Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Terrace Of St Cloud, The during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and high care needs did not receive care in accordance with their documented care plans. Staff frequently provided one-person assistance for ADLs and transfers when two-person assistance was required, and care plans were inconsistently documented and difficult for staff to access or interpret. This led to confusion among CNAs and care that did not align with the residents' assessed needs.
Surveyors found that three residents with vascular access devices did not receive care and services consistent with professional standards and physician orders. Issues included undated and improperly maintained dressings, lack of documentation for monitoring and maintenance, and absence of physician orders for care and removal. Nursing staff and the DON confirmed these deficiencies, including failure to change dressings as required and to ensure proper documentation.
Surveyors found that staff failed to follow infection control protocols, including improper placement of a biohazard waste container for a resident on contact isolation and an LPN not using gloves or cleaning equipment during blood glucose monitoring and injectable medication administration. These actions did not comply with facility policies for infection prevention and control.
Three residents with central lines or similar devices did not receive care and services according to standards of practice and physician orders. Dressings were found undated or improperly maintained, and in one case, there were no physician orders for monitoring or maintenance. Staff acknowledged the omissions, and facility policy requiring dating and documentation was not followed.
Surveyors found that the facility did not have the most recent 'Nursing Home Inspections Ratings' page available in the survey binder for residents and visitors. The Administrator, who was responsible for updating the binder, was unaware of the requirement to include this page and did not know how to access the information.
The facility did not maintain up-to-date annual testing records for emergency battery back-up exit lighting, with the last documented test occurring over a year ago. This deficiency was confirmed by the Assistant Director of Maintenance and reconfirmed with facility leadership during the survey.
Surveyors identified that the facility did not maintain required annual testing of the fire alarm system, specifically the duct detector differential testing, with the last documented test occurring nearly a year prior. The deficiency was acknowledged by facility leadership during the survey.
Surveyors found that external wiring was improperly loaded onto fire sprinkler piping during an above-ceiling inspection near the Dietary Department. The Assistant Director of Maintenance was unaware of this issue, and both the Administrator and Assistant Director of Maintenance confirmed the finding during the exit conference. Photographic evidence was provided.
A resident with multiple medical conditions fell during a transfer due to the use of an incorrect and oversized sling by CNAs. The resident, dependent on staff for transfers, slipped through the sling and sustained a head injury. The facility's policy on mechanical lift use was not followed, as staff failed to ensure the correct sling size and type.
The facility failed to implement their abuse policy and provide education for an injury of unknown origin for a resident with multiple diagnoses. Despite initiating an investigation, the facility's DON revealed conflicting information and was unable to provide a Root Cause Analysis or a completed timeline. Not all staff received the required in-service education, and there was no written evidence that the necessary steps were completed.
Failure to Implement and Communicate Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with severe cognitive impairment and significant care needs. For one resident with vascular dementia, diabetes, end stage renal disease, and other conditions, the care plan required two-person assistance for transfers and activities of daily living (ADLs) due to her fragility and risk of injury. Despite this, multiple CNAs admitted to providing care alone, contrary to the care plan, and could not recall if they had assistance on the day the resident was found with a bruise on her face. The care plan interventions were not consistently followed, and staff could not provide a reason for not adhering to the two-person assistance requirement. Another resident with congestive heart failure, colon cancer, Alzheimer's disease, and dementia was also dependent on staff for ADLs and at risk for skin breakdown and bruising due to fragile skin and combative behaviors. The care plan for this resident was inconsistent with the MDS assessment, listing one-person assistance for transfers and ADLs despite the assessment indicating a need for two or more staff. Staff reported difficulty accessing or understanding the electronic care plan system, often relying on verbal reports rather than documented care plans to determine the level of assistance required. Interviews with CNAs and facility leadership revealed that staff were not consistently able to access or interpret care plan information in the electronic system, leading to confusion and inconsistent care. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables, but these were not effectively implemented or communicated to staff, resulting in care that did not meet the documented needs of the residents.
