Terrace Of St Cloud, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 out of 2 residents, of a total sample of 7 residents, (#2, and #6).Findings:1.Resident #2 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, type 2 diabetes mellitus, end stage renal disease, dependence on renal dialysis, anxiety disorder and seizures.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed resident # 2's cognition was severely impaired, and she was dependent on two or more staff for assistance with activities of daily living (ADL) and transfers.Review of resident #2's care plan initiated on 10/27/23 and most recently revised on 10/01/25 indicated the resident required two-person assistance for transfers via mechanical lift, bed mobility and ADLs. On 11/04/25 at 10:23AM, resident # 2 was in bed and had a small, round, bluish mark on her left cheek. She was calm but did not answer any questions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide intravenous (IV) care and services according to standards of practice and plan of care, and failed to obtain physician orders for the care and maintenance of a peripheral IV for 3 of 3 residents reviewed for IV care, of a total sample of 49 residents, (#466, #106 and #520). Findings: 1. Resident #466 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of fracture of unspecified metatarsal left foot, peripheral vascular disease, Type 2 diabetes mellitus, urinary tract infection and sepsis. Current physician's orders indicated resident #466 had a midline IV line in his right upper arm for administration of IV antibiotics. The physician orders showed he received 1 gram (gm) of Ertapenem solution (antibiotic) intravenously daily at 9:00 PM from 4/17/25 until 4/27/25 for a bloodstream infection. A midline catheter is put into a vein by the bend in the elbow or the upper arm . a midline catheter may allow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control practices to prevent the development, transmission and potential spread of infection by not adhering to proper contact precautions for 1 of 2 residents reviewed for isolation precautions, (#56); and failed to ensure acceptable standards of practice were implemented when performing blood glucose monitoring and administration of injectable medication for 1 of 6 residents observed during medication administration, (#64); of a total sample of 49 residents. Findings: 1. On 4/21/25 at 11:25 AM, resident #56's door had a sign indicating contact isolation precautions were implemented. Inside the resident's room, the biohazard waste receptacle for used personal protective equipment (PPE) was located in the middle of the resident's room between resident #56's and her roommate's dressers. In order to dispose of soiled PPE, the wearer would have to walk past resident #56's bed and dresser in order to dispose of soiled PPE.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to implement their abuse policy to fully investigate and provide education for injury of unknown origin for 1 of 2 residents, of a total sample of 4 residents, (#2). Findings: Resident #2 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, heart failure, stroke, dementia, and left-hand contracture. The resident received hospice services. Review of resident #2's medical record revealed a nurse's Progress note dated 9/17/23 at 4:51 AM, which indicated a purple discoloration was noted to the top of the resident's right hand, but no swelling or redness was noted. A few hours later another Progress note indicated the nurse was notified by the Certified Nursing Assistant (CNA) that the resident's right arm was swollen with a faint yellowish discoloration, and he complained of pain. The nurse noted the medical provider and resident Power of Attorney were contacted and a STAT radiograph of the right arm was ordered. On 9/17/23 an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The Minimum Data Set (MDS) admission assessment with Assessment Reference Date (ARD) 6/16/2023 noted the resident scored 12 out of 15 on the Brief Interview for Mental Status that indicated the resident was not cognitively impaired. The Functional Status on the assessment showed she required extensive staff assistance to complete Activities of Daily Living (ADL). Bladder and Bowel section noted the resident had frequent urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. On 08/23/23 at 5:12 PM, during an interview, the MDS Director was unable to answer if a Performance Improvement Plan (PIP) was currently in place for Minimum Data Set (MDS) assessment transmittals. She noted she was unsure of what a PIP was. The Administrator was present and noted there was no PIP in place for MDS assessments. On 08/24/23 at 1:35 PM, the DON stated there was a discussion at the last QAPI meeting about PIP and MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide timely notice of right to appeal for 1 of 4 residents reviewed for Beneficiary Notification out of a total sample of 41 residents, (#265). Findings: Resident #265 was admitted to the facility on [DATE] with diagnoses including syncope and collapse, dementia, difficulty in walking and history of falls. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of 7/06/23 revealed resident #265 had a Brief Interview for Mental Status score of 09 out of 15 that indicated she had moderate cognitive impairment. The document indicated resident #265 expected to return to the community. Resident #265's medical record contained a Notice of Medicare Non-Coverage (NOMNC) which indicated coverage of skilled nursing facility services for resident #265 would end 7/07/23. The form was signed by resident #265's daughter on 7/06/23. Review of resident #265's Electronic Medical Record (EMR) revealed a social services progress noted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate related to administration of anticoagulant medication (#26, #29, #74 N), discharge location (#112), and hospice services (#41), for 6 of 51 sampled residents. Findings: 1. Resident #78's Quarterly MDS assessment with assessment reference date (ARD) of 11/04/21 indicated the resident received an anticoagulant or blood thinner medication on six days during the seven day lookback period. Review of resident #78's medical record revealed a physician order dated 10/07/21 for Clopidogrel 75 milligrams (mg), the generic equivalent of Plavix 75 mg, once daily for coronary artery disease (CAD). This drug is classified as a platelet aggregation inhibitor, not an anticoagulant, since it prevents platelet adhesion that causes blood clots (retrieved on 12/20/21 from Drugs.com at www.drugs.com). Review of the Centers for Medicare & Medicaid Services MDS Resident Assessment Instrument (RAI) Version 3.0 Manual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to properly secure 2 of 2 medication carts on 1 of 2 units, (Unit 1). Findings: 1. On 12/06/21 at 10:00 AM, a medication cart was parked on Unit 1, 300 hallway with the lock in the open position. The nurse for the cart was not seen anywhere in the hall or near the cart. The drawers were tested and access was available to the medications inside the cart. Several residents were observed nearby, wandering in the hallway and seated in wheelchairs a few rooms away. A few minutes later RN B came out of a resident room and acknowledged her medication cart was unlocked. The Unit 1 manager approached and stated the medication carts should be locked, but that she borrowed RN B's medication cart keys. The Unit 1 manager acknowledged the medication carts could still be locked by RN B without having the key. She stated nurses are expected to lock the medication carts when they are not in immediate use by the nurse. On 12/06/21 at 12:14 PM, with translation provided by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the failed to provide and promote dignity during meals for 1 of 51 sampled residents, (#17). Finding: Resident #17 was admitted to the facility on [DATE] with diagnoses of stroke, Parkinson's disease and psychosis. The resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) score of 0. The assessment also noted the resident required extensive assistance from staff for eating. On 12/7/21 at 12:34 PM, resident #17 was in bed. The resident was not able to answer any questions and did not respond to his name. The resident's roommate was seated in a wheelchair near the foot of the resident #17's bed and was eating his lunch on an over bed table in sight of resident #17. Resident #17 did not have his meal at this time and staff were in the hallway passing out meal trays to other residents. On 12/9/21 at 12:30 PM, resident #17 was observed in bed and did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide wound dressing per physician's order for 1 of 4 residents reviewed for non-pressure related skin condition of a total sample of 51 residents, (#30). Findings: Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of metabolic encephalopathy, pemphigoid, dementia, and non-pressure chronic ulcer right and left lower leg. A physician order dated 12/07/21 for Neosporin read, Cleanse right distal lateral foot with normal saline, apply thin layer to wound bed, apply skin prep to peri wound area and cover with dry dressing and gauze wrap two times daily (BID). On 12/09/21 at 11:30 AM, resident #30 was in bed positioned to her right side. A dressing to her right foot was dated 12/07/21. On 12/09/21 at 11:36 AM, Licensed Practical Nurse (LPN) C stated all the resident's dressings were to be done daily. Observation of the dressing to resident #30's right foot was conducted with LPN C. The LPN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure oxygen was administered as ordered and consistent with professional standards of practice, for 1 of 1 resident reviewed for respiratory care, of a total sample of 51 residents, (#6). Findings: Resident #6 was admitted to the facility from the hospital on 5/18/21 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), pneumonia, pleural effusion or fluid around the lungs, pulmonary hypertension, and dependence on supplemental oxygen. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 5/18/21 revealed on discharge from the hospital, resident #6 used oxygen at 2 liters per minute (L/min) as needed. Review of resident #6's medical record revealed a physician's order dated 5/18/21 for oxygen at 2 L/min via nasal cannula, as needed to maintain oxygen levels above 92% and to treat shortness of breath. This order was discontinued and re-written on 11/11/21 to prescribe oxygen as needed to maintain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.