Inspection·February 18, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few could report allegations of abuse and neglect. She shared the facility had two hours to report abuse and neglect. On 2/18/25 at 10:22 AM, the Administrator (NHA) stated grievances were discussed in morning meetings but were not read verbatim just discussed as a general concern. She mentioned whoever received a grievance needed to inform her if a reportable was questionable. On 2/18/25 at 3:42 PM, the NHA and SSD reviewed resident #7's grievance form dated 2/05/25. The SSD stated she gave a copy to the Unit Manager (UM) to follow up and she was waiting for disciplinary action and education for the resolution. The NHA stated she had not seen the grievance and was not aware of it. The NHA read the concerns of resident #7 and stated the grievance, sounded as [like] verbal abuse. The NHA confirmed the grievance was not followed up with resident #7 or reported to the State agency. On 2/18/25 at 3:55 PM, the NHA stated the SSD told her she had not seen this grievance, it may have fallen through the cracks, or was probably given to the Unit Manager (UM) directly by the Direct Patient Experience Coordinator. The NHA stated when the form was handed to the SSD by the UM, she did not read it and just filed it. The NHA confirmed this was not investigated as required. Review of the facility's Complaint/Grievance policy revised on 10/24/22 revealed the intent to support each resident's right to voice a complaint/grievance and to make prompt efforts to resolve the complaint/grievance and inform the resident of the progress towards resolution. The document read, Grievances discovered to meet the definition of Abuse, Neglect, Exploitation or Misappropriation will be handled per the facility's Abuse Policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 2 of 9 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 02/18/2025 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 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 interview, and record review, the facility failed to prevent further abuse, and timely and accurately report an allegation of abuse to the State Agency for 2 of 4 residents reviewed for abuse, of a total sample of 8 residents, (#1 and #7). Findings: 1. Review of resident #7's medical record revealed she was readmitted to the facility on [DATE] with diagnoses including encephalopathy (disorder that affects the brain), chronic obstructive pulmonary disease, type 2 diabetes, liver disease, and dementia. Review of the Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) of 1/22/25 revealed resident #7 was usually understood by other and she usually understood others. Resident #7 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated she was cognitively impaired. The MDS assessment noted no behaviors and no rejection of care necessary to obtain goals for her health and well-being. She was dependent on staff for toileting hygiene and needed substantial/maximal assistance for personal hygiene. She was always incontinent of bladder and bowel. Review of the Resident Grievance Log revealed resident #7 filed a concern on 2/05/25. The Complaint/Grievance Report read, resident #7 had to be changed for the second time and the CNA (Certified Nursing Assistant) yelled at her saying, I just changed you. [Resident #7] says this is not the first time and does not like being yelled at. Incident occurred at night. Review of the Reportable Event Log in February 2025 did not include resident #7. There was no report submitted to the State Agency. On 2/18/25 at 3:42 PM, the Administrator (NHA) stated she had not seen the grievance from resident #7 and was not aware of it. The NHA read the concerns in the grievance form from resident #7 and stated it sounded as verbal abuse and confirmed it was not followed up or reported. Later at 3:55 PM, the NHA stated the Social Service Director told her she had not seen this this grievance, that it may have fallen through the cracks, or was probably given to the Unit Manager (UM) directly by Direct Patient Experience Coordinator. The NHA confirmed this was not investigated as required. 2. Review of resident #1's medical record revealed he was admitted to the facility on [DATE] with diagnoses including encephalopathy, cellulitis of right lower limb, difficulty walking, orthopedic aftercare, arthritis, and repeated falls. Review of the MDS quarterly assessment with ARD of 12/11/24 revealed resident #1 had a BIMS score of 14 out of 15 which indicated he was cognitively intact. The MDS assessment noted no behaviors and no rejection of care necessary to obtain goals for his health and well-being. Resident #1 needed substantial assistance from staff for toileting hygiene and personal hygiene. He was always incontinent of bladder and occasionally incontinent of bowel. Review of a State Agency report for physical abuse submitted by the facility on 2/11/25 revealed the NHA learned of resident #1's allegation of abuse at 2:15 PM on 2/11/25. The report included the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 3 of 9 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 02/18/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few following description of the allegation/incident: Resident #1 wanted to be changed, CNA C