Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avante At St Cloud Inc during CMS and state inspections, most recent first.
Two residents experienced deficiencies in pain management at the facility. One resident with multiple sclerosis reported ear pain due to wax buildup, but an ENT consult was delayed, and the issue was not promptly addressed. Another resident with dementia and neuropathy suffered from severe pain, with Biofreeze not administered as ordered due to unavailability. The facility failed to follow physician orders and ensure timely pain management, highlighting communication and adherence issues.
A resident with intact cognition was self-administering Hydrocortisone cream without proper assessment or authorization. The resident had been applying the cream for over a year, and it was found on her overbed table. The East Wing Unit Manager and DON acknowledged that the resident was not assessed for self-administration, and the necessary protocols were not followed.
A resident in hospice care was found with four side rails raised on her bed, which were considered restraints, without proper assessment or documentation. Despite a physician's order for bilateral upper grab bars, the facility staff were unaware of the use of four side rails until it was reported. The facility's policy required an assessment and family consent for restraints, which were not documented, leading to the deficiency.
Two residents reported abuse by staff, but the facility failed to report these allegations to State agencies as required. One resident experienced rough treatment by CNAs during personal care, while another was forcibly catheterized without consent. Despite internal discussions and staff reassignment, the incidents were not reported to the Administrator or authorities, violating the facility's policy on abuse reporting.
The facility failed to provide written Notification of Transfer or Discharge forms to two residents or their representatives before hospitalization. One resident with multiple diagnoses was sent to the hospital due to bloody urine, and another with conditions like pancreatic cancer was transferred due to altered mental status. The forms were completed but not signed, and staff interviews revealed confusion about notification responsibilities.
The facility failed to ensure accurate MDS assessments for residents, leading to deficiencies in documenting tracheostomy care, insulin administration, and oxygen therapy. A resident with respiratory failure had an MDS assessment that incorrectly indicated no tracheostomy care. Another resident's assessment inaccurately recorded insulin administration without supporting medical records. Additionally, two residents' oxygen therapy was not accurately reflected in their MDS assessments, despite physician orders and care plans indicating its use.
A facility failed to refer a resident with newly diagnosed mental disorders for a Level II PASARR evaluation. The resident was admitted with conditions including metabolic encephalopathy and diabetes, and later diagnosed with unspecified psychosis and major depressive disorder. The Level I PASARR screening did not reflect these diagnoses, and the DON acknowledged the oversight.
A facility failed to adhere to professional standards in two cases: a resident was catheterized without a physician's order or proper consent, and another resident did not receive a prescribed palm cone to prevent skin breakdown. The first resident reported discomfort from the unauthorized procedure, while the second resident, who was cognitively intact, was not included in the care plan for palm cone usage despite an existing order. These incidents reveal communication and documentation lapses within the facility.
A resident with cognitive impairment and health issues was observed smoking without a required protective apron, despite facility policy. Staff failed to provide the apron, and the resident's gown showed cigarette burns. The absence of a care plan for smoking-related injury was noted.
The facility failed to obtain a physician's order for oxygen therapy for a resident with respiratory diagnoses and administered oxygen at an incorrect flow rate for another resident. The nursing staff did not verify oxygen settings as required, leading to discrepancies in oxygen administration.
A resident with cellulitis did not receive prescribed Bactrim DS for several days due to unavailability and inaccurate documentation in the MAR. The RN was unaware of the medication's availability in the dispensing machine, leading to missed doses. The DON confirmed inaccuracies in the medical record, as the medication was documented as administered when it was not.
