Terrace View Long Term Care Facility

Inspectors wroteBased on interviews and record reviews conducted during survey, the facility failed to ensure that each residents' environment remained as free of accidents as possible and that each resident received adequate supervision and assistance devices to prevent accidents for one (1) (Resident #1) of three (3) residents reviewed for accidents. Specifically, on 09/17/2025, the facility failed to use two (2)-person bed mobility assistance, for overall rolling bed mobility, resulting in Resident #1 falling to the floor, sustaining an acute post-traumatic subdural hematoma (collection of blood that forms between the brain and its outer covering, often due to head trauma), and requiring hospitalization. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.

Inspectors wroteBased on video surveillance, interviews, and record review conducted during the survey, the facility failed to protect the residents from physical, mental and verbal abuse by staff for one (1) (Resident #1) of three (3) residents reviewed for abuse. Specifically, on 12/08/2025, Certified Nurse Aide #1 was observed striking Resident #1, which resulted in a red mark to the resident's cheek. Certified Nurse Aide #1 was also witnessed using profane language directed towards the resident at the time of the incident, in response to the resident's behavior. [...]

Inspectors wroteBased on interview, and record review conducted a Compliant investigation (Complaint # NY00339904) during the Standard survey completed on 8/26/24, the facility and pharmacy services did not effectively implement processes to acquire, dispense and administer medications to meet the needs of each resident. Specifically, one (Resident #260) of four residents reviewed for controlled substances was not administered a regularly scheduled controlled antiseizure medication as ordered and missed a total of 5 doses. Subsequently, the resident experienced seizure activity was transferred to the hospital. Additionally, facility staff did not notify the provider of the unavailability of the medication, and the pharmacy provider did not notify the medical provider that only a 14-day supply of the mediation was dispensed versus the 30-day as ordered. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Compliant investigation (Complaint # NY00339904) during the Standard survey completed on 8/26/24 the facility did not ensure that its residents were free of significant medication errors for one (Resident #260) of three residents reviewed for anti-seizure medications. Specifically, Resident #260 was not administered 5 doses of their anti-seizure medication. This resulted in a significant medication error for Resident #260. The resident had seizure activity and was transferred hospital for evaluation and treatment. The finding is: Refer to F 755 Pharmacy Services/procedures, scope and severity F. The facility policy titled Medication and Treatment Administration Record with an effective date of 7/2023 documented the purpose is to assure accurate administration of medication and treatments. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 8/26/24, it was determined the facility did not ensure residents received routine dental services to meet the needs of each resident for two (Residents #10, #112) of three residents reviewed. Specifically, Resident #10 had been missing dentures since 10/28/20 and was not provided with timely follow up appointments for denture replacement. There were no dental consults completed after 10/20 through 08/24. Additionally, Resident #112 had a delay in receiving routine dental services on admission, there was no physician order for dental consults and had not received a dental consult until 1/3/24.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard Survey completed on 8/26/24, the facility did not ensure that each resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for one (Resident #314) of six residents reviewed. Specifically, Resident #314 was observed with dark brown debris under their fingernails on both hands and eating with their hands. The finding is: The policy titled Activities of Daily Living with an effective date of 2/2024, documented individual care plan interventions will be developed and implemented to encourage self-performance at the resident's highest functional level. [...]

Inspectors wroteBased on interview, and record review conducted during a Complaint investigation (Complaint #NY00321223) during the Standard survey completed on 8/26/24, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #73) of seven residents reviewed. Specifically, Certified Nurse Aide #3 did not provide/utilize a calf board per the plan of care and the resident sustained an injury to their toe/s. The finding is: The policy and procedure titled Closest Care Plan with an effective date of 11/2019, documented the purpose of the closet care plan was to provide care instructions, ready and available in the resident's room, to any caregiver based on the comprehensive care plan team. The policy documented that all caregivers were trained to check the closet care plan prior to assisting any resident. [...]

Inspectors wroteBased on interview, observation, and record review during a complaint investigation (#NY00329554) completed on 12/18/23, the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than 2-hours after the allegation is made, to the Administrator of the facility and to appropriate officials (including the State Survey Agency) for three (Residents #1, #2, and #3 ) of three residents reviewed. Specifically, alleged staff-to-resident verbal abuse allegations for Resident #1 and Resident #2 and staff-to-resident physical abuse allegations for Resident #3 were not reported to the Administrator and State Agency as required.

Inspectors wroteBased on observation, interview and record review conducted during a Standard survey started 10/25/22 and completed 11/1/22, the facility did not employ sufficient staff with the appropriate competencies and skill sets to carry out the necessary functions of the food and nutrition service to carry out the functions of the food and nutrition service safely and effectively. Specifically, the facility did not ensure sufficient support personnel resulting in extended meal wait times, accuracy of foods, and proper food safety with preparation and serving of foods. This included Residents #35, 230, 239 and 296.