asked him to give her a moment, but he wanted to be changed immediately. CNA C walked up to resident #1 to advise him that she would get to him when she finished the other resident. Resident #1 stated he felt uncomfortable with how close she got to him when she approached him. On 2/17/25 at 8:50 AM, resident #1 stated prior to admission to the facility, he had right hip surgery, fell after surgery at the hospital, and had not been able to walk again or work with therapy. Resident #1 shared he experienced an abuse incident early one morning. He explained a CNA raised her hand to hit him, and he reacted by using foul language towards her. He mentioned that was the first time the CNA had worked with him. He stated the police came to talk to him and he was told she would not care for him again. He explained his nurse told the CNA to change him, but the CNA left him naked then left the room. He mentioned when she returned, she made a gesture to hit him, and he closed his fists and raised his arms to protect himself because he felt like she would hit him. He stated he could not get up to defend himself. He said, She must have been drugged or something because someone who does that to a patient lying in bed cannot be right. He recalled someone else came to get him dressed. He stated a manager later spoke with him about the incident. On 2/17/25 at 5:44 AM, Registered Nurse (RN) A recalled early one Saturday morning resident #1 reported CNA C raised her hand and he perceived it as she was going to hit him. She explained that morning, CNA C called RN A into resident #1's room and the resident told her he was wet and needed to be changed. RN A stated CNA C responded she would return to change him. RN A indicated CNA C stepped out of the room and sat by the nurses' station to document and did not change resident #1 at that time. RN A mentioned she later returned to give resident #1 his medications and he told her CNA C returned to his room later and he had to hold her hand to not get hit. She indicated she reported the incident to the Weekend Supervisor and completed a witness statement. She stated she and the Weekend Supervisor called the Director of Nursing (DON) that same morning and reported the allegation. She stated she did not know what happened after that because she did not work the rest of the weekend. She indicated she did not perform a head-to-toe assessment for resident #1. She stated he was not crying, agitated or upset when he told her about the incident and he did not request a change of assignment. She recalled the oncoming shift CNA B reported what resident #1 told her and she told CNA B she had already reported the incident to the DON. She explained after that day, no one in the facility asked her any questions about that incident. On 2/17/25 at 8:09 AM, the Weekend Supervisor stated the Abuse Coordinator was the NHA. She shared allegations of abuse or neglect were reported immediately because the facility had 2 hours to file a report. When asked about the incident for resident #1, she recalled CNA B told her resident #1 reported a CNA had, smacked him or put her hand towards him. She indicated she was unable to interview resident #1 because he spoke Spanish. She shared she and CNA B went to resident #1's room to interview him. The Weekend Supervisor stated resident #1 said the CNA who had him last night put her hands toward him. She indicated she later asked RN A and she confirmed she was aware of the incident. The Weekend Supervisor shared she then called the DON and reported it. She explained typically we would have the nurse do a skin check but she did not do it. She said, My time in his room was limited because resident #1's roommate did not like anyone in the room who did not speak Spanish. She indicated CNA C was assigned to that room from 11 PM to 7 AM and did not speak Spanish. She said, We do not always have Spanish speaking CNAs at night, but there was a staff member working who could translate if or when needed. She stated she did not recall if she wrote a statement or not that morning but remembered reporting it to Administration. She shared she worked on nursing carts in the South Wing both Saturday and Sunday and did not know what happened after she reported the incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 4 of 9 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 02/18/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/17/25 at 9:25 AM, CNA B stated on Saturday 2/08/25, she started her shift at 6:30 AM, and did her rounds as always. She mentioned resident #1 liked his privacy curtain closed and the light off at night. She recalled when she went to resident #1's room, he was crying. She stated she asked him what happened, and he shared an incident that occurred earlier during the night. She stated resident #1 told her he had urinated in his brief and was burning so he pressed his call light and the CNA responded she did not have time to change him, turned the call light off and told him to go to sleep. CNA B indicated he said he turned on the call light for a second time, the same CNA returned and she started yelling at him. He told her the CNA raised her hands like she was going to hit him on his face so he put his hands up and he asked her, Are you going to hit me on my face? then the