Avante At St Cloud Inc

F-F609

1. Review of resident #276's medical record revealed she was admitted to the facility on [DATE REDACTED] with diagnoses including metabolic encephalopathy, anemia and depression.

Review of resident #276's medical record revealed Progress Notes dated 8/05/24 and 8/06/24 which showed

she was alert and oriented to person, place and time.

On 8/12/24 at 12:54 PM, resident #276 stated a nurse collected a urine sample using a catheter without her consent, through force, which hurt her. Resident #276 indicated she was taken to the bathroom, but she was unable to urinate at that time. She explained when she could not urinate, the nurse told her she would get

the urine sample another way and collected the specimen using a catheter.

Review of resident #276's physician orders revealed an order dated 8/05/24 which read, U/A C&S (urinalysis and culture and sensitive). The Treatment Administration Record (TAR) showed this was completed on 8/05/24. There was no evidence of a physician order to collect the U/A via urinary catheterization in the medical record.

Urinary catheterization is the aseptic process of inserting a sterile hollow pliable tube into the urethra to facilitate urine drainage . Urinary catheters should be inserted only when medically [necessary] . Document attempts at and inadequacy of alternative methods for bladder elimination prior to insertion of the indwelling catheter . Urinary catheters should be placed only under the direction of a physician order, (Retrieved from https://www.ahrq.gov/ on 8/22/24).

On 8/12/24 at 3:39 PM, Registered Nurse (RN) Q in broken English stated resident #276 had a physician order for a urinalysis and culture and it needed to be a sterile procedure. She explained she told the resident

the procedure and resident #276 agreed. She stated she first asked resident #276 if she could go to the bathroom and she tried to collect the urine sample in the bathroom, but resident #276 was unable to urinate at that time. She explained the resident returned to her bed and she told her to relax. She waited a few minutes for resident #276, to calm down. She stated she told resident #276, Procedure, catheterize urine and cultivo urinary, me catheterize, I can, while showing her the equipment she was going to use. She indicated resident #276 responded yes more than once. RN Q stated she, Did not even touch her much, because the urine came out fast. I almost did not touch her. She recalled resident #276's husband approached her during morning report at the nurse's station. She stated he was upset and said his wife told him she was handled roughly, and was catheterized without her consent.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 21 105670 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105670 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avante at St Cloud Inc 1301 Kansas Ave 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 0684 On 8/15/24 at 2:03 PM, the East Wing Unit Manager (UM) recalled the morning of 8/07/24 resident #276's husband brought up a concern that last night his wife's nurse catheterized his wife without needing to. The Level of Harm - Minimal harm or UM recalled the husband told her his wife was uncomfortable and he asked why she was not taken to the potential for actual harm bathroom for the sample. The UM indicated she went to resident #276's room with the Assistant Director of Nursing (ADON) to speak with them. She explained she told them there was a physician's order for the urine Residents Affected - Few sample and since resident #276 could not urinate, the nurse asked if she could collect the sample with a catheter instead. The UM told her resident #276 had approved of the procedure. The UM indicated resident #276, Could not really understand the nurse, I think it was miscommunication. The UM stated when she reviewed the TAR she noticed there was no documentation of RN Q's collection of the U/A in resident #276's medical record. She confirmed there was no physician order for the alternate collection procedure, which was required for the urinary catheterization. She validated the Lab log showed urine was collected on 8/07/24 for resident #276's and her assigned nurse was RN Q.

On 8/15/24 at 5:57 PM, the Director of Nursing (DON) stated she was unaware RN Q did not document she had collected the urine specimen without a new order. She confirmed RN Q did not have an order to collect

the urine specimen using a straight catheter. She explained their process for collection of U/A which was collected by the night shift nurses. She confirmed there was no evidence the urine was collected on 8/05/24 as documented in the TAR. She validated there was no evidence the urine sample was sent to the laboratory

before 8/07/24. She explained RN Q was required to obtain a new physician's order to collect the urine specimen using a straight catheter and repeated there was no order to recollect the urine sample and no order for straight catheter. She stated the assigned nurse on 8/05/24 should have never signed the U/A completed if not done. She stated RN Q should have verified the orders and notified the physician to obtain a new order. The DON validated RN Q performed the catheterization without a physician's order.

