The October incident at The Terrace of St Cloud exposed a facility-wide problem: nursing assistants couldn't navigate the electronic system containing residents' care plans and instead relied on verbal updates from colleagues about patient needs.
Resident #6, who has Alzheimer's disease and severely impaired cognition, sustained the injuries when CNA C failed to follow the care plan requiring two-person assistance for activities of daily living. The facility filed the federal abuse report on October 1st.
The 83-year-old resident's care plan, initiated October 9th, detailed multiple risk factors that made two-person care essential. She was prone to easy bruising due to fragile skin, exhibited unsafe hand movements, impulsively grabbed items from her surroundings, displayed combative behaviors, and would fling and swing her hands.
Her care plan specifically called for two staff members "as needed to prevent shearing during positioning." Yet the same document contradicted itself, indicating she required only one person for transfers, bed mobility and daily care activities.
During the November 5th inspection, investigators found CNAs struggling with basic computer access. CNA E attempted to look up assistance requirements in the electronic system but couldn't locate the information. She logged into her computer but remained unable to find what she needed.
The Unit Manager for Unit 2 confirmed CNA E couldn't navigate the facility's electronic system without help. The manager acknowledged that nursing assistants "relied on verbal reporting instead of what was in the care plan."
"The expectation was for CNAs to know how to look up the information from the care plan," the Unit Manager said.
But the reality was different.
CNA D, assigned to resident #6, told investigators the woman required only one person for assistance with daily activities and transfers. When asked to verify this information in the electronic system, she explained she didn't have computer access and would need to speak with the Director of Nursing to get it.
CNA F said the information in the electronic system "seemed confusing." Both nursing assistants told investigators they "didn't usually access the electronic system for that information but instead relied on verbal reports from the nurse or other staff to update them of any changes with the resident."
The disconnect between written care plans and actual practice had dangerous consequences. During the inspection, resident #6 was found in bed with torn pool noodles attached to her side rails. CNA D explained that the woman "tried to get out of bed, constantly tore the pool noodles off the rails, and bumped into the rail."
The resident's quarterly assessment revealed the full scope of her care needs. She was diagnosed with congestive heart failure, colon cancer, Alzheimer's disease, unspecified dementia, and generalized anxiety disorder. The assessment indicated she required "two or more staff for care and was dependent on staff for ADL care."
Her care plan identified her as being at risk for skin breakdown and pressure injuries due to multiple factors: combative behaviors, impaired cognition, decreased mobility, incontinence, need for assistance with care, poor oral intake, daily psychiatric medications, fragile skin, and impulsive body movements when in bed or chair.
The Nursing Home Administrator and Director of Nursing acknowledged the October incident during their November 4th meeting with investigators. The Director of Nursing explained that their investigation revealed CNA C had not followed the resident's care plan for two-person assistance, which resulted in the bruising to her leg and face.
The Director of Nursing told investigators her expectation was that "all staff would know how to access the residents' care plans, follow the care plan interventions and ask for help if needed." However, she acknowledged that recent education on care plans "did not ensure staff understood how to navigate or access the care plans on the computer."
The facility's own policy, revised in January 2025, requires "a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs" for each resident. The policy states that care plans must be "consistent with the resident's rights including the right to receive the services and or items included in the plan of care."
Yet the inspection revealed a fundamental breakdown in this system. Staff couldn't access the very documents designed to protect residents like #6, whose complex medical conditions and behavioral challenges required specific interventions to prevent injury.
The reliance on verbal communication created a dangerous game of telephone, where critical safety information could be lost, misunderstood, or never passed along. For resident #6, whose impulsive movements and fragile skin made her particularly vulnerable, this communication failure had painful consequences.
The woman who required careful, coordinated care from two trained staff members instead received assistance from a single nursing assistant who believed she needed only one-person help. The resulting bruises on her leg and face became evidence of what happens when care plans exist only on paper - or in this case, in computer systems that the people providing direct care cannot access.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terrace of St Cloud, The from 2025-11-05 including all violations, facility responses, and corrective action plans.