Failure to Follow Standards for Vascular Access Device Care and Documentation
Penalty
Summary
Surveyors identified that the facility failed to provide care and services according to professional standards and physician orders for three residents with vascular access devices. For one resident, a vascular access dressing was observed to be undated, contrary to the physician's order requiring weekly changes and dating of the dressing. The assigned RN confirmed the omission and acknowledged the importance of dating to prevent infection and complications. The Director of Nursing (DON) also confirmed that dressings should always be dated. Another resident was found with a vascular access dressing that was undated and loose, with the edges lifting from the skin. The resident could not recall when the dressing was last changed. A nurse later wrote a date on the existing dressing without changing it, despite the dressing being loose and undated. The DON confirmed that the dressing should have been changed, not just dated, and that the facility protocol required dating upon insertion and changing every Tuesday. A third resident had a vascular access device placed, but there were no physician orders for monitoring or maintenance, and no documentation in the medical or treatment administration records to indicate that the site had been monitored or maintained. The dressing was initially undated and later dated without evidence of proper monitoring or maintenance. The DON confirmed that there should have been physician orders for care, maintenance, and removal, and acknowledged that without such orders, nurses would not be prompted to check or document the site.
Plan Of Correction
A) What corrective action will be accomplished for these residents found to be effective: Resident #106 and #466 were immediately changed on . On a physician's order was obtained to remove Resident #520's, . No adverse consequences were identified at that time. On an in-service for all licensed nurses was initiated by the Staff Development Coordinator which addressed Central Care changes and care and maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central and B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents with Central and/or have the potential to be affected by this deficient practice. On a facility-wide audit was conducted for all residents with Central and/or to ensure that accurate and were appropriate physicians' orders were in place; and that appropriately dated and were being appropriately maintained. All other residents were found to have appropriately maintained site and appropriate orders in place. On , an in-service for all licensed nurses was initiated by the ADON which addressed Central Care and changes and care and maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central and C) What measures will be put in place or what system change will be made to ensure this will not recur: On , an in-service for all licensed nurses was initiated by the ADON which addressed Central Care and changes and care and maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central and Unit Managers, or designee will audit admission/readmission orders for any resident with a Central and/or to ensure that there are physician orders in place for care and maintenance of the. Audits will be completed with every new admission and/or order for times 4 weeks. Any identified problems will be addressed immediately. Audits will be submitted to the DON, or designee weekly. D) How the corrective action will be monitored to ensure the potential will not occur: The DON, or designee, will report the findings of the audits to the QA and QAPI committees monthly times 3 months, then quarterly x 4 quarters. maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central and. Unit Managers, or designee will audit admission/readmission orders for any resident with a Central and/or to ensure that there are physician orders in place for care and maintenance of the. Audits will be completed with every new admission and/or order for times 4 weeks. Any identified problems will be addressed immediately. Audits will be submitted to the DON, or designee weekly. D) How the corrective action will be monitored to ensure the potential will not occur: The DON, or designee, will report the findings of the audits to the QA and QAPI committees monthly times 3 months, then quarterly x 4 quarters. F 694
Deficiencies in Infection Control and Isolation Precautions
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control practices. In one instance, a resident placed on contact isolation for a staph infection had a biohazard waste receptacle for used personal protective equipment (PPE) located in the middle of the room, between the beds of two residents. This placement required staff to walk past the resident's bed and dresser to dispose of soiled PPE, rather than having the disposal container near the exit as required by facility policy and standard infection control practices. The infection preventionist confirmed that this setup constituted a break in isolation protocol, as it increased the risk of transmitting the organism to other residents. Another deficiency was observed during medication administration for a resident with diabetes and other medical conditions. An LPN performed a blood glucose check and administered an injectable medication without donning gloves, despite the potential for exposure to blood. The LPN also failed to sanitize his hands before and after the procedure and did not clean the glucometer before placing it back into the medication cart. The Director of Nursing confirmed that the facility's policy required the use of gloves and cleaning of equipment between residents, and acknowledged that the LPN did not follow these procedures. Facility policies reviewed by surveyors indicated that staff were required to wear gloves during procedures involving potential exposure to blood or body fluids, and to clean reusable equipment after each use. The observed failures to adhere to these policies during both isolation precautions and medication administration led to the cited deficiencies in infection prevention and control.