Deficiencies in Pain Management for Two Residents
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents, leading to deficiencies in care. Resident #42, who was admitted with multiple diagnoses including multiple sclerosis and paraplegia, reported discomfort in his left ear due to earwax buildup. Despite a cognitively intact status and requiring total assistance for personal care, the resident's complaint was not promptly addressed. An order for an ENT consult was placed on 7/19/24, but the appointment was scheduled for December 2024, and the resident continued to experience pain without timely intervention. The Director of Social Services was unaware of the resident's current pain, and the Unit Manager failed to communicate the need for an audiologist consult. Resident #274, admitted with dementia and neuropathy, experienced severe pain that was inadequately managed. The resident's Power of Attorney expressed concerns about the facility's attitude towards the resident's pain management, noting that the resident struggled with therapy due to pain. Although Biofreeze was ordered for shoulder pain, it was not administered on multiple occasions in June and July 2024, as indicated by the use of code 9 in the Medication Administration Record. The Registered Nurse responsible for administering the medication stated that Biofreeze was not available in the treatment cart, and the Director of Nursing was unaware of this issue. The facility's failure to follow physician orders and ensure timely pain management for these residents highlights a lack of communication and adherence to professional standards of practice. The facility's policy required that all physician orders be followed as prescribed, and any deviations be documented, which was not consistently done in these cases. The deficiencies in pain management for both residents were identified through observations, interviews, and record reviews, indicating systemic issues in the facility's approach to managing resident pain.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to conduct a medication self-administration assessment for a resident who was self-administering Hydrocortisone 1% cream without proper authorization. The resident, who had intact cognition as indicated by a Brief Interview for Mental Status exam score of 13 out of 15, had been applying the cream to her private area for over a year. This was observed during a visit when the resident was found with a white plastic bin containing personal items, including the cream, on her overbed table. The East Wing Unit Manager acknowledged the presence of two tubes of Hydrocortisone cream on the resident's bed and noted that the resident's husband might have brought them in. The resident had an order for the cream due to a rash, but the nurse was supposed to apply it as the resident was not assessed or approved for self-administration. The Director of Nursing confirmed that a resident must be assessed for self-administration and, if deemed appropriate, physician orders are obtained. However, these protocols were not in place for the resident in question.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by the use of four side rails on the resident's bed without proper assessment or documentation. The resident, an elderly female with diagnoses including convulsions, cerebral atherosclerosis, repeated falls, major depressive disorder, and generalized muscle weakness, was admitted to hospice services. Despite the physician's order for bilateral upper grab bars, the resident was observed with both upper and lower side rails raised, which were considered restraints. The use of these restraints was reportedly requested by the resident's family, but there was no documentation or consent for the use of four side rails in the resident's clinical records. The facility's staff, including the RN, Unit Manager, and DON, were unaware of the use of four side rails until it was brought to their attention. The DON acknowledged that the use of four side rails required an assessment by the Interdisciplinary Team and consent from the family, neither of which were documented. The facility's policy on restraints emphasized the use of the least restrictive alternative and ongoing re-evaluation, which was not adhered to in this case. The lack of proper assessment, documentation, and consent for the use of four side rails led to the deficiency identified by the surveyors.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to State agencies as required for two residents. Resident #110, who was admitted with osteomyelitis, a pressure ulcer, and bipolar disorder, reported that two CNAs were disrespectful and rough while cleaning her after episodes of diarrhea. Despite informing her nurse, who acknowledged the resident's concerns and reported them to her supervisors, the allegations were not documented in the facility's Abuse Log, and the Administrator was unaware of the incident. Resident #276, admitted with metabolic encephalopathy, anemia, and depression, alleged physical abuse by a nurse who forcibly catheterized her without consent to obtain a urine sample. The resident's husband filed a grievance, and the ADON and Unit Manager addressed the concern by removing the involved staff from the resident's care. However, the incident was not reported to the Administrator or State agencies as required, as the ADON misunderstood the reporting requirements, believing that if the resident or family did not want to proceed, reporting was unnecessary. The facility's policy mandates immediate reporting of abuse allegations to the administrator and relevant authorities within two hours. However, in both cases, the facility failed to adhere to this policy, resulting in a lack of timely reporting and investigation of the abuse allegations. The Administrator only became aware of the incidents after the fact, highlighting a breakdown in communication and understanding of reporting protocols among the staff.