CNA left the room. She explained he shared the nurse came in and he explained what happened to the nurse but still he was not changed. CNA B indicated she changed resident #1 at that time, and he was soaking wet so she took him to the shower room and gave him a shower. She shared she noticed he had a lot of DermaSepting ointment on. She explained, only a little of that ointment should be used in red areas but not the private areas because it could cause burning sensation. She indicated before she gave resident #1 a shower she spoke with the Weekend Supervisor. She recalled the Weekend Supervisor came to resident #1's room, he was upset and talking in Spanish, so she tried to translate. She mentioned she was present when the Weekend Supervisor and the nurse called the DON. She stated resident #1 was very upset the rest of the day, he called his son, and his son tried to calm him down. CNA B mentioned whenever he remembered the incident, he cried, he was very upset. She stated she, wrote a statement right away. She shared CNA E who was also a witness when resident #1 told her about the incident also wrote a statement. She stated she worked on 2/08/25, 2/09/25 and 2/10/25 and no one from Administration spoke with her or asked her questions about the incident. On 2/17/25 at 10:26 AM, the DON recalled resident #1's incident started on 2/08/25 when he turned his call light on because he needed to be changed. He indicated resident #1 did not speak much English, so CNA C called the nurse, and the nurse explained to the CNA he needed to be changed. He stated CNA C left resident #1's room and returned to change him. The DON said, According to the resident, he saw the CNA was agitated with him, the CNA went to provide the care, the resident told the CNA hey do you want to hit me, hit me. The DON stated he asked resident #1 if CNA C hit him and the answer was no and the CNA provided care, and that was the end. The DON recalled the Weekend Supervisor called him after Licensed Practical Nurse (LPN) D told her about the incident. He indicated he spoke with resident #1 via video call with LPN F who was working in that unit but was not assigned to resident #1. The DON stated he called LPN F because she spoke Spanish. The DON stated he asked resident #1 if he felt intimidated or unsafe and the resident responded he was okay, but he did not want CNA C caring for him. The DON said, On that day there is nothing to report because it was a customer service issue. On 2/17/25 at 10:50 AM, the DON and NHA presented their report to the State Agency dated 2/11/25. The NHA stated the Direct Patient Experience staff was informed by resident #1's CNA about an incident with CNA C. The DON stated on 2/08/25, CNA B mentioned resident #1 was crying about something that happened that morning, and his night shift CNA did not understand him. The DON and NHA did not answer why they did not have witness statements from the staff assigned to resident #1 the day of the allegation. The DON stated the staff did not mention resident #1 thought CNA C was going to hit him. The DON did not answer whether he read the progress note from LPN D in resident #1's medical record. The NHA stated they did not have RN A's or CNA B's statements in their investigation folder. On 2/17/25 at 11:47 AM, the DON and CNA B stated they wanted to clarify that resident #1 did not say he was hit by CNA C. The DON and CNA B validated CNA B's statement was correct. The DON verified he instructed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 5 of 9 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 02/18/2025 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 0609 Weekend Supervisor to collect witness statements, but he did not follow up with her. Level of Harm - Minimal harm or potential for actual harm On 2/17/25 at 11:59 AM, LPN D stated during morning medication pass on 2/08/25, resident #1 told her he did not want the antibiotic he was on because it made him pee too much and turned his urine orange. She shared she could tell he was upset, and he shared, They do not want to take him to the bathroom. She explained he had a Urinary Tract Infection (UTI), and he needed to take his antibiotic. She recalled he shared I go to the bathroom too much and someone tried to hit me. She indicated his main language was Spanish, but he spoke some English. She mentioned she spoke with CNA B and they told the Weekend Supervisor about what resident #1 shared. She recalled the Weekend Supervisor informed the DON who got on the phone with resident #1 but they were talking in Spanish, so she did not understand their conversation. She stated CNA B, the DON and herself were in the room when the DON spoke with resident #1. She recalled when resident #1 told her someone tried to hit him, he was not crying but he was agitated, and I could tell he was upset. She stated she entered a progress note in his medical record but was not asked to write a witness statement. LPN D said, There was no other conversation about this incident until today. Residents Affected - Few Review of resident #1's medical record revealed a Progress Note entered on 2/08/25 at 9:04 AM, by LPN D. The note read, During a.m. (morning) med (medication) pass pt (patient) seem upset, pt didn't want to take ABT for UTI, pt was stating it