/25/23 showed follow-up services were provided, resident #15 verbalized he was sad, and staff reported he appeared to be depressed, not per his usual. On 8/16/23 at 10:30 AM, the Social Services Director said the Interdisciplinary Team (IDT) determines if a new PASARR is needed. She said the facility completed a new form if a resident was discharged to another facility or had a significant change in mental conditions. On 8/16/23 at 10:39 AM, the Director of Nursing (DON) stated she was responsible for PASARR completions. She explained that she completed the screens on a paper form if a resident was admitted to the facility. She checked resident #15's form scanned to the medical record and acknowledged it did not indicate the resident had any MI or dementia and that was not current. She said that Social Services was responsible for notifying the IDT of changes or updates and she had not updated any PASARRs for changes after a resident was admitted . 3. Review of resident #39's medical record revealed the resident was admitted to the facility on [DATE] from a nursing home. The resident had diagnoses that included schizoaffective disorder, bipolar type, major depressive disorder, bipolar disorder, major depressive disorder, aphasia (loss of speech), muscle weakness, pseudobulbar affect (uncontrolled emotional neurological disorder), and vascular dementia with behavioral disturbance noted as secondary. The Minimum Data Set quarterly assessment with Assessment Reference Date 7/19/23 noted the resident scored 5 out of 15 for the Brief Interview for Mental Status that indicated he was severely cognitively impaired, had continual signs and symptoms of delirium with disorganized thinking, and disruptive behavior directed at himself for 1-3 days. The Functional Status noted he required extensive assistance provided by two staff to complete Activities of Daily Living (ADL). Urinary and Bowel function was shown as always incontinent. Nutritional status was noted with excess weight loss, and the resident received antidepressant medication for 7 out of 7 days during the look back period. The Pre-admission Screen and Resident Review completed by a hospital on 3/31/17 did not note the resident had diagnoses for bipolar disorder, other neurological conditions, or dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 2 of 15 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 105888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769 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 0644 Level of Harm - Minimal harm or potential for actual harm The Comprehensive Care Plan noted the resident had cognitive deficits with physical limitations and he was dependent on staff for his emotional, intellectual, social, and physical needs. The care plan showed the resident required staff assistance to complete his ADLs related to a history of falls, risk of elopement, and impaired safety awareness. A focus for monitoring for behaviors related to schizophrenia, depression, bipolar disorder, and dementia was included with the use of antidepressant and antiseizure medications. Residents Affected - Few The psychology Progress Notes dated 8/01/23 documented resident #15 had been receiving care and services to treat conditions that included schizoaffective disorder, bipolar disorder, seizures, vascular dementia, and pseudobulbar affect with repetitive behavior disturbances of agitation, wandering, verbal and/or physical aggression, and impulsiveness since the resident was admitted to the facility 6 years prior. On 8/16/23 at 10:39 AM, the Director of Nursing (DON) checked resident #39's form scanned to the medical record and acknowledged the PASARR completed 3/31/17 did not note the resident had bipolar disorder, neurological conditions, or dementia. She could not explain why an updated PASARR was not completed after the resident's plan of care changed. The facility's policies and procedures dated 11/08/21 titled Preadmission Screening and Resident Review (PASRR) read, The center will assure that all Serious Mentally ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting . If it is learned that after admission that a PASRR Level II screening is indicated, it will be the responsibility of the Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 3 of 15 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 105888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to complete and submit a Preadmission Screening and Resident Review (PASARR) in accordance with the state process for 1 of 5 residents reviewed for PASARR from a total sample of 40 residents. (#23) Residents Affected - Few Finding: Review of the medical record revealed resident #23 was admitted to the facility on [DATE] and re-admitted on [DATE] from an acute care hospital. The resident had diagnoses that included schizoaffective disorder, bipolar type, bipolar disorder, major depressive disorder, anxiety disorder, cognitive communication deficit, and other symbolic dysfunctions (communication disorder). The Minimum Data Set quarterly assessment with Assessment Reference Date 7/12/23 showed the