Failure to Provide Written Notification of Transfer or Discharge
Penalty
Summary
The facility failed to provide written Notification of Transfer or Discharge forms to residents or their representatives for two residents who were hospitalized. Resident #121, who had multiple diagnoses including atrial fibrillation and acute kidney failure, was scheduled for discharge but was sent to the hospital due to bloody urine. Although the facility completed the Notification of Transfer or Discharge form, it was not signed by the resident or their representative, and the resident did not return to the facility. Similarly, Resident #123, with diagnoses such as pancreatic cancer and congestive heart failure, was transferred to the hospital due to altered mental status and abnormal vital signs. The Notification of Transfer or Discharge form was completed but not signed by the resident or their representative. Interviews with facility staff revealed a lack of clarity and responsibility regarding who was supposed to provide the notification to the residents or their representatives, resulting in the failure to notify them in writing.
Inaccurate MDS Assessments for Tracheostomy, Insulin, and Oxygen Therapy
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for several residents, leading to deficiencies in the documentation of tracheostomy care, insulin administration, and oxygen therapy. Resident #86, who was admitted with diagnoses including nontraumatic brain bleed and respiratory failure, had an MDS assessment that incorrectly indicated no tracheostomy care, despite physician orders for tracheostomy care and oxygen saturation monitoring. The MDS Coordinator acknowledged the error, noting that the assessment should have included a comprehensive review of the resident's medical records and observations. Resident #15, admitted with conditions such as multiple sclerosis and pulmonary embolism, had an MDS assessment that inaccurately recorded insulin administration, despite no physician orders or records of insulin administration in the resident's medical file. The MDS Coordinator admitted to the incorrect coding and emphasized the need for thorough chart reviews and resident observations during the assessment period. Additionally, the facility failed to accurately assess oxygen therapy for residents #64 and #95. Resident #64, who was on hospice care and used oxygen continuously, had an MDS assessment that did not reflect oxygen therapy, despite a care plan indicating its use. Similarly, Resident #95, with a diagnosis of COPD and dependence on supplemental oxygen, had an MDS assessment that omitted oxygen therapy, even though there was a physician order for continuous oxygen. The MDS Coordinators confirmed these oversights, highlighting a lack of comprehensive review and documentation during the assessment process.
Failure to Update PASARR for Resident with New Mental Disorder
Penalty
Summary
The facility failed to refer a resident with a newly evident mental disorder for a Level II Preadmission Screening and Resident Review (PASARR) evaluation. The resident was admitted with diagnoses including metabolic encephalopathy, diabetes mellitus, unspecified psychosis, and depression. A review of the Minimum Data Set Admission assessment indicated the resident was cognitively intact, with active diagnoses of depression and a psychotic disorder. The resident's electronic medical record showed the onset of unspecified psychosis and major depressive disorder, but the Level I PASARR screening form did not reflect these mental illness diagnoses. The Director of Nursing acknowledged the discrepancy and stated that the PASARR should have been updated following the new psychiatric diagnoses.
Deficiencies in Urinary Catheterization and Palm Cone Usage
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice in two separate incidents. In the first incident, a resident was subjected to urinary catheterization without a physician's order and without proper consent. The resident, who was alert and oriented, reported that a nurse collected a urine sample using a catheter without her consent, causing her discomfort. The nurse involved claimed that the resident had agreed to the procedure, but there was no documentation of consent or a physician's order for catheterization, which is required for such a procedure. In the second incident, another resident with multiple sclerosis and other conditions was not provided with a palm cone as ordered by occupational therapy to prevent skin breakdown. The resident was cognitively intact and dependent on staff for various activities. Despite an order for the use of a palm cone, the resident reported not receiving occupational therapy and not using the palm cone. The facility's Director of Rehab confirmed the order for restorative nursing care, but the resident was not on the list for palm cone usage, and there was no care plan addressing this need. Both incidents highlight a lack of communication and documentation within the facility. In the first case, the nurse did not obtain a new physician's order for the catheterization, and there was no record of the procedure being documented. In the second case, the failure to include the resident on the palm cone list and the absence of a care plan indicate a breakdown in the communication process between the therapy department, the Director of Nursing, and the MDS coordinators.