Review of the facility's policy and procedures titled Laboratory, Radiology, and Other Diagnostic Services dated 3/02/19 revealed the facility would ensure laboratory, radiology, and other diagnostic services met the needs of the residents with prompt reporting to the ordering provider.

Review of the facility's policy and procedures titled Physician Services dated 3/02/19 revealed the facility would provide Physician Services according to State and Federal regulations. The documented read, A physician . must provide orders for the resident's immediate care and needs. It also read, All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift.

Review of the Facility Assessment reviewed by the Quality Assessment and Assurance Committee on 7/31/24 revealed nurses were competent in specialized care including catheterization insertion/care and received education/training/in-services Foley catheter and lab orders.

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2. Resident #42 was admitted to the facility on [DATE REDACTED] with diagnoses that included multiple sclerosis, muscle weakness, paraplegia, adjustment disorder with depressed mood and anxiety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 21 105670 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105670 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avante at St Cloud Inc 1301 Kansas Ave 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 0684 Review of the Quarterly Minimum Data Set (MDS) dated [DATE REDACTED], revealed resident #42 had a Brief Interview for Mental Status score of 15 out of 15, meaning he was cognitively intact. The assessment indicated he did Level of Harm - Minimal harm or not exhibit any rejection of care behaviors and was dependent on staff for toileting, personal hygiene, potential for actual harm dressing, and mobility.

Residents Affected - Few Review of resident #42's physician's orders dated 3/23/23 revealed an order by Occupational Therapy (OT) for a right palm cone to be worn daily as tolerated and removed for meals, activities, and activities of daily living.

On 8/12/24 at 11:59 AM, resident #42 was observed in his room sitting up in his wheelchair. His right hand was closed, and he stated he was unable to open the right hand without assistance. Resident stated he was not receiving OT, and did not have a palm cone. A blue palm cone was observed on his nightstand and the resident explained he no longer needed to wear it.

Review of the OT evaluation and plan of treatment with a certification period from 3/23/23 to 4/21/23 revealed resident #42 was referred for OT by nursing due to a new onset of weakness, reduced functional endurance, and increased fisting posture in the right hand. The note indicated the new conditions placed the resident's right palm at risk for wounds. Further review of OT treatment notes dated 3/23/23 revealed a short-term goal that resident #42 would tolerate the right palm cone daily for 3 hours without signs or symptoms of adverse effects to reduce risk of skin breakdown in the palm of his hand. The document indicated resident #42 tolerated the palm cone for one hour as of 3/23/23.

On 8/15/24 at 10:37 AM, the Director of Rehab (DOR) stated resident #42 was discharged from OT on 4/21/23 with an order for restorative nursing care and to continue with right palm cone to prevent skin break down. He explained the DON oversaw the restorative program, and she was responsible for communicating with the MDS coordinator to create the care plan. The DON would also be responsible for communicating with the west wing UM for the new order. Resident #42 was compliant with wearing the palm cone while receiving OT services, but the DOR said that sometimes resident #42 would refuse to wear it. He explained that it was important for the resident to wear the palm cone to prevent skin breakdown.

On 8/15/24 at 10:50 AM, the west wing UM stated that resident #42 did not have a palm cone because his name was not on the list of residents with palm cones. She said that she received a list of residents with palm cones from the DON and it would be placed at the nurse's station. She looked in resident #42's medical

record and confirmed there was an order for a palm cone dated 3/23/23. The DON stated that resident #42 refuses medical care sometimes. She was unsure why the DON had not added the resident to the palm cone list. The west wing UM stated that the DON was the person responsible for the restorative program and for communicating with the MDS coordinators. [NAME] wing UM explained that it was important for resident #42 to use the palm cone to prevent skin breakdown.