resident scored 15 out of 15 on the Brief Interview for Mental Status that indicated she was cognitively intact, and had not rejected evaluation or care. Functional Status noted the resident required staff supervision and support to complete Activities of Daily Living (ADL). Antipsychotic, antianxiety, antidepressant, and opioid medications were noted as received for 7 out of 7 days during the look back period. The medical record showed a PASARR screening was completed on 1/03/22 by the facility. Section I did not include the Mental Illness (MI) schizoaffective disorder. The form did not show a case identification number to indicate it had been submitted to or processed with the State appointed vendor. The Comprehensive Care Plan included focuses for potential decline of ADL self-functioning with goals for maintenance, behavior concerns related to mood swings, bipolar disorder, and schizophrenia with an intervention for psychiatric care as needed, and monitoring for adverse effects of psychotropic medications. The Electronic Health Record (EHR) noted physician's active medication orders included Seroquel 200 milligrams (MG) at bedtime for schizoaffective disorder, Xanax 1 MG every day for anxiety, Cymbalta 30 MG every day for depression, Trazodone 100 MG at bedtime for depression, Lyrica 100 MG twice daily for seizures, and Norco 10-325 MG and 7.5-325 MG for pain. The Psychiatric Progress Note dated 8/23/22 noted diagnoses of schizoaffective disorder, bipolar type, bipolar disorder, anxiety, depression, and insomnia. On 8/16/23 at 10:39 AM, the Director of Nursing (DON) stated she was responsible for PASARR completions. She explained that she completed the screens on a paper form if a resident was admitted to the facility and did not have one, and she then gave it to medical records to scan into the record. She checked resident #23's form scanned to the medical record and acknowledged it did not include the MI diagnosis of schizoaffective disorder. She said she was not aware of the state vendor's electronic access portal process for facility appointed providers, and she did not know a completed paper form had to be faxed for further processing. On 8/16/23 at 10:58 AM, the Medical Records Coordinator explained that she scans PASARR documents to the EHR after the DON completes them on paper. She said she did not fax the records to the State vendor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 4 of 15 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 105888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769 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 0645 Level of Harm - Minimal harm or potential for actual harm The facility's policies and procedures dated 11/08/2021 titled Preadmission Screening and Resident Review (PASRR) read, The center will assure that all Serious Mentally ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 5 of 15 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 105888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure 1 of 4 residents reviewed for care planning participated in their care conference of a total sample of 45 residents. (#97) Findings: Resident #97, a [AGE] year-old male was admitted to the facility on [DATE] from an acute care hospital. His diagnoses including cerebral infarction, hypertension, diabetes type II, hemiplegia/hemiparesis following cerebrovascular disease affecting left non-dominant side, atrial fibrillation, and aphasia. Review of the resident's admission Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 7/22/23, indicated the resident's cognition was moderately impaired with a Brief Interview For Mental Status (BIMS) score of 12/15. The assessment indicated the resident required extensive assistance of one person for bed mobility, dressing, toilet use, and personal hygiene. He had impairment in functional limitation in range of motion (ROM) to one side of his upper and lower extremities. On 8/15/23 at 10:02 AM, resident #97 stated he had not been to a care plan meeting, he said he wanted to go home, and did not know what plans were made for his discharge from the facility. On 8/16/23 at 9:31 AM, Registered Nurse (RN) MDS Coordinator, explained that two weeks before the scheduled date of a resident's care conference, she would start sending invitations for the care conference to family/responsible party, and the resident. The RN MDS Coordinator said invitations would be mailed to the family/representative, and hand delivered to the residents. She stated that if the resident was their own responsible person, she would ask the resident if they wanted someone to be notified/invited to the care conference. The MDS Coordinator verbalized that on the day of the care conference, a sign in sheet would be completed for all persons in attendance. Review of the resident's Care Conference Record revealed care conferences for resident #97 were held on 2/09/23, 5/04/23, and 8/03/23. Documentation on 5/04/23 indicated the resident was in attendance, and his wife attended via telephone. Documentation on 2/09/23, and 8/03/23 revealed the resident or his wife was not