Inspection·October 10, 2025

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few anything was done to keep resident #2 from returning to resident #1's room. He said he had witnessed at other times, resident #2 entering other resident rooms uninvited and touching their belongings. He explained that resident #2 used to be his roommate and he requested to change rooms because he used to touch his things without permission. He said he felt resident #1 was affected by the incident because she was scared to sleep that night and was crying.On 10/09/25 at 1:29 PM, resident #3 was sitting in the common area of the facility. He could not recall the event nor any details of what happened.On 10/10/25 at 12:14 PM, LPN B confirmed he had worked on 10/06/25 during the overnight 7:00 PM to 7:00 AM shift. He said that between the hours of 11:00 PM and 11:30 PM he was in the 100-hallway where residents #1, #2, and #3 lived, passing medications alongside LPN A. The LPN recalled that residents #1 and #3 walked casually down the hallway to LPN A and reported that resident #2 had entered resident #1's room to touch her but they did not say where she was touched. LPN A told resident #1 to go back to her room and she would come see her. LPN B said he did not see resident #2 in the hallway at that time, which he indicated was rare because he usually paced the hallways at night. LPN B said he was not resident #1 or #2's nurse, so he was not involved and did not report the incident to the on-call Supervisor. The nurse said he was not asked to write a statement by anyone at the facility.On 10/10/25 at 11:52 AM, LPN A confirmed she was the assigned nurse for residents #1 and #2 on 10/06/25. She said that between the hours of 10:30 PM and 11:00 PM, she passed medications in the 100-hallway when resident #1 walked up to her cart and was visibly shaking. LPN A recalled resident #1 told her that resident #2 had been in her room and touched her hand and back. The nurse explained she told resident #1 to return to her room and she would come to see her. LPN A said she saw resident #2 standing near the doorway of his room and she asked him what happened. The nurse said resident #2 was unable to remember anything. The LPN recalled that resident #2 told her if he had done something to resident #1, he wanted to apologize but she told him to stay in his room. LPN A said she shut resident #1's room door and positioned herself where she could watch resident #2 in case he came out of his room. The nurse said she sent the Director of Nursing (DON) a text message, but it never went through until the morning. She did not say why she did not attempt to call the DON or the Administrator who was the Abuse Coordinator, when she did not get a reply. LPN A said she received a message from the DON at approximately 6:00 AM, directing her to write a statement of what happened and to get statements from the residents. The DON told her that resident #2 would be put on one-to-one supervision that morning. She said she did not perform a skin check on resident #1 because when she spoke to her, she told her she was fine, so she did not think a skin check was needed. LPN A said she returned to work on 10/08/25 at 7:00 PM and saw resident #2 was on one-to-one supervision.On 10/10/25 at 11:21 AM, the Assistant Director of Nursing (ADON) said that on 10/07/25 at approximately 10:00 AM, she heard resident #1 talking about the incident in the hallway to another staff member so she approached her. Resident #1 told her resident #2 had come to her room and touched her shoulder. The ADON reported the incident to the Administrator and DON so that an investigation could be started. She said that the psychiatric provider was consulted to evaluate both residents on 10/08/25. Resident #1 spoke with the psychiatric provider via telehealth and told her that she was scared to sleep at night and could not eat. The ADON said she did not instruct LPN A to complete an incident report because this incident did not require one. She expressed that the expectation for staff was to call the DON or Administrator to report all incidents and for staff to take any allegations of abuse seriously. She said that on 10/08/25 she passed out a handout to staff instructing them to watch resident #2 closely to ensure he did not enter other resident rooms.On 10/10/25 at 1:22 PM, in a joint interview with the DON and Administrator, the DON said that on 10/07/25 at 6:20 AM, he received a text (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105888 If continuation sheet Page 2 of 3 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 10/10/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete message from LPN A that resident #1 alleged resident #2 had entered her room to touch her on the shoulder and wake her up. The DON said he instructed LPN A to write a statement but said there were no other instructions given. The Administrator confirmed she received a call from the DON telling her about the incident, and that resident #1 was doing fine. The Administrator said they had a meeting with resident #1's sister on 10/07/25 to discuss the incident with her but confirmed they did not tell the sister what would be done to ensure resident #2 did not get near resident #1 again. They said they spoke with resident #1 who told them she was fine and felt safe at the facility. She said they did not gather statements from staff until 10/08/25 because they felt the event did not rise to the level of harm. The DON confirmed he did not instruct LPN A to conduct a skin assessment on either resident or complete an incident report. He said there was no order to do one-to-one supervision with resident #2 until 10/08/25 after the sister insisted something be done to ensure resident #2 did not repeat his actions as he still wandered the hallways freely at night. The Administrator said LPN A should have continued to reach out to the DON when she did not hear back from him right away. She said she was the Abuse Coordinator, and her number was posted throughout the facility. She confirmed they did not do a full investigation because resident #1 said she was doing fine. She agreed that all allegations of abuse should be investigated thoroughly to ensure proper actions were taken to keep residents safe.Review of the facility's Abuse, Neglect, Exploitation, and Misappropriation Policies and Procedures revised 11/16/22, revealed that sexual abuse was defined as non-consensual sexual contact of any type and was not limited to unwanted intimate touching of any kind. Generally, sexual contact was non-consensual if the resident did not want the contact to occur. The procedure for investigation was to immediately upon an allegation of abuse, the suspect should be segregated from residents pending the investigation. The assigned nurse or DON should perform and document a thorough nursing evaluation and notify the attending physician. An incident report should be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. The policy indicated the Abuse Coordinator or DON should take statements from the victim, suspects, and all possible witnesses including those within the vicinity of the alleged abuse, and upon completion of the investigation, a detailed report should be prepared. Event ID: Facility ID: 105888 If continuation sheet Page 3 of 3