turns his urine orange and stated that it burns, pt was educated on the importance of taking meds, and that his urine turning orange is a harmless side effect that goes away after completion of taking med, and the medication will help the burning, pt took meds and stated he didn't have a good night because CNA tried to hit him because he turns on light to be changed, stating he urinates too much. Supervisor was notified. On 2/17/25 at 12:17 PM, CNA E shared before 7:00 AM on 2/08/25 CNA B called her to come into resident #1's room. She indicated CNA B told her she wanted a witness to ensure she understood correctly what resident #1 was saying. CNA E stated resident #1 was crying and she asked what happened. She mentioned he stated he was very, very upset because he got into an argument with the night shift CNA because he wanted his brief to be changed and felt a burning sensation, and they were like fighting verbally. CNA E stated resident #1 raised his hands showing them what he did when he thought the CNA was going to slap him. She explained she and CNA B asked resident #1 if the CNA hit him and he responded no, but he raised his hands because he thought she was going to hit him. She stated she reported the incident to the night nurse who told her she had spoken with the resident. She mentioned no one asked her for her witness statement until today. On 2/18/25 at 9:02 AM, CNA C stated resident #1 communicated with her in English. She recalled performing her rounds as usual on that particular night. She mentioned at around 3:00 AM she was collecting cups to get new ones with fresh water for all her assigned residents. She stated she answered a call light in resident #1's room and he said he needed his cup of water and began speaking to her in Spanish. She indicated she asked him what he was saying, but he continued speaking in Spanish, so she left the room to get the nurse because she did not understand Spanish. She stated she returned with RN A and the nurse told her resident #1 said he was wet and needed to be changed. She indicated she changed his brief and accidentally bumped into his bedside table causing some things to fall to the floor. CNA C stated she pulled his pants up, got all the things from the floor and told him to pull his sheet over his head the way he liked and always did. She indicated she made the hand gesture for him to pull the sheet over his head. She stated she left the blanket over his chest, instructed him to pull it over and he told her not to talk to him like that and made a gesture with his finger pointing at her. She indicated she left his room after that, and returned to check on him around 5:00 AM and he was sleeping. She mentioned she did not talk to him again. She recalled she finished her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 6 of 9 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 02/18/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shift and left for the day. No one mentioned anything or asked any questions. She explained when she returned to work on Monday 2/10/25, she noticed her assignment was changed so she wondered why. She shared she spoke to the other CNA who had her assignment, and they discussed changing their assignments. She stated a CNA working on the unit asked her if she had received a call from Human Resources (HR). She shared she was told by that CNA resident #1 made an allegation, apparently on Friday you threw your hands up and that was the rumor she heard. CNA E stated she did not receive a call that weekend from the facility and was shocked about the allegation. She stated she was told by that CNA if I were you, I would leave the assignment the way it was. She indicated she tried to speak with RN A who working that night, but she did not speak much English. She mentioned RN A confirmed she had to stay over on Saturday to write a statement about what happened that morning. CNA E stated she did not go into resident #1's room on 2/10/25 to 2/11/25. She stated she attended a town hall meeting the morning of 2/11/25 and left the facility at approximately 9:00 AM. She indicated she received a call from HR later that day, between 4:00 and 5:00 PM and was informed she was suspended and had to come in to write a statement. She shared she came to the facility on Wednesday 2/12/25, wrote her statement and learned the facility's protocol was to suspend her for three days until they completed an investigation. She stated HR called her yesterday and told her she needed to come in for a class today. On 2/18/25 at 11:54 AM, the Direct Patient Experience explained she visited all residents daily to ensure everything is up to par with them. She explained on 2/11/25, a CNA shared resident #1 had a concern. The Direct Patient Experience staff stated she and the NHA spoke with resident #1. She shared resident #1 explained he had a verbal altercation with CNA C one night, and he felt safe in the facility, but did not want that CNA to care for him any longer. On 2/17/25 at 1:30 PM, the NHA explained HR spoke with CNA C to inform her of the suspension. The NHA stated she felt CNA C's statement was clear and she did not have any follow up questions for her. She shared when the DON called her on 2/08/25, he explained resident #1 was upset at a CNA but the resident was