Review of resident #42's medical record revealed that there were no care plans addressing restorative services or palm cone usage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 21 105670 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105670 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avante at St Cloud Inc 1301 Kansas Ave 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 0684 On 8/15/24 at 11:03 AM, MDS coordinator #1 and MDS coordinator #2, both Licensed Practical Nurses (LPNs) stated that they are both responsible for creating care plans. The stated that they were not aware Level of Harm - Minimal harm or resident #42 had an order for a palm guard and they did not find a care plan for it. MDS coordinator #1 potential for actual harm explained that when a resident was recommended for a palm cone or restorative services, therapy would communicate with DON. The DON would then communicate with the MDS office so that a care plan could be Residents Affected - Few created. If the resident was refusing care that would be added to the care plan along with interventions addressing the behavior.

On 8/15/24 at 01:24 PM, an interview with the DON revealed that she was aware that resident #42 had an order for the palm cone to the right hand. She stated that she had a conversation with the resident on 8/15/24 and he did not want to wear the palm cone. She confirmed that that there was no documentation that showed resident declined the palm cone since 3/23/23. She confirmed that she oversaw the restorative program and was responsible for communicating with the MDS coordinators to create a plan of care for the palm cone.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 21 105670 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105670 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avante at St Cloud Inc 1301 Kansas Ave 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40892

Residents Affected - Few Based on interview observation and record review, the facility failed to implement accident intervention for 1 of 5 residents reviewed for accidents, of a total sample of 53 residents, (#22)

Findings:

Resident #22 was admitted to the facility on [DATE REDACTED] with diagnoses including multiple fractures of ribs, chronic obstructive pulmonary disease, and schizophrenia.

The Minimum Data Set Admission assessment with assessment reference date 6/26/24 revealed resident #22 had a Brief Interview Memory score of 6/15, which indicated moderate cognitive impairment. The assessment indicated she required moderate assistance with bed mobility and personal hygiene and maximum assistance for transfers.

A review of the Smoking assessment for resident #22 dated 7/02/24 read the resident must wear a smoking apron.

On 8/12/24 at 2:14 PM, resident #22 was observed on the smoking patio dressed in a hospital gown, sitting

in a wheelchair, smoking a cigarette. She was not wearing a smoking apron.

On 8/13/24 at 11:37 AM, resident #22 was observed smoking with Certified Nursing Assistant (CNA) J's supervision. The resident was not wearing a smoking apron and flicked ashes from her cigarette to the ground. CNA J stated she was given the cigarettes and lighters for the residents but was not given an apron for any resident who required them.

On 8/15/24 at 9:36 AM, resident #22 was observed dressed in two hospital gowns and assisted to light a cigarette by CNA G. The resident again was not wearing an apron. Resident #22's gown had three cigarette burns on the front.

On 8/15/24 at 10:14 AM, the East Wing Unit Manager (UM) validated the cigarette burns on the hospital gown. The UM conducted a skin assessment and stated the resident had no injury. The UM confirmed resident #22 should use an apron when smoking.

A review of resident #22's medical record revealed no care plan for potential injury related to smoking for staff to follow.

On 8/15/24 at 10:20 AM, the Director of Nursing (DON) stated the resident was a safe smoker with an apron at the last assessment.

A review of the facility's policy and procedure dated 1/11/19 read, If the IDT members determine that the resident is an unsafe smoker, the resident may be required to wear a protective smoking vest/apron and have a greater degree of staff supervision while smoking.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 21 105670 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105670 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avante at St Cloud Inc 1301 Kansas Ave 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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49840 potential for actual harm Based on observation, interview and record review the facility failed to ensure a physician's order was Residents Affected - Few obtained prior to the administration of oxygen (O2) therapy for 1 of 1 resident, (#64), and failed to ensure the flow rate for O2 therapy was administered as per physician's order for 1 of 1 resident, (#95) reviewed for O2 therapy, of a total sample of 53 residents.

Findings:

1. Resident #64 was admitted to the facility on [DATE REDACTED] with diagnoses that included dysphagia, obstructive sleep apnea, acute respiratory failure, shortness of breath, and encounter for palliative care.