Failure to Implement Smoking Safety Measures for Resident
Penalty
Summary
The facility failed to implement necessary accident interventions for a resident with moderate cognitive impairment and multiple health conditions, including chronic obstructive pulmonary disease and schizophrenia. The resident required moderate assistance with bed mobility and personal hygiene and maximum assistance for transfers. Despite a smoking assessment indicating the need for a smoking apron, the resident was repeatedly observed smoking without the protective apron. This was noted on multiple occasions, with the resident's hospital gown showing cigarette burns, indicating a potential risk of injury. Staff members, including CNAs, were observed supervising the resident while smoking but did not provide the required smoking apron. The East Wing Unit Manager confirmed the absence of the apron and validated the presence of cigarette burns on the resident's gown. The Director of Nursing acknowledged that the resident was assessed as a safe smoker with an apron, yet no care plan addressing potential injury related to smoking was found in the resident's medical record. The facility's policy required a protective smoking vest/apron for residents deemed unsafe smokers, which was not adhered to in this case.
Deficiencies in Oxygen Therapy Administration
Penalty
Summary
The facility failed to obtain a physician's order for oxygen therapy for a resident who was admitted with several respiratory diagnoses, including dysphagia, obstructive sleep apnea, and acute respiratory failure. The resident was observed receiving oxygen therapy at 2 liters per minute (LPM) via nasal cannula without a corresponding physician's order in the medical record. The nursing staff, including a registered nurse and the unit manager, confirmed the absence of a physician's order and acknowledged the responsibility of obtaining such orders upon a resident's admission to ensure the correct administration of oxygen therapy. Another resident, who had a physician's order for continuous oxygen therapy at 3 LPM due to chronic obstructive pulmonary disease and other respiratory conditions, was found to be receiving oxygen at an incorrect flow rate of 8 LPM. The discrepancy was discovered during an observation, and the registered nurse on duty adjusted the flow rate to the correct setting. The nurse admitted to not checking the oxygen settings at the beginning of her shift, which was against the facility's policy that required nurses to verify oxygen settings at the start and periodically throughout their shifts. The Director of Nursing reiterated the expectation for nurses to administer oxygen therapy as per physician orders and to ensure the correct flow rate is maintained.
Medication Administration Documentation Failure
Penalty
Summary
The facility failed to accurately document the administration of medications in the Medication Administration Record (MAR) for a resident diagnosed with an open wound, pain, and cellulitis. The resident was prescribed Bactrim DS for cellulitis, to be taken every 12 hours for 10 days. However, the MAR indicated that the 9:00 PM doses on several consecutive days were not administered, as denoted by code 9, which referred to 'Other / See Nurse Notes.' The resident confirmed that she did not receive the medication for three days, and a progress note indicated that the facility was awaiting the medication's arrival. Further investigation revealed that the Registered Nurse (RN) responsible for administering the medication was unaware that Bactrim could be accessed from the automatic medication dispensing machine, resulting in missed doses. Additionally, the Director of Nursing (DON) confirmed that another RN documented the 9:00 AM doses as administered when they were not, due to the medication's unavailability. This inaccurate documentation was verified by checking the dispensing machine, which confirmed the medication was not available on those days, leading to inaccuracies in the medical record.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Cloud
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At St Cloud | 0.9 mi | ★★★★★ | 1 | 0 |
| Terrace Of St Cloud, The | 1.2 mi | ★★★★★ | 1 | 0 |
| Solaris Healthcare Osceola | 1.4 mi | ★★★★★ | 0 | 0 |
| Kissimmee Health And Rehabilitation Center | 7.2 mi | ★★★★★ | 0 | 0 |
| Terrace Of Kissimmee, The | 7.9 mi | ★★★★★ | 2 | 0 |
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