the one yelling to the CNA and it escalated. The NHA indicated she ran it by the Regional Nurse Consultant and was told it sounded more like a grievance. She shared all grievances were discussed during morning meetings but she did not realize the whole situation, and the DON made it seem like the Weekend Supervisor was not making it a severe incident. The NHA stated when she was called, a physical or verbal abuse allegation was not mentioned. She indicated she assumed the DON took it as not an abuse allegation or undermined it. The NHA stated LPN F said she did not get a statement from CNA B, but CNA B confirmed she wrote a statement. The NHA stated she did not review and was not aware of LPN D's progress note in resident #1's medical record and did not think management looked at the note. She confirmed the facility did not interview other residents assigned to CNA C. Review of the facility's Abuse, Neglect, Exploitation & Misappropriation policy revised on 11/16/22 included the steps for investigating allegations of abuse. The form read, Immediately upon an allegation of abuse or neglect, the suspect(s) shall be segregated from residents pending the investigation of the resident allegation. The nurse or Director of Nursing/designee shall perform and document a thorough nursing evaluation and notify the attending physician. An incident report shall be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. This report shall be filed as soon as possible in order to provide the most accurate information in a timely fashion, and submitted to the Abuse Coordinator. The Investigation section included, 'The Abuse Coordinator and/or Director of Nursing shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. Any suspect who is an employee will be suspended when identified. Increased supervision of alleged victim and residents . The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 7 of 9 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 02/18/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Protection section read, Provide the resident with emotional support and counseling during and after the investigation, if needed. The Reporting/Response section revealed reporting should be immediately, but no later than 2 hours after the allegation was made if the events that caused the allegation involved abuse to the Administrator and other officials in accordance with State law. The policy included the DON was the designated abuse coordinator in the absence of the Executive Director. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 8 of 9 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 02/18/2025 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview, and record review, the facility failed to ensure implementation of policies to the extent of including thorough monitoring of previously identified areas of concern and adequately tracking performance to ensure prior improvement measures were realized and sustained. Findings: Review of the complaint survey conducted on 12/10/24 at the facility revealed citations including F609 for concerns related to reporting of abuse allegations. During the course of the current survey, F609 was again identified for concerns of investigating and reporting allegations of abuse and/or neglect. As a result of the repeat citation, it was identified there was insufficient auditing and oversight of the previous mentioned citation. On 2/18/25 at 3:55 PM, the Administrator explained she did not look at the actual grievance forms, just the grievance log brought in monthly to the Quality Assurance and Performance Improvement (QAPI) meeting. She stated the facility's last QAPI meeting was held on 2/13/25 and the focus was the facility's new QAPI plan. The Administrator stated she was not the Administrator during the survey in December 2024 when the facility was previously cited for failure to report allegations of abuse and neglect, and could not say what was done after those concerns were found to prevent repeat deficiencies from occurring. Review of the facility's Complaint/Grievance policy revised on 10/24/22 revealed grievances would be review by the Quality Assurance Performance Improvement Program Committee. Review of the facility's Abuse, Neglect, Exploitation & Misappropriation policy revised on 11/16/22 read, The center will review allegations of Abuse, Neglect, misappropriation of resident property and exploitation during QAPI meetings. QAPI committee will review info including but not limited to: The thoroughness of the investigation, Protection of the resident(s), Risk factors identified, Root-cause analysis of the investigation, Systemic changes that may be required. Review of the facility's Quality Assurance Performance Improvement Program policy revised on 10/24/22 revealed the objective was to focus on indicators of the outcomes of care and quality of life. The document mentioned the review of activities such as resident/family complaints/satisfaction. The policy read, The center will collect and monitor data from different departments reflecting its performance. The center will identify data sources and timeframes for collection. Data sources may include but are not limited to . Grievance logs . Medical record reviews . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 9 of 9