Plan Of Correction
F 880 A) What corrective action will be accomplished for these residents found to be effective: On Resident #56, biohazard waste receptacle for used PPE was moved to the appropriate location near the exit of the resident's room. On Resident #64, was assessed and no adverse side effects were noted at that time. On LPN A, received education from the ADON on appropriate handwashing, appropriate use of PPE, isolation precautions, and how to appropriately clean multi-use items. B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents with isolation precautions or who require monitoring. On no other residents were able to be identified upon review of LPN A's assigned residents. On LPN A, received education from the ADON on appropriate handwashing, appropriate use of PPE, isolation precautions, and how to appropriately clean multi-use items. On the ADON, initiated education for all licensed nurses on appropriate handwashing, appropriate use of PPE, isolation precautions, and how to appropriately clean multi-use items. On biohazard waste receptacles in isolation rooms were moved to the appropriate location near the exit of the resident rooms. Staff have been educated on the appropriate placement of the waste receptacles. C) What measures will be put in place or what system change will be made to ensure this will not recur: On LPN A, received education from the ADON on appropriate handwashing, appropriate use of PPE, isolation precautions, and how to appropriately clean multi-use items. On the ADON, initiated education for all licensed nurses on appropriate handwashing, appropriate use of PPE, isolation precautions, and how to appropriately clean multi-use items. On staff, initiated education on handwashing, implementation of appropriate isolation precautions, and appropriate use of PPE. On biohazard waste receptacles in isolation rooms were moved to the appropriate location near the exit of the resident rooms. Staff have been educated on the appropriate placement of the waste receptacles. The Unit Managers, or designee, will randomly audit, 3 times a week, across all shifts, staff handwashing, implementation of appropriate isolation precautions, appropriate placement of biohazard waste receptacles, medication administration for appropriate use of PPE, and use and cleaning of multi-use items. Audits will be submitted to the DON weekly. Any identified problems will be addressed immediately. D) How the corrective action will be monitored to ensure the potential will not occur: The DON, or designee, will report the findings of the audits to the QA and QAPI committees monthly for 3 months, then quarterly for 4 quarters.
Failure to Maintain and Document Central Line Care per Standards and Orders
Penalty
Summary
The facility failed to provide care and services according to standards of practice and the plan of care for three residents who had central lines or similar devices. For one resident, a central line was present in the right upper arm for medication administration, but the dressing was undated, contrary to physician orders and facility policy requiring weekly changes and dating. The assigned RN confirmed the omission and acknowledged the importance of dating the dressing to prevent complications. The Director of Nursing (DON) also confirmed that dressings should always be dated. Another resident had a line in the left upper arm for medication administration, with physician orders specifying weekly dressing changes and monitoring for signs of infection. The dressing was found to be undated and loose, with the edges lifting from the skin. The resident could not recall when the dressing was last changed. An RN later wrote a date on the dressing without changing it, and the DON acknowledged that the dressing should have been changed, not just dated, as the duration it had been in place was unknown. Facility policy required labeling dressings with initials and date at the time of application. A third resident had a line placed in the left arm, but there were no physician orders for monitoring or maintenance of the line, nor documentation in the medical or treatment administration records indicating that the site had been monitored or maintained. The dressing was undated initially, and staff could not locate orders for care or removal of the line. The DON confirmed that there should have been physician orders for monitoring, maintenance, and removal, and acknowledged that without such orders, nurses would not be prompted to check or document the site.
Plan Of Correction
A) What corrective action will be accomplished for these residents found to be effective: Resident #106 and #466 were immediately changed on a physician’s order was obtained to remove Resident #520’s. No adverse consequences were identified at that time. On an in-service for all licensed nurses was initiated by the Staff Development Coordinator which addressed Central and changes and care and maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central Care. B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents with Central have the potential to be affected by this deficient practice. On a facility-wide audit was conducted for all residents with Central and/or to ensure that accurate and appropriate physicians orders were in place; and that were appropriately dated and were being appropriately maintained. All other residents were found to have appropriately maintained site and appropriate orders in place. On an, an in-service for all licensed nurses was initiated by the ADON which addressed Central Care and changes and care and maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central and. C) What measures will be put in place or what system change will be made to ensure this will not recur: On, an in-service for all licensed nurses was initiated by the ADON which addressed Central Care and changes and care and maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central and Unit Managers, or designee will audit admission/readmission orders for any resident with a Central to ensure that there are physician orders in place for care and maintenance of the. Audits will be completed with every new admission and/or order for times 4 weeks. Any identified problems will be addressed immediately. Audits will be submitted to the DON, or designee weekly. D) How the corrective action will be monitored to ensure the potential will not occur: The DON, or designee, will report the findings of the audits to the QA and QAPI committees monthly times 3 months, then quarterly x 4 quarters.