On 8/12/24 at 11:47 AM, resident #64 was observed in bed receiving O2 via nasal cannula at 2 liters per minute (LPM). He stated he used oxygen all the time and received hospice care.

A review of resident #64's medical record revealed no physician's order for oxygen.

The Quarterly Minimum Data Set (MDS) dated [DATE REDACTED], revealed that resident #64 was cognitively intact, dependent on staff for all activities of daily living (ADLs), had several respiratory diagnoses, and received hospice services. Oxygen therapy was not documented as being provided.

Review of resident #64's medical record revealed a hospital record dated 4/25/24 showed the resident had a diagnosis of oxygen dependence and used 2 LPM of O2 via nasal cannula.

On 8/12/24 at 4:46 PM, Registered Nurse (RN G) confirmed resident #64 had been received O2 therapy since being admitted to the facility. She was unable to verify how many LPM of oxygen the resident was on because there were no physician's order for O2 in the medical record. RN G explained when a resident with O2 was admitted to the facility, it was the responsibility of the nurse to obtain an order for O2 therapy. She acknowledged having an order in the medical record would ensure the resident received the correct amount of oxygen.

On 8/12/24 at 4:50 PM, the [NAME] wing Unit Manager (UM) stated nurses were responsible for checking

the oxygen concentrators in the resident rooms to ensure they were set to the correct amount and matched

the physicians' orders. She confirmed resident #64 had no physician's order for oxygen therapy in the medical record. The [NAME] wing UM explained the expectation was for all nurses to obtain physicians' orders and ensure they were entered into the medical record.

On 8/15/24 at 1:15 PM, the Director of Nursing (DON) stated the expectation was for nurses to obtain the appropriate physician orders and enter them into the medical record as soon as possible.

32131

2. Resident # 95 was admitted to the facility on [DATE REDACTED], with diagnoses that included chronic obstructive pulmonary disease (COPD) with acute exacerbation, asthma, malignant neoplasm bronchus or lung, cough, and dependence on supplemental oxygen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 21 105670 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105670 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avante at St Cloud Inc 1301 Kansas Ave 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 0695 A physician order dated 7/10/24 for O2 continuous at 3 liters per minute (LPM) via nasal cannula (N/C) for shortness of breath. Level of Harm - Minimal harm or potential for actual harm A care plan for shortness of breath, cough, stable bilateral Pulmonary nodules, nebulizer treatment and requires continuous Oxygen was initiated on 7/10/24. There were no interventions that addressed the Residents Affected - Few settings of the resident's O2 therapy.

On 8/13/24 at 10:16 AM, and at 10:23 AM, resident #95 was sitting up in bed. She confirmed she used O2, and stated she should be on O2 at 2 LPM. Observation of the resident's flow rate showed her O2 therapy via N/C was infusing at 8 LPM.

On 8/13/24 at 10:29 AM, Registered Nurse (RN) B stated O2 was considered medication. The resident's physician orders were reviewed with RN B, she stated the resident had a physician order for O2 at 3 LPM continuously.

On 8/13/24 at 10:30 AM, an observation of the resident's O2 therapy was conducted in the resident's room with RN B, which showed the O2 via NC was infusing at 8 LPM. This was confirmed by RN B, who at that time adjusted the settings down to 3 LPM. RN B stated that during change of shift she received shift report regarding O2 therapy. She stated she did not check the resident's O2 setting this morning, and verbalized

the O2 flow rate should be checked by nurses at the beginning and end of their shifts.

On 8/13/24 at 10:36 AM, the [NAME] Wing RN/Unit Manager (UM) stated nurses adjust O2 settings and should ensure O2 was at the right setting. The RN/ UM reviewed the resident #95's physician orders and said the resident's order was for O2 at 3 LPM via N/C continually.

On 8/13/24 at 10:44 AM, the Director of Nursing (DON) stated O2 therapy was administered per physician order. She stated her expectation for O2 therapy, was a physician order was in place, and nurses were expected to ensure the O2 therapy was being administered at the right flow rate. The DON said nurses should check O2 settings at the beginning of the shift and periodically throughout their shift to ensure O2 therapy was being infused as ordered by the physician.

