Terrace of St Cloud, The

In the surveyor’s words

From the most serious findings on record at Terrace of St Cloud, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Dec 9, 2021

  Based on observation, interview, and record review, the facility failed to develop and implement an individualized care plan for smoking with appropriate interventions to minimize risks and ensure the safety of 1 of 2 residents reviewed for accidents, of 51 sampled residents, (#61). This failure contributed to resident #61 smoking inside his room and placed him and others at risk for serious injury/impairment/death. While resident #61 smoked in his room with an oxygen concentrator nearby, there was likelihood he could have suffered and/or caused burn injuries and/or death from unsafe smoking practices or oxygen combustion. On 12/06/21 at 12:35 PM, resident #61 informed a staff member he wanted to smoke. […]

• Immediate jeopardy, isolatedF689Dec 9, 2021

  Based on observation, interview and record review, the facility failed to conduct an admission smoking risk evaluation; failed to maintain smoking materials in a secure location to ensure a safe environment; and failed to provide appropriate supervision for 1 of 2 residents reviewed for accidents, of a total sample of 51 residents, (#61). These failures contributed to resident #61 smoking inside his room and placed him and others at risk for serious injury/impairment/death. While resident #61 smoked in his room with an oxygen concentrator nearby, there was likelihood he could have suffered and/or caused burn injuries and/or death from unsafe smoking practices or oxygen combustion. On 12/06/21 at 12:35 PM, resident #61 informed a staff member he wanted to smoke. […]

• Actual harm, isolatedF689Jul 24, 2024

  Based on observation, interview and record review, the facility failed to provide adequate supervision and a safe environment to prevent accidents for 1 of 1 resident reviewed for falls with injuries, out of 2 sampled residents, (#1). The facility's failure to ensure nursing staff were knowledgeable to utilize the required transfer sling and ensure proper positioning of the resident during transfers to prevent fall with injury and transfer to a higher level of care for treatment, resulted in isolated actual harm at F689, for resident #1. […]

• No harm, potential for more than minimal, patternF656Aug 24, 2023

  Based on observation, interview, and record review, the facility failed to develop and implement an indwelling urinary catheter plan of care for 1 of 1 resident reviewed for Urinary Catheters from a total sample of 41 residents, (#110). Finding: Review of resident #110's medical record revealed the resident was admitted to the facility on [DATE] from an acute care hospital and had diagnoses that included urinary tract infection (UTI), multiple sclerosis, Bell's Palsy, Vestibular Schwannoma (brain tumor), pressure ulcer of sacral region, gastrostomy (feeding tube), and muscle weakness. […]

• No harm, potential for more than minimal, patternF865Aug 24, 2023

  Based on interview, and record review, the facility failed to demonstrate the effectiveness of a Performance Improvement Plan (PIP) for timely transmissions of Minimum Data Set (MDS) assessments. Findings: On 08/24/23 at 11:00 AM, the MDS Regional Nurse Consultant stated the facility had an employee turnover at the end of May 2023, and an entire facility MDS assessment audit was conducted. She noted a problem was identified for late transmittals of MDS assessments. She explained a Quality Assurance and Performance Improvement Plan (QAPI) plan was discussed and the Regional Nurse presented the MDS plan to the monthly QAPI team in the August 2023 meeting. […]