Nursing Home Guide Not Posted as Required
Penalty
Summary
The facility failed to ensure that the most recent version of the Nursing Home Guide, specifically the 'Nursing Home Inspections Ratings' page, was available and accessible to residents and visitors in the survey binder located in the front lobby. During the survey, it was observed that this required page was not printed or placed in the binder for review. An interview with the Administrator revealed that she was responsible for updating the survey binder but was unaware that the inspection ratings page needed to be included quarterly and did not know how to access the necessary information from the appropriate website. This deficiency was identified through both record review and staff interview, and it was determined that the facility did not meet the statutory requirement to post all pages listing the facility in the most recent version of the Nursing Home Guide in prominent positions accessible to residents and the public.
Plan Of Correction
A) What corrective action will be accomplished for these residents found to be effective: All residents had the potential to be affected by this deficient practice. The new Administrator of the facility was educated by the Consultant Administrator on the need to post the most recent Nursing Home Guides in a location(s) accessible to all residents, staff, and visitors and how to access the information. The most recent Nursing Home Guide was placed in the Nursing Home Inspection Ratings binder in the front lobby. Information was shared at Resident Council regarding what information is available in the binder containing the Nursing Home Guide. B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents had the potential to be affected by this deficient practice. The new Administrator of the facility was educated on the need to post the most recent Nursing Home Guides in a location(s) accessible to all residents, staff, and visitors and how to access the information. On [date], the most recent Nursing Home Guide was placed in the Nursing Home Inspection Ratings binder in the front lobby. Information was shared at Resident Council regarding what information is available in the binder containing the Nursing Home Guide. C) What measures will be put in place or what system change will be made to ensure this will not recur: All residents had the potential to be affected by this deficient practice. The new Administrator of the facility was educated on the need to post the most recent Nursing Home Guides in a location(s) accessible to all residents, staff, and visitors and how to access the information. On [date], the most recent Nursing Home Guide was placed in the Nursing Home Inspection Ratings binder in the front lobby. Information was shared at Resident Council regarding what information is available in the binder containing the Nursing Home Guide. The Administrator, or designee, will audit the Nursing Home Inspection Ratings binder and website weekly to ensure that the most recent Nursing Home Guide is in the binder. Any identified concerns will be immediately addressed. D) How the corrective action will be monitored to ensure the potential will not occur: The Administrator, or designee, will report the findings of the audits to the QA and QAPI committees monthly for 3 months, then quarterly for 4 quarters.
Failure to Maintain Annual Emergency Lighting Testing
Penalty
Summary
The facility failed to maintain yearly testing of the emergency battery back-up exit lighting as required by NFPA 101. During a record review, surveyors found that the most recent documented test of the emergency lighting was performed on 7/12/23, and there was no evidence of a more recent annual test. This deficiency was confirmed through interviews with the Assistant Director of Maintenance, who acknowledged the lack of complete records for the required testing. The absence of up-to-date annual testing records for the emergency lighting was further reconfirmed with both the Administrator and the Assistant Director of Facilities during the exit conference. The deficiency was supported by photographic evidence, and no specific individual was identified as solely responsible for the deficient practice.
