F 0557
Level of Harm - Minimal harm
or potential for actual harm
Honor the resident's right to be treated with respect and dignity and to retain and use personal
possessions.
Based on observation, and interview, the facility failed to promote dignity for one of four residents sampled
for activities for daily living, (#3).
Residents Affected - Few
Findings:
On 5/15/2024 at 12:25 pm, resident #3 was seated at a square table in the day room on the 100 hall.
Resident #3 wore a yellow hospital gown that tied around the neck. The resident's left hip was exposed and
visible to staff and visitors as they walked by the day room.
On 5/15/2024 at 12:29 pm, the resident stated, I don't like wearing a hospital gown. I have very few clothes
in my room. I am more of a short-sleeved shirt and pants person.
On 5/15/2024 at 12:40 pm, the Director of Nursing (DON) walked by and commented that she could see
the resident's side and bottom exposed from the hallway. The DON said the resident should not be wearing
only a hospital gown in the day room but might not have clothes in her room. The DON explained if the
resident did not have any clothes in their room, they could get clothes from the laundry department.
On 5/15/2024 at 12:43 pm, observation of resident #3's closet revealed one drawer with a sweatshirt and
pants.
On 5/16/24 at 3:50 pm, the Administrator said, the expectation is the resident should be covered while in a
common area like the day room for dignity. The Administrator explained the facility would reach out to family
if the resident did not have any clothing and noted they had some donated clothes in the laundry
department. The Administrator then acknowledged the resident was again wearing a hospital gown, second
day in a row.
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:
105888
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
05/17/2024
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 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, and interview, the facility failed to serve food at proper safe food temperature during
the dinner meal.
Residents Affected - Some
Findings:
On 5/15/24 at 5:04 pm, the cook began serving dinner from the serving line. The cook did not take the
temperature of the food before serving the line. The first dinner cart was pushed out the kitchen door at
5:30 pm. The temperatures of the food on the serving line were taken by the cook on 5/15/24 at 6:02 pm,
after the meal service.
On 5/15/24 at 6:05 pm, the temperature of the parmesan baked zucchini liquid was 109 degrees Fahrenheit
(F). The cook continued taking temperatures of the rest of the serving line and did not explain why the
temperature of the zucchini liquid was not at the appropriate temperature.
On 5/16/24 at 3:32 pm, during an interview, the Interim Certified Dietary Manager (CDM) explained the
temperature of the parmesan baked zucchini liquid at 109 degrees F was too low and stated the
temperature of any food item on the steam table, even after meal service, should be above 135 degrees F
to prevent food borne illnesses.
On 5/16/24 at 3:46 pm, the Administrator said they expected the temperature of the food on the steam table
to be hotter than 109 degrees F to prevent food borne illnesses.
On 5/15/24 at 6:09 pm, the cook took the temperature of the hamburgers that were served from a flat half
tray placed across the top of the steam table from the beginning of meal service at 5:04 pm. At 6:09 pm,
the temperature of the hamburgers was 98 degrees F.
On 5/16/24 at 3:34 pm, the Interim CDM said the hamburgers should have been placed in a pan in the
steam in beef broth to keep it warmer. The cook needs to heat all food to 165 degrees F before it leaves the
kitchen.
On 5/16/24 at 3:48 pm, the Administrator said the hamburgers should have been placed inside a well on
the steam table to achieve a safe temperature. The Administrator noted the half tray sat on top of the steam
table, and not in the well.
On 5/16/24 at 3:37 pm, the Interim CDM explained best practice was to take food temperatures right before
the first plate was served to make sure food was served at the proper safe temperature.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105888
If continuation sheet
Page 2 of 2