in attendance, and indicated a voicemail was left for the resident's wife, this was confirmed by the MDS coordinator. She stated the resident's BIMs score was 12/15, and the resident was able to participate in his care conference meeting. The MDS Coordinator stated she did not inquire from the resident if he wanted to attend the care conference on 8/03/23, she did not go to his room, or invite him to the conference room. When asked why not, the MDS Coordinator said I have no idea. She stated the resident should have been allowed to participate in his care conference. On 8/16/23 at 10:07 AM, the Social Services Director (SSD) stated resident #97 was able to participate in his care conference. On 8/16/23 at 12:27 PM, the Director of Nursing (DON) stated residents should have the opportunity to participate in their care conference, if they were alert and oriented. The facility's policy Care Plan Invitation with effective date of 11/30/14, and revision date of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 6 of 15 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 105888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 9/25/17, read, The resident and/or the resident representative shall be invited to attend each of the Interdisciplinary Care Planning Conferences for the specified resident. The policy Plans of Care with effective date of 11/30/14, and revision date of 9/25/17 read, An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance. Event ID: Facility ID: 105888 If continuation sheet Page 7 of 15 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 105888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure clinical staff administered medication according to standards of practice, facility policy and procedure for administration of medication through enteral route via gastrostomy tube for 1 of 2 residents out of a total sample of 12 residents observed for medication administration. (#72) Residents Affected - Few Findings: Florida Board of Nursing, Nurse Practice Act, 464.003 (19) (20) (a) (b) reads, Practice of practical nursing means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm; the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician . A practical nurse is responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. 20) Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (a) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. (b) The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. Review of the facility Policies and Procedures Medication Administration Via Enteral Tube with an effective date of 11/30/14 on page two revealed under the section for checking for placement of enteral tube, to Pour one, individual liquefied medication in the syringe, and allow gravity to drain medication into the stomach. Followed by at least 15cc (or physician order if different) of water in between each medication. Resident #72 medical record revealed a re-admission on [DATE] with a previous admission on [DATE] with diagnosis of gastroenteritis, colitis, gastrostomy status, hypertension, protein calorie malnutrition, and type 2 diabetes. The Quarterly review Minimum Data Set (MDS) assessment, dated 5/16/23, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 4, which is severe cognition impairment. Resident #72's care plan initiated on 10/11/22 shows a focus for difficulty swallowing, resident requires tube feeding, and interventions include checking the gastroenteritis tube for placement, gastric contents, residual volume as ordered, and record. On 08/16/23 at 1:19 PM, observation during a medication administration pass revealed Registered Nurse (RN) C crushed Diazepam 5 milligrams (mg) tablet, and then dissolved the medication in a medicine cup with water at the bedside table for resident #72. She then used a syringe to draw up the medication from the medication cup. RN C then uncapped resident #72's gastrostomy tube (G tube) and pushed the medication into the resident's G-tube. She then re-clamped the resident's G tube, returned to the bedside table, withdrew 30 cubic centimeters (cc) of water into the syringe, returned to resident #72, uncapped the G tube, and used the plunger of the to advance the water flush into the resident's G tube. Observation revealed RN C did not check for residual, allow medication or water flush to flow by gravity, medication to drain into residents G tube, or check for placement of the tube. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 8 of 15 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 105888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Boullata [NAME], Long Carrera A, [NAME] L, et al. ASPEN safe practices for enteral nutrition therapy. JPEN J Parenter Enteral Nutr. 2017; 41(1):15 –103 https://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Toolkits/Enteral_Nutrition_Toolkit/Safe_Practices_for_En On 08/16/23 at 4:09 PM, RN C, with RN D as a Spanish interpreter, and Unit Manager for 100 unit, RN C stated she checked G tube placement for resident #72 with her hand. After a reenactment of the observation of medication administration through G tube of resident #72 with RN C, she then confirmed she did not check for placement, residual, and she pushed through the G Tube the administered medication with the plunger of the syringe when she administered the medication and flush to resident #72. She stated that the administered medication and water flush were not administered by pouring them into the G tube to infuse by gravity. She said she did not remember the last time she received education on administration of medications through an eternal route (G tube). On 08/16/23 11:00 AM, Director of Nursing (DON) stated the expectation for nurses is to follow the facility procedure for administration medication via enteral tube. Review of RN C's job description dated 2/13/23 showed the primary purpose is to provide direct resident care in accordance with established plans, and is accountable for carrying out duties and responsibilities. Must be knowledgeable of nursing medical practices and procedures, as well as laws, regulations, guidelines that pertain to nursing care facilities, and act in compliance with regulatory and professional standards, and guidelines include providing supervision as needed to nursing staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 9 of 15 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 105888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769 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 - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a Restorative Nursing Program (RNP) to maintain function as recommended by Physical Therapy for 1 of 1 resident reviewed for rehabilitative/restorative services of a total sample of 45 residents. (#97) Findings: Resident #97, a [AGE] year-old male was admitted to the facility on [DATE] from an acute care hospital. His diagnoses including cerebral infarction, hypertension, diabetes type II, hemiplegia/hemiparesis following cerebrovascular disease affecting left non-dominant side, atrial fibrillation, and aphasia. Review of the resident's admission Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 7/22/23, indicated the resident's cognition was moderately impaired with a Brief Interview For Mental Status (BIMS) score of 12/15. The assessment indicated the resident required extensive assistance of one person for bed mobility, dressing, toilet use, and personal hygiene. He had impairment in functional limitation in range of motion (ROM) to one side of his upper and lower extremities. Physician order dated 10/14/22 revealed the resident could have restorative/maintenance programs as indicated. Review of the resident's Physical Therapy (PT) Discharge Summary revealed resident #97 had PT from 10/15/22 to 12/18/22 and was discharged to an Alternate site/setting for continued services. Discharge recommendation was for Restorative Nursing Program, and the document read Prognosis to maintain CLOF (current level of function) was excellent with participation in RNP. On 8/16/23 at 2:09 PM, the Director of Nursing (DON) stated the Rehab department determined the need for a resident to be on the RNP. She explained that Therapy would then educate and train the Restorative Certified Nursing Assistant (CNA) to ensure they knew how to execute the program. She confirmed that she would be the person to oversee the RNP, the restorative program would be given to the DON, signed off by the DON and nurse, and would then be implemented. The DON stated documentation regarding the RNP would be completed in a notebook on the units by the Restorative CNAs. On 8/16/23 at 2: 45 PM, the DON stated she could not locate or identify the RNP developed for resident #97, and the Director of Rehab would be researching to locate/identify if a RNP was developed. On 8/16/23 at 3:25 PM, the Director of Rehab stated he recalled he discharged resident #97 from PT and signed off on recommendation for RNP. He explained that the RNP would be developed by Rehab, and a therapist would educate/train the restorative CNAs. He stated a communication sheet would be provided to the DON/Assistant DON, and nursing would implement the recommendation, and a copy of the RNP would be kept by the Therapy department. The Director of Rehab stated he could not locate a copy of the RNP developed for resident #97, and he could not verify that the recommendation was implemented. On 8/16/23 at 3:36 PM, the DON stated that a RNP was not developed/implemented for resident #97 as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 10 of 15 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 105888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769 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 was recommended by Therapy. She stated the RNP should have been implemented as recommended for the resident. The Facility assessment last reviewed on 7/28/2023 indicated that services and care offered was based on the resident's needs, and included restorative nursing. Residents Affected - Few The facility's policy Restorative Nursing Services with effective date 2/01/2016 and revision date 4/15/22 read, The center provides restorative nursing to encourage and enable