The facility's policy Oxygen issued date 9/02/2020 read, Oxygen is administered under orders of a physician .

The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 21 105670 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105670 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avante at St Cloud Inc 1301 Kansas Ave 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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43192

Residents Affected - Few Based on interview and record review, the facility failed to accurately document administered medications in

the Medication Administration Record (MAR) for 1 of 6 residents reviewed for choices, of a total sample of 53 residents, (#279).

Findings:

Review of resident #279's medical record revealed she was admitted to the facility on [DATE REDACTED] with diagnoses including open wound on the left lower leg, pain, and cellulitis (bacterial skin infection).

Review of resident #279's physician orders revealed an order dated 8/09/24 for Bactrim DS 800-160 milligrams every 12 hours for cellulitis for 10 days.

Review of resident #279's Medication Administration Record (MAR) revealed code 9 was used for the 9:00 PM dose of Bactrim on 8/09, 8/10, 8/11, and 8/12/24 and on 8/13/24 for the 9:00 AM dose. The MAR showed

the 9:00 AM dose of Bactrim was documented as given on 8/10, 8/11, and 8/12/24. The legend showed when code 9 was used it indicated Other / See Nurse Notes.

Review of resident #279's medical record revealed a Progress Notes dated 8/10/24 which indicated on oral antibiotic Bactrim, awaiting medication to arrive.

On 8/13/24 at 9:57 AM, resident #279 stated she was prescribed an antibiotic for an infection on her legs, but

she had not received it for 3 days.

On 8/15/24 at 4:38 PM, Registered Nurse (RN) O stated she entered code 9 for the 9:00 PM dose of Bactrim

on 8/10, 8/11, and 8/12/24 because the antibiotic was not available. She stated she did not know she could access Bactrim from the automatic medication dispensing machine. RN O validated she did not give resident #279 the night dose of Bactrim for 3 days.

On 8/15/24 at 6:15 PM, the Director of Nursing (DON) stated RN P did not give the 9:00 AM dose of Bactrim to resident #279 on 8/10 and 8/11/24 despite documentation showing he administered it. She mentioned he signed a written statement which indicated he documented the medication as administered accidentally instead of documenting not administered because it was not available. She explained she verified the automatic medication dispensing machine and confirmed Bactrim was not available those days therefore the medical record was inaccurate.

Review of the Documentation policy and procedure dated 3/02/19 revealed guidelines for timeliness in documentation to ensure accuracy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 21 105670

F-F695

3. Resident #64 was admitted to the facility on [DATE REDACTED] with diagnoses that included dysphagia, obstructive sleep apnea, acute respiratory failure, shortness of breath, and encounter for palliative care.

On 8/12/24 at 11:47 AM, resident #64 was observed in bed wearing a nasal cannula connected to an O2 concentrator set at 2 liters per minute (LPM). He stated that he used oxygen all the time and was received hospice care.

The Quarterly MDS assessment dated [DATE REDACTED], revealed resident #64 was cognitively intact, was dependent

on staff for all activities of daily living (ADLs), had several respiratory diagnoses, and received hospice services. The assessment incorrectly reflected O2 therapy was not provided.

A review of resident #64's medical record revealed no physician's order for O2.

Review of resident #64's medical record revealed a hospital record dated 4/25/24 showed the resident had a diagnosis of O2 dependence, and used 2 LPM of O2 via nasal cannula.

Resident #64 had a care plan for O2 therapy initiated on 6/09/23. Interventions included the use of O2 via nasal cannula at bedtime per resident request as ordered.

On 8/15/24 at 11:03 AM, MDS coordinator #1 and MDS coordinator #2, both Licensed Practical Nurses (LPNs) stated they were both responsible for completing the MDS assessments. They confirmed resident #64 had been on O2 since he was admitted to the facility, nor was there an order in the medical record for O2 therapy. They explained it was therefore missed during the last Quarterly MDS assessment.