Plan Of Correction
A) What corrective action will be accomplished for these residents found to be effective: All residents, employees, and visitors have the potential to be affected by this deficient practice; however, a specific individual was not identified in this deficiency. On 7/17/24, a testing of the emergency battery back-up exit lighting was completed. No concerns were identified at that time. On 4/28/2025, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct testing of the emergency battery back-up exit lighting yearly. B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents, employees, and visitors have the potential to be affected by this practice. On 7/17/24, a testing of the emergency battery back-up exit lighting was completed. No concerns were identified at that time. On 4/28/2025, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct testing of the emergency battery back-up exit lighting yearly. C) What measures will be put in place or what system change will be made to ensure this will not recur: On 7/17/24, a testing of the emergency battery back-up exit lighting was completed. No concerns were identified at that time. On 4/28/2025, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct testing of the emergency battery back-up exit lighting yearly. The Administrator Consultant developed a tracking schedule for the yearly testing of the emergency battery back-up exit lighting. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director on the tracking schedule. The schedule noted the date on which the Maintenance Director is to complete the yearly testing of the emergency battery back-up exit lighting. The Maintenance Director is to provide documentation to the Administrator of the date of the inspection and testing. Upon completion of the inspection and testing, the Maintenance Director is to provide a copy of the report to the Administrator. D) How the corrective action will be monitored to ensure the potential will not occur: The Maintenance Director, or designee, will report the findings of yearly testing of the emergency battery back-up exit lighting to the QA and QAPI committee monthly x 12 months.
Failure to Maintain Annual Fire Alarm System Testing
Penalty
Summary
The facility failed to maintain annual testing of the fire alarm system, specifically the annual duct detector differential testing. During a record review, surveyors found that the most recent documented testing was completed nearly a year prior, and no evidence was provided to show that the required annual testing had been performed since then. The Assistant Director of Facilities was present during the review and acknowledged the deficiency. This finding was confirmed during the exit conference with both the Administrator and the Assistant Director of Facilities. The lack of current documentation for the annual duct detector differential testing was the sole focus of the deficiency, and no additional patient or resident details were provided in the report.
Plan Of Correction
A) What corrective action will be accomplished for these residents found to be effective: All residents have the potential to be affected by this deficient practice; however, a specific individual was not identified in this deficiency. On 3/12/25, duct detector differential testing was completed. Any identified problems were immediately corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct the annual duct detector differential testing. B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents have the potential to be affected by this practice. On 3/12/25, duct detector differential testing was completed. Any identified problems were immediately corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct the annual duct detector differential testing. C) What measures will be put in place or what system change will be made to ensure this will not recur: On 3/12/25, duct detector differential testing was completed. Any identified problems were immediately corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct the annual duct detector differential testing. The Administrator Consultant developed a tracking schedule for the completion of the testing of the duct detector differential. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director on the tracking schedule. The schedule notes the dates on which the Maintenance Director is to have the annual duct detector differential completed. The Maintenance Director is to provide documentation to the Administrator of the date of the testing. Upon completion of the testing, the Maintenance Director is to provide a copy of the report to the Administrator. D) How the corrective action will be monitored to ensure the potential will not occur: The Maintenance Director, or designee, will report the findings of the annual duct detector differential testing to the QA and QAPI committee monthly for 12 months.
