Terrace Health & Rehab Center

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for four of seven residents (Resident R7, R21, R32, and R81).

Inspectors wroteBased on a review of facility policy and records and staff interviews, it was determined that the facility failed to ensure that facility nursing personnel maintain current CPR (cardiopulmonary resuscitation) certification for Healthcare Providers through a CPR provider whose training includes a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards for 16 of 33 licensed nurses: Licensed Practical Nurse (LPN) Employees E1, E2, E3, E4, E5, E6, E7, E8, E9, E10, E11, E12, and Registered Nurse (RN) Employees E13, E14, E15, E16). [...]

Inspectors wroteBased on review of facility policy, documents, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for two of ten residents (Resident R13 and Resident R53).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications and medical supplies were stored and/or disposed of appropriately in one of two medication rooms (Second Floor medication room) and two of two medical supply rooms (Second and Third Floor medical supply rooms).

Inspectors wroteBased on review of facility policy, clinical records, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, to prevent pressure ulcers (PU/PIs - injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for two of six residents (Resident R4 and R24).

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the Psychiatry Group provided progress notes for continuity of care with each visit for one of two residents reviewed (Resident 39).

Inspectors wroteBased on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on emergency preparedness annually to all staff members.

Inspectors wroteBased on a review of the food council minutes, resident group meeting information, observation and staff interview, it was determined that the facility failed to serve food that was palatable and attractive.

Inspectors wroteBased on observations, and staff interview, it was determined that the facility failed maintain sanitary conditions to prevent the potential for cross-contamination or foodborne illness in the main kitchen (Main Kitchen).

Inspectors wroteBased on a review of facility policy, facility records, resident, and staff interviews, it was determined that the facility failed to make certain call lights were accessible for six of twelve residents as required (Resident R1, R20, R72, R94, R109, and R502). Based on a review of facility policy, facility records, resident, and staff interviews, it was determined that the facility failed to make certain call lights were accessible for six of twelve residents as required (Resident R1, R20, R72, R94, R109, and R502).

Inspectors wroteBased on interview with therapy staff and resident, clinical record review and staff interview, it was determined facility failed to ensure that residents received proper treatment and assistive device to maintain hearing abilities for one of three residents (Resident R30).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of two residents (Residents R2 and R92).

Inspectors wroteBased on staff interview it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 11 out of 12 months (October 2024 through August 2025).

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to provide a dining experience that promoted resident dignity for 1 of 5 residents (Resident R62).

Inspectors wroteBased on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure the comprehensive care plan was implemented related to assisting/cueing a resident for eating for one of five residents (Resident R70).

Inspectors wroteBased on review of facility policy, observation, clinical record review, and staff interview, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of five residents (Residents R70).

Inspectors wroteBased on observations, and staff interview, it was determined that the facility failed to provide a resident adaptive eating equipment and utensils for one out of five residents (Resident R70). Findings Include:Review of the facility policy Assistive Eating Devices dated 3/28/25, indicated the facility will provide assistive eating devices to residents with limited arm mobility, grasp. range of motion as recommended by nursing or therapy to promote independence in drinking and eating to their maximum ability. During an observation on 8/27/25, at 8:40 a.m., Resident R70 was in her room having difficulty eating. [...]

Inspectors wroteBased on a review of facility policy, observations and staff interviews it was determined that the facility failed to properly store food products in the Main Kitchen, which created the potential for foodborne illness. Findings Include: Review of the facility policy Food Storage: Cold Foods last reviewed on 3/25/24, indicated that all time/temperature control for safety foods will be appropriately stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code. All food items will be stored 6 inches above the floor and 18 inches below the sprinkler units. During an initial observation on 9/10/24, at 10:30 a.m., of the dietary department the following was identified: Three staff lunch bags were in the cooler with resident food items. The deep freezer had ice build up on vent pipes with food stored directly under ice dripping onto boxes. [...]

Inspectors wroteBased on review of facility policies, facility provided documents, clinical records and staff interview, it was determined that the facility failed to make certain a resident was free from abuse, neglect or misappropriation of property for one of two residents reviewed (Resident R69).

Inspectors wroteBased on review of facility documents, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Nurse Aide (NA) Employees E2 and E3).

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for two of ten staff members (Employee E2 and E5).

Inspectors wroteBased on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on behavioral health for three of ten staff members (Employees E1, E2, and E3).

Inspectors wroteBased on review of clinical records, and staff interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for eight of 12 residents (Resident R1, R2, R3, R4, R5, R6, R7, and R8).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to accurately assess residents for social services needs for eight of 12 residents (Resident R1, R2, R3, R4, R5, R6, R7, and R8). Review of the facility Social Service Director job description dated 9/18/23, previously reviewed 3/2/22, indicated the Social Service Director provides planning, assessing, coordinating, and implementation of services to enhance each resident's social and psychological well being. The job description further stated the Social Service Director prepares, evaluates, and charts social service documentation, including the initial social service assessment. During a review of the Social Service Assessments completed on Resident R1, R2, R3, R4, R5, R6, R7, and R8 failed to include documentation for previous substance abuse and post-traumatic stress disorder. [...]