32131

4. Resident # 95 was admitted to the facility on [DATE REDACTED], with diagnoses that included chronic obstructive pulmonary disease (COPD) with acute exacerbation, asthma, malignant neoplasm bronchus or lung, cough, and dependence on supplemental oxygen.

A physician order dated 7/10/24 was for continuous O2 at 3 LPM via nasal cannula for shortness of breath.

The resident's Admission MDS assessment with ARD of 7/16/24 revealed the resident's cognition was intact with a BIMS score of 15 out of 15. Section O for O2 therapy while a resident was not assessed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 21 105670 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105670 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avante at St Cloud Inc 1301 Kansas Ave 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 0641 On 8/15/24 at 1:33 PM, MDS Coordinator 1 stated MDS assessments were completed by doing a seven day look back of the resident's clinical records, observation of the resident, interview of the resident if the Level of Harm - Minimal harm or resident's cognition was intact, if not the family would be interviewed, interview of nurses, and Certified potential for actual harm Nursing Assistants (CNAs). MDS Coordinator 1 reviewed the resident's Admission MDS assessment with ARD of 7/16/24 and confirmed O2 therapy was not assessed. She reviewed the resident's physician orders, Residents Affected - Few which revealed an order dated 7/10/24 for O2 therapy at 3 LPM. The LPN MDS Coordinator confirmed the MDS assessment dated [DATE REDACTED] was not accurate.

On 8/15/24 at 1:35 PM, the Regional MDS Specialist stated the facility did not have a policy regarding accuracy of assessment. She said they followed the guidelines outlined in the RAI Manual.

The Centers for Medicare & Medicaid Services Long term Care Facility Resident Assessment Instrument effective October 2019 on page 2-41 read The RAI process, which includes the Federally mandated MDS, is

the basis for an accurate assessment of nursing home residents. The MDS information and the CAA (Care Area Assessment) process provide the foundation upon which the care plan is formulated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 21 105670 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105670 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avante at St Cloud Inc 1301 Kansas Ave 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 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40892

Residents Affected - Few Based on interview and record review, the facility failed to refer residents with a newly evident mental disorder for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 1 of 4 residents reviewed for PASARR, of a total sample of 53 residents, (#97).

Findings:

Resident #97 was admitted to the facility on [DATE REDACTED] with diagnoses including metabolic encephalopathy, diabetes mellitus, unspecified psychosis, and depression.

A review of the Minimum Data Set Admission assessment with assessment reference date of 6/12/24 revealed resident #97 had a Brief Interview for Mental Status score of 13, which indicated she was cognitively intact. The document stated her active diagnoses included depression (other than bipolar) and psychotic disorder (other than schizophrenia).

Review of resident #97 's electronic medical record revealed the diagnoses of unspecified psychosis with an onset date of 6/05/24 and major depressive disorder also with an onset date of 6/05/24

The record contained a Level I PASARR screening form dated 6/03/24 which did not indicate resident #97 had a mental illness (MI) or suspected MI. The record did not contain a Level II PASARR screening form.

On 8/15/24 at 1:05 PM, the Director of Nursing (DON) stated that new admissions from the hospital should have a level l PASARR Screening completed by the hospital before admission to the facility. She explained when psychiatry services made a new diagnosis, the PASARR should be updated. The DON reviewed the Level I PASARR and current diagnoses for resident #97. The DON acknowledged the PASARR did not reflect the resident 's current MI diagnoses of unspecified psychosis and major depressive disorder. The DON stated she did not know why the diagnoses were not listed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 21 105670 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105670 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avante at St Cloud Inc 1301 Kansas Ave 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43192 potential for actual harm Based on observation, interview, and record review, the facility failed to provide care and services in Residents Affected - Few accordance with professional standards of practice related to the collection of an urine specimen for 1 out of 5 residents reviewed for abuse, (#276), and for limited range of motion and contracture care, for 1 of 2 residents reviewed for limited range of motion and positioning, (#42), out of a total sample of 53 residents.

Findings:

Cross Reference