Terrace Of St Cloud, The

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

improving or if there was some other change in the care plan, those interventions would not change.On 11/04/25 at 1:25 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) acknowledged that the incident resulted in a federal report for abuse filed on 10/01/25. The DON continued to explain that from their investigation, the assigned Certified Nursing Assistant (CNA) C did not follow the resident's care plan for assistance of two persons with ADL care which resulted in bruises to her leg and face.2. Resident #6 was admitted to the facility on [DATE REDACTED] with diagnoses that included unspecified congestive heart failure, malignant neoplasm of the colon, Alzheimer's disease, unspecified dementia, and generalized anxiety disorder.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed resident #6's cognition was severely impaired. The assessment indicated resident #6 required two or more staff for care and was dependent on staff for ADL care.Review of resident #6's plan of care initiated

on 10/09/25, revealed the resident was at risk for easy bruising due to fragile skin, unsafe hand movement behaviors, impulsively grabbing items on the floor or surroundings, combative behaviors, and flings and swings her hands. Resident #6 also had a care plan for risk for skin breakdown and pressure injuries related to combative behaviors, impaired cognition, decreased mobility, incontinence, require assist with care, poor oral intake, daily use of psychiatric medications, fragile skin, impulsive body movement behaviors when in bed or chair. Interventions included the use of two staff members as needed to prevent shearing during positioning. In contradiction to the MDS of 10/09/25, the plan of care indicated resident #6 required one person assistance with transfers, bed mobility and ADL care.On 11/05/25 at 12:46 PM, resident # 6 was in bed with torn pool noodles on the side rails of her bed. The assigned CNA D said that resident #6 tried to get out of bed, constantly tore the pool noodles off the rails, and bumped into the rail.On 11/05/25 at 1:48 PM, CNA E looked in the Kardex to determine if a resident was a one- or two-person assistance with ADLs and transfers. She logged into her computer but could not find the desired information. At 1:51 PM, the Unit Manager (UM) for Unit 2 arrived and confirmed CNA E was unable to find

the information in the computer for how many staff were needed by the resident for assistance without the UM's help. The UM acknowledged CNA E was unable to navigate the facility's electronic system and stated

the CNAs relied on verbal reporting instead of what was in the care plan. The UM's said the expectation was for CNAs to know how to look up the information from the care plan.On 11/05/25 at 1:56 PM, in a joint

interview with CNA D and CNA F, resident #6's assigned CNA D said that resident #6 required one person to assist with ADLs and transfers. She was unable to verify the information in the electronic charting system because, she explained, she did not have computer access. The CNA said she had to speak with the DON to give her access. CNA F said the information she saw in the electronic system seemed confusing. Both CNAs said 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. On 11/05/25 at 2:34 PM, in a joint interview with the NHA and DON, the DON stated her expectation was all staff would know how to access the residents' care plans, follow the care plan interventions and ask for help if needed. She acknowledged recent education on care plans did not ensure staff understood how to navigate or access

the care plans on the computer. The facility's policy statement for Care Plans, Comprehensive Person-Centered, revised on January 2025 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy interpretation and implementation in section 4 g. detailed, Each resident's comprehensive person-centered care plan will be consistent with the resident's rights .including the right to receive the services and or items included in the plan of care.

Event ID:

Facility ID:

If continuation sheet