Avante St Cloud: Oxygen Given Without Orders - FL
Resident 64 was found wearing a nasal cannula connected to an oxygen concentrator set at 2 liters per minute during an August inspection. He told inspectors he received hospice care and used oxygen continuously. His care plan, initiated over a year earlier in June 2023, called for oxygen therapy via nasal cannula at bedtime "as ordered."
No order existed.
Hospital records from April showed the resident had been diagnosed with oxygen dependence and used 2 liters per minute via nasal cannula. But after his admission to Avante, no physician had written an order continuing the treatment.
Two Licensed Practical Nurses who served as MDS coordinators confirmed the resident had been on oxygen since his admission. They also confirmed no order existed in his medical record. "It was therefore missed during the last Quarterly MDS assessment," they told inspectors.
The facility's assessment system had failed in multiple ways. The Quarterly MDS assessment incorrectly stated that oxygen therapy was not provided, even though the resident was visibly using it daily.
A second resident faced similar problems. Resident 95 was admitted with chronic obstructive pulmonary disease, asthma, lung cancer, and documented dependence on supplemental oxygen. A physician had ordered continuous oxygen at 3 liters per minute via nasal cannula for shortness of breath on July 10.
Six days later, the resident's admission assessment failed to document oxygen therapy at all. The resident had intact cognition with a perfect score of 15 out of 15 on cognitive testing, but the oxygen therapy section was left blank.
MDS Coordinator 1 explained the assessment process to inspectors. Staff completed evaluations by reviewing seven days of clinical records, observing residents, interviewing cognitively intact residents or their families, and talking with nurses and nursing assistants.
Despite this multi-step process, she confirmed the admission assessment was "not accurate." She had reviewed the physician orders showing the July 10 oxygen therapy order but somehow failed to include it in the assessment.
The facility had no policy regarding accuracy of assessments. The Regional MDS Specialist said they followed guidelines from the RAI Manual, the federal assessment handbook.
Federal regulations require accurate assessments as the foundation for resident care plans. The Centers for Medicare & Medicaid Services manual states that "the RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents."
These assessment failures extended beyond oxygen therapy. The facility also failed to properly screen residents for mental health services under federal PASARR requirements.
Resident 97 was admitted with metabolic encephalopathy, diabetes, unspecified psychosis, and depression. Her medical record showed diagnoses of unspecified psychosis and major depressive disorder, both with onset dates of June 5.
The facility's Level I PASARR screening form, completed June 3, did not indicate she had mental illness or suspected mental illness. No Level II screening was completed, despite federal requirements for residents with newly evident mental disorders.
The resident scored 13 out of 15 on cognitive testing, indicating she was mentally intact. Her admission assessment listed active diagnoses including depression and psychotic disorder. Yet the screening system designed to ensure appropriate mental health services had missed both conditions entirely.
The Director of Nursing acknowledged the screening failures during the inspection. She explained that hospitals should complete Level I PASARR screening before admission, and facilities should update screening when psychiatry services make new diagnoses.
She reviewed the screening form and current diagnoses for Resident 97. The screening did not reflect the resident's diagnoses of unspecified psychosis and major depressive disorder. "She did not know why the diagnoses were not listed," inspectors noted.
The assessment problems revealed broader issues with the facility's attention to clinical details. In one case, staff had been providing oxygen therapy for over a year without proper authorization. In another, they had documented the need for oxygen but failed to include it in required assessments.
Both situations involved basic clinical documentation that forms the foundation of nursing home care. Federal assessments determine Medicare payments, care planning, and regulatory compliance. When coordinators "miss" critical details like oxygen therapy or mental health diagnoses, residents may not receive appropriate services.
The oxygen therapy violations were particularly concerning given the residents' conditions. Resident 64 had dysphagia, sleep apnea, acute respiratory failure, and shortness of breath. He was receiving palliative care, indicating his condition was serious enough to focus on comfort rather than cure.
Resident 95 had chronic obstructive pulmonary disease with acute exacerbation, asthma, and lung cancer. His physician had specifically ordered continuous oxygen for shortness of breath, recognizing the critical nature of his breathing problems.
For both residents, oxygen therapy was not an optional comfort measure but a medical necessity documented by their diagnoses and symptoms. Yet the facility's systems had failed to properly authorize, document, or assess this essential treatment.
The inspection found that basic quality assurance measures were absent. The facility had no policy ensuring assessment accuracy beyond following federal guidelines. Staff responsible for assessments admitted missing obvious clinical details without apparent consequences or corrective measures.
These documentation failures occurred despite the facility's multi-step assessment process involving record reviews, observations, and interviews. The system was designed to catch errors through multiple checkpoints, but coordinators still missed physician orders and failed to document ongoing treatments.
The violations suggest systemic problems with clinical oversight at Avante at St Cloud. When assessment coordinators consistently miss critical details about oxygen therapy and mental health diagnoses, it raises questions about what other clinical needs might be overlooked or inadequately documented.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avante At St Cloud Inc from 2024-08-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 18, 2026 · Our methodology
AVANTE AT ST CLOUD INC in SAINT CLOUD, FL was cited for violations during a health inspection on August 15, 2024.
Resident 64 was found wearing a nasal cannula connected to an oxygen concentrator set at 2 liters per minute during an August inspection.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.