residents to be as independent as possible based on their individual condition, and goals. Restorative nursing programs are considered for residents who: Are not a candidate for rehab services * Benefit from restorative along with rehab services. Procedure included: A Restorative Care Plan to be developed by Restorative Nurse/designee. * Restorative nurse/designee to document in the medical record the initiation of a restorative program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 11 of 15 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 105888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status related to weight loss for 1 of 5 residents reviewed for nutrition out of a total sample of 45. (#70) Residents Affected - Few Findings: Resident #70 was admitted to the facility on [DATE] with diagnoses including encephalopathy, altered mental status, Alzheimer's disease, anxiety disorder, gastro-esophageal reflux disease, major depressive disorder and malignant neoplasm of larynx. Review of the Minimum Data Set 5-Day Medicare assessment with assessment reference date of 7/05/23 revealed resident #70 had a Brief Interview for Mental Status score of 10 which indicated she had moderate cognitive impairment. The document indicated resident #70 had an unplanned weight-loss of 5% or more in 30 days. Review of resident #70's Electronic Medical Record (EMR) revealed resident weighed 113.8 pounds on 5/30/2023 and weighed 108.0 pounds on 6/27/2023 which was a weight loss of 5.10 percent. Review of resident #70's medical record revealed a care plan for at risk for nutritional problem initiated 5/24/23, revised 7/08/23. The stated goal was resident would maintain adequate nutritional status as evidence by maintaining weight with no significant change. Interventions included for Registered Dietician (RD) to evaluate and make diet change recommendations as needed and to provide and serve supplements as ordered. Review of a Dietary Progress Note dated 7/08/23 revealed a recommendation by the RD for Health Shakes supplement twice a day at 10:00 AM and 2:00 PM. The RD documented she would continue to monitor and follow-up as needed. Review of resident #70's physician orders revealed no order for Health Shakes. Review of the Medication Administration Record (MAR) for July and August 2023 revealed no nursing documentation to validate resident #70 received a Health Shake twice a day as recommended. On 8/14/23 at 1:02 PM, resident #70 was observed reclined in bed with a meal tray on the overbed table in front of her. Resident stated lunch was good but observation showed she had eaten less than 25%. On 8/15/23 at 12:43 PM, resident was observed in bed with the meal tray on the overbed table in front of her. A bite was taken out of the hamburger and a chewed bite of food was observed on the overbed table next to the tray. The resident stated she did not want anything else to eat. On 8/17/23 at 10:07 AM, the Certified Dietary Manager (CDM) stated restorative aides were responsible for obtaining weekly and monthly weights that were provided to the dietary department. She explained the facility had weight meetings once a week to discuss focus residents and evaluate interventions. The CDM clarified the Registered Dietician (RD) usually attended those meetings. On 8/17/23 at 10:36 AM, the RD reviewed resident #70's medical record and recalled the note she entered on 7/08/23. She verified she recommended a health shake twice a day at 10:00 AM and 2:00 PM for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 12 of 15 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 105888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 30 days. The RD acknowledged she could not verify if resident #70's weight stabilized as no weight was entered since 6/27/23. She stated she would need a current weight in order to determine if intervention was effective. The RD verified the facility held weight meetings every week. She clarified the committee had discussed monthly weights, but had not specifically discussed resident #70's weight loss. On 8/17/23 at 2:21 PM, the RD stated a current weight had been obtained for resident #70. She reported resident #70's current weight was 102.5 which was a decrease of 5.09 percent from her previous weight making a 9.93 percent weight loss since 5/30/23. The RD confirmed resident #70 was still losing weight. On 8/17/23 at 4:07 PM, the RD explained she usually provided a recommendation form to the Director of Nursing (DON) for supplements to be entered into the EMR. She stated the (DON) or Unit Manager should have entered the order for the health shake when recommended on 7/08/23. She explained if put into orders it would appear on the Medication Administration Record (MAR) so nurses could document the percentage consumed. The RD reviewed physician orders for resident #70 and verified there was no order for the house shake. She stated it did not appear the recommendation was implemented. She acknowledged if it was not on the MAR, there was no documented evidence that resident #70 received the health shake as recommended. On 8/17/23 