Inspectors wroteBased on interview and record review conducted during the Standard survey started 10/25/2022 and completed on 11/1/2022, the facility did not ensure they immediately consulted with the resident's physician when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one (Resident #343) of two residents reviewed. Specifically, there was a delay in notification to the medical provider when a peripheral intravenous line (PIV-a tiny flexible tube that is inserted into a vein for the delivery of fluids/medications) access was unable to be obtained for antibiotic (ABT) administration. The finding is: [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey started on 10/25/22 and completed on 11/1/22, the facility did not ensure that grievances were resolved in a timely manner for one (Resident #240) of four residents reviewed for personal property. Specifically, there was lack of a thorough investigation and resolution into a resident's report of missing property. The finding is: Review of the facility policy and procedure (P&P) titled Prevention of Resident Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 10/19, revealed all staff were trained annually and on orientation regarding misappropriation of resident property. Complaints regarding resident property required an investigation. [...]

Inspectors wroteBased on observation, interview, and record review completed during a Standard survey started 10/25/22 and completed on 11/1/22, the facility did not ensure that the resident is free from physical restraints imposed for purposes of convenience, that are not required to treat the resident's medical symptoms, and when the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints for one (Resident #51) of one resident reviewed. Specifically, the resident had a merry walker (a seated rolling walker used to assist ambulation) with no doctor's order in place and no re-evaluation of the need for continued use of the restraint. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey started on 10/25/2022 and completed on 11/1/22, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for three (Residents #58, #150 and #279) of seven residents reviewed for ADLs. Specifically, there was lack of hand hygiene and glove changes during morning (AM) care and staff did not wash the residents face, hands, and underarms (Resident #58), Resident #150 had greasy, long, and unkempt hair, with no access to a barber, and Resident #279 had long fingernails with brown debris under their thumb nails. Additionally, Resident #279 did not have rolled washcloths to both hands as ordered.

Inspectors wroteBased on observation, record review and interview conducted during the Standard survey started on 10/25/22 and completed on 11/1/22, the facility did not ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for three (Units 2B, 2D, and 3D medication carts) of 11 medication carts reviewed for medication storage. Specifically, there was an open insulin pen not labeled with a resident's name (Unit 2B medication cart), and opened and outdated multidose vials of insulin (Units 2D and 3D medication carts). In addition, three blister packs of medications were left unattended on the 2B medication cart. Residents #32, 81, and 266 were involved.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey started 10/25/22 and completed 11/1/22, the facility did not follow the prepared menus. One (Unit 4D) of four test tray lunch meals on 10/31/22 did not provide broccoli slaw portion on the test tray and to the residents on Unit 4D as planned. The finding is: The Current Menus 2022 Week 2 Monday documented the following lunch meal: oven fried chicken thigh, mashed potatoes, broccoli slaw, dinner roll, rice Krispie treat, 2% milk, and coffee. The Resident Council Minutes dated 7/12/22 documented that missing items continue to be an issue and the concern was sent to the Food Service Director (FSD). During an interview on 10/25/22 at 10:09 AM, Resident #43 stated they were not getting what is on the menu. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey started 10/25/22 and completed 11/1/22, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. One of one main kitchen and one (Unit 4D) of four units had issues with safe food handling. Specifically, dietary staff (Cook #1 and Dietary Aide #1) did not change gloves in accordance with professional standards, touched multiple surfaces, and did not use appropriated utensils to prepare pureed food (Cook) and to serve ready to eat food items (Dietary Aide).

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 2/12/20, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, one (Employee #4) of six personnel files reviewed for background checks had not been screened through the New York State Nurse Aide Registry prior to their employment. The finding is: The facility's policy and procedure titled Drug/Alcohol Test and Background Check, reviewed 3/2019, documented all Skilled Nursing Facility employees must be cleared through the NYS Nurse Aide Registry verification system and the Central Registry. All information will be kept in the Employee Criminal Background Check folder. [...]

Inspectors wroteBased on observation, interview and record review conducted during the Standard survey completed on 2/12/20, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #371) of six residents reviewed for accidents. Specifically, the lack of supervision/cueing during meals for a resident with a diagnosis of dysphagia (difficulty swallowing). The finding is: 1. Resident #371 had diagnoses including dementia, hypertension (HTN, high blood pressure), and heart failure. The MDS (minimum data set-resident assessment tool) dated 1/20/20 documented the resident had severe cognitive impairment and was on a mechanically altered diet. The speech therapy swallow evaluation dated 1/14/20 documented the resident had moderate to severe swallowing impairment and dysphagia. [...]