Terraces At The Clare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to ensure residents were free of physical restraints. Specifically, the facility failed to ensure one (R1) of three residents reviewed for restraints was free of physical restraints unless medically necessary in the sample of three. R1 was physically restrained with a blanket across the chest that was then tied to the frame of R1's bed.Findings include: Facility's final incident report of 5.24.2026, documents, in part: At approximately 5:45 am on 5.19.2026, a first shift CNA observed that the top left corner of the resident's blanket had been tied to the bed frame near the bed enabler closet to the hallway. The CNA informed the nurse. At approximately 6:15 pm, on 5.19.2026, the third shift CNA returned the DON's calls and texts and spoke with both the DON and Administrator. The CNA stated that she had secured the resident's blanket to the bed in an effort to prevent the resident from getting up independently and potentially falling.…

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 observations, interviews, and record reviews the facility failed to follow their policy and procedure for preventing foodborne illnesses to ensure foods in the walk-in coolers were properly labeled and dated when they were opened and prepared and discarded on the best by date. The facility also failed to ensure kitchen staff was wearing facial hair/beard restraint while in the kitchen and failed to ensure potentially hazardous refrigerated foods were stored at the appropriate temperatures. These failures have the potential to affect 47 residents in the facility who are receiving oral diet. Findings Include: On 4/29/25 at 10:47 AM, during the initial tour in the kitchen (17th floor) with V26 (Chef), surveyor observed the main walk-in cooler external thermometer read 49 degrees Fahrenheit (F) and inside thermometer read 47 degrees F. V26 stated a contracted worker will be coming in to fix the cooler because the thermometers are faulty. Inside the main walk-in cooler was found a container of slices of liver with no label. V26 stated it will be served that day. Inside the…

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 observations, interviews, and record reviews, the facility failed to assess, ientify, and involve the local public health department to determine if their water management plan was adequate to prevent the growth of Legionella or other opportunistic waterborne pathogens. This failure affects five (R22, R28, R30, R204, and R209) out of a total sample of twelve residents reviewed and potentially affects all forty-eight residents residing in the facility. Findings: On 5/1/25 at 10:30 AM, V8 (Director of Plant Operations) stated that the expansion tank does not have enough air pressure and this could possibly cause growth of Legionella, and that the company will be coming next week Friday 5/9/25 to fix the tank, and the mixing valve will be fixed next week Monday or Tuesday 5/5/25 or 5/6/25. On 5/1/25 at 11:50 AM, V14 (Assistant Director of Nursing/Infection Preventionist) stated that when she became aware of the first legionella results, she notified the physician, family members, and staff to monitor the residents for respiratory symptoms. V14 was not sure of the date. She…

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 observations, interviews, and record reviews, the facility failed to conduct a thorough risk assessment to identify why opportunistic waterborne Legionella could grow and spread in the facility water. This failure affects five (R22, R28, R30, R204, and R209) out of a total sample of twelve residents reviewed and potentially affects all forty-eight residents residing in the facility. Findings: On 4/30/25 at 10:39 AM, V8 (Director of Plant Operations) stated that he has been in this facility for almost two years and the facility checks for legionella quarterly. The testing was done on 3/26/25 and 4/18/25 with positive result in five rooms. He also stated that the facility performs daily flushing twice a day on the affected rooms, obtains water temperature log in one room weekly on each floor, and provided water filters for the sink. At 2:35 PM V8 stated that the facility has been positive with Legionella since February 2023 before he joined the facility. V8 said the facility has been cleaning the mixing…

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 closely monitor a resident receiving continuous oxygen and failed to follow physician's order to ensure a resident was receiving the correct oxygen flow rate for one (R31) out of two residents reviewed for oxygen use in the final sample of 12. Findings Include: On 4/29/25 at 12:03 PM, R31 was sitting on her wheelchair alert and able to verbalize needs. R31 was observed using oxygen (O2) via nasal cannula (NC) and her oxygen concentrator flow rate was set to 2 liters per minute (LPM). R31's oxygen concentrator was located behind her wheelchair and not within R31's reach. R31 stated that somebody comes in in the morning and checks her oxygen. R31 stated she does not know how to change her oxygen setting. R31 stated, I don't even know why I'm on it. The other nurse told me I needed it. Some nurses tell me I don't need it. R31 stated she never touches the dial on the oxygen concentrator because the nurses do it for her and that she can't…

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 maintain accurate record of usage and accountability for 1 resident (R35) who receives controlled substances from 1 of 2 inspected medication carts. Findings Include: On 4/29/25 at 12:29 PM, a narcotic reconciliation count conducted with V2 (Director of Nursing/DON) for the tenth floor's medication cart. Observed R35's Diazepam 2 milligrams (mg) medication administration blister pack had 39 half tablets in the card. The count on R35's CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM documents 60 half tablets were received on 1/30/25 