F 0577
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Level of Harm - Potential for
minimal harm
Based on record review and interview, the facility failed to maintain the survey book with all surveys over
the past three years.
Residents Affected - Some
Findings:
Review of the survey book located outside the social service office did not include all recent surveys. A
complaint survey conducted on 8/20/20, resulting in an Immediate Jeopardy, was missing for viewing by
residents, visitors and staff.
On 6/15/21 at 3:20 PM, the administrator agreed the complaint investigation's statement of deficiencies was
not in the survey book. There were no additional survey books readily available for review.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
105670
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
105670
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/17/2021
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review, the facility failed to ensure foods were correctly stored
in the walk-in cooler and walk-in freezer to prevent contamination, failed to ensure staff members had
appropriate hand hygiene/grooming, and failed to ensure the walk-in cooler was in good repair.
Findings:
1. On 6/14/21 at 9:20 AM observation of the walk-in freezer with the Certified Dietetic Manager (CDM)
revealed bags of vegetables store directly under the evaporator fan. There was ice buildup on the line under
the fan that had the potential to drip onto the bags of vegetables.
2. On 6/14/21 at 9:25 AM, Dietary Aide (DA) A was working on clean side of dish machine removing and
stacking clean dishes. She had long painted fingernails over 1/2 inch past the tip of her fingers. Her thumbs
had punched through barrier gloves. The CDM acknowledged that DA A had long nails and that it was
unacceptable for her to have nails that long.
3. On 6/14/21 at 9:30 AM, the outdoor walk-in refrigerator had an empty steam table bucket under the
evaporator fan. There was condensation build up on the underside of the fan. The CDM said the soup
bucket was there to catch the water that sometimes drips from the line under the fan. Food items stored on
the shelf under fan included cooked turkey breast, cooked diced potatoes and cooked corned beef. The
door to the walk-in refrigeration did not seal when closed. Light from outside was visible on the top of the
door, the handle side of the door, and the bottom left of the door.
4. On 6/15/21 at 3:10 PM, the walk-in cooler door gasket was torn, shredded., and covered in a black-like
substance. At 3:30 PM, the Director of Maintenance said that he was aware of the problem with the gasket.
He acknowledged that when he cleaned the refrigerator on 5/27/21, the gasket was torn.
Review of the work order in the electronic work order log noted the damaged gasket on 5/27/21. The
Director of Maintenance confirmed he had not contacted any service company to repair the gasket.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105670
If continuation sheet
Page 2 of 2