Improper External Loading on Fire Sprinkler Piping
Penalty
Summary
During a facility inspection, surveyors conducted an above-ceiling inspection in the corridor outside of the Dietary Department. They observed that external wiring was loaded onto the fire sprinkler piping, which is not compliant with NFPA 101 and NFPA 25 standards for the maintenance and testing of automatic fire sprinkler systems. The Assistant Director of Maintenance, who was present during the inspection, confirmed that he was not aware of the issue prior to the surveyors' findings. The deficiency was acknowledged and confirmed by both the Administrator and the Assistant Director of Maintenance during the exit conference. The report includes photographic evidence of the deficiency. No information regarding specific residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
A) What corrective action will be accomplished for these residents found to be effective: All residents have the potential to be affected by this deficient practice; however, a specific individual was not identified in this deficiency. On 4/28/25, the external loading of wiring on the fire sprinkler piping noted above the ceiling in the corridor outside the Dietary Department was corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct inspections above the ceiling to ensure that there is no wiring touching or around the automatic fire sprinkler system and is maintained in compliance with the regulations (NFPA Code 101). B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents have the potential to be affected by this practice. On 4/28/25, the external loading of wiring on the fire sprinkler piping noted above the ceiling in the corridor outside the Dietary Department was corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct inspections above the ceiling to ensure that there is no wiring touching or wrapped around the automatic fire sprinkler system and is maintained in compliance with the regulations (NFPA Code 101). On 4/28/25, the Maintenance Director and Assistant Maintenance Director completed an inspection of the wiring for the fire sprinkler in the area above the ceiling. Any concerns were addressed. C) What measures will be put in place or what system change will be made to ensure this will not recur: On 4/28/25, the external loading of wiring on the fire sprinkler piping noted above the ceiling in the corridor outside the Dietary Department was corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct inspections above the ceiling to ensure that there is no wiring touching or wrapped around the automatic fire sprinkler system and is maintained in compliance with the regulations (NFPA Code 101). On 4/28/25, the Maintenance Director and Assistant Maintenance Director completed an inspection of the wiring for the fire sprinkler in the area above the ceiling. Any concerns were addressed. The Administrator Consultant developed a tracking schedule for the completion of inspections of the wiring for the fire sprinkler in the area above the ceiling. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director on the tracking schedule. The schedule notes the dates on which the Maintenance Director is to complete inspections of the wiring for the fire sprinkler in the area above the ceiling. The Maintenance Director is to provide documentation to the Administrator of the date of the inspections. Upon completion of the inspections, the Maintenance Director is to provide a copy of the report to the Administrator. D) How the corrective action will be monitored to ensure the potential will not occur: The Maintenance Director, or designee, will report the findings of the inspections to the QA and QAPI committee monthly x 12 months.
Inadequate Supervision and Incorrect Sling Use Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment to prevent accidents for a resident who was dependent on staff for transfers and required the use of a Hoyer lift. The resident, who had multiple medical conditions including atrial fibrillation and dementia, was involved in a fall incident during a transfer from a wheelchair to a bed. The incident occurred because the nursing staff used an incorrect type of sling, specifically a shower/toilet sling, which was also too large for the resident. This resulted in the resident slipping through the sling and sustaining a head injury. The incident was documented in a progress note, which revealed that two CNAs were involved in the transfer. One CNA admitted to not ensuring the sling was the correct size and type for the resident. The resident fell and hit her head on the floor, resulting in a laceration that required evaluation and treatment at an emergency room. The hospital evaluation showed no acute diagnoses, and the resident returned to the facility the same day. The facility's policy on using mechanical lifts was not followed, as it requires staff to visually check the size of the sling to ensure it is appropriate for the resident. The CNAs involved in the incident did not adhere to this policy, leading to the resident's fall and injury. The Director of Nursing conducted follow-up interviews with the CNAs, confirming the misuse of the sling and the lack of knowledge regarding the correct sling size and type.
Failure to Implement Abuse Policy and Provide Education
Penalty
Summary
The facility failed to implement their abuse policy to fully investigate and provide education for an injury of unknown origin for one resident. The resident, who had multiple diagnoses including type 2 diabetes mellitus, heart failure, stroke, dementia, and left-hand contracture, was found with a purple discoloration on the right hand and later a swollen right arm with a faint yellowish discoloration. An X-ray revealed an acute spiral fracture of the right proximal humerus. Despite initiating an investigation, the facility's Director of Nursing (DON) revealed conflicting information regarding the timing and cause of the injury, and the facility was unable to provide a Root Cause Analysis or a completed timeline of the investigation. The DON admitted that not all staff received the required in-service education following the incident, and there was no written evidence that the necessary steps were completed. The facility's investigation included obtaining statements and performing record reviews, but the information gathered was inconsistent. The DON confirmed that the expectation was for the Administrator to write up the report and conduct an in-service for all staff, which did not occur in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Cloud
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Solaris Healthcare Osceola | 0.5 mi | ★★★★★ | 0 | 0 |
| Avante At St Cloud Inc | 1.2 mi | ★★★★★ | 0 | 0 |
| Aviata At St Cloud | 1.4 mi | ★★★★★ | 1 | 0 |
| Kissimmee Health And Rehabilitation Center | 6.9 mi | ★★★★★ | 0 | 0 |
| The Good Samaritan Society-kissimmee Village | 7.6 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.