at 2:52 PM, the DON confirmed the restorative aides were responsible for obtaining weights and she would input them into the EMR. She acknowledged no weight had been entered since 6/27/23 and explained resident #70 would sometimes refuse to be weighed. The DON reviewed the weight sheet provided by the restorative aides which showed resident #70 refused to be weighed twice on 8/03/23 and refused to be weighed 3 times on 8/10/23. The DON verified the facility held weight meetings weekly. She explained the weight meetings had not been held since February 2023 and only restarted two weeks ago. She reviewed the minutes from the weekly weight meetings for the last two weeks and reported resident #70 was not discussed during those meetings. She clarified a progress note would have been entered in resident #70's EMR if her weight loss had been discussed during the weight meeting. On 8/17/23 at 4:39 PM, the DON stated she did not remember getting a recommendation from the RD for health shakes for resident #70. She reviewed resident #70's medical record and verified the order was not entered. The DON could not provide documentation to show resident #70 received house shakes or the amount consumed. She acknowledged the recommendation was not followed and it was unlikely resident #70 was provided with health shakes as recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 13 of 15 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 105888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide routine dental services to 1 of 3 Medicaid-funded residents reviewed for dental from a total sample of 40 residents. (#91) Residents Affected - Few Findings: Review of the medical record revealed resident #91 was admitted to the facility on [DATE] from an acute care hospital and had diagnoses that included gastric ulcer, intestinal infection, difficulty swallowing, gastroesophageal reflux disease (GERD), diabetes, vitamin deficiency, anemia, and muscle weakness. The Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date 7/01/23 noted the resident scored 15 out of 15 on the Brief Interview for Mental Status that indicated the resident was cognitively intact. The assessment showed the resident did not have any episodes of behavior or rejection of care or services, and she required staff supervision and support to complete activities of daily living. On 8/14/23 at 10:53 AM, resident #91 was observed sitting in a wheelchair in her room. The resident said she had lived at the facility for a year and a half, and she still had not been provided any dental health services. She explained she was upset and felt like she had been ignored. She stated, they don't listen, and their system is broken. Review of the Order Review Report included active physicians' orders entered on 3/23/22 that read, Dental as needed. The Comprehensive Care Plan included a focus for potential skin integrity impairment and abnormal bleeding related to use of blood thinner medications with goals that included encouragement of maintenance of good nutrition and hydration to promote healthier skin. The plan of care did not include interventions for oral/dental health and maintenance. The resident's Patient Progress Reports by the dental provider dated 11/25/22, 1/03/23, and 2/08/23 showed she did not receive care and services. The Screening Report dated 4/06/23 noted the resident was screened by the Dentist and read, Dental Hygienist is authorized to treat patient: Yes. On 8/17/23 at 11:45 AM, the Social Services Director said resident #91 had been enrolled in the Medicaid dental program on 11/10/22, 8 months after she had been admitted to the facility. She explained there were no notes for follow up care and services. She checked the medical record and stated the resident was first seen and had been cleared for treatment by the dentist on 4/06/23, 5 months after she was enrolled. On 8/17/2023 at 4:54 PM, the Social Services Director explained she had verified with the dental provider that the resident had not received follow up care and services after she was screened and cleared for treatment. She said they normally responded quickly, were at the facility frequently, and treated residents at most within 30 days. She could not explain why resident #91 was not included on their list and had not been treated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 14 of 15 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 105888 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769 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 0791 Level of Harm - Minimal harm or potential for actual harm The facility's policies and procedures dated 11/27/2017 titled Dental Services, read, Medicaid residents services and routine services covered under the State plan at no charge. If any resident of the facility is unable to pay for needed dental services, the facility will attempt to find alternative funding sources or alternative service delivery systems to ensure the resident maintains his/her highest practicable level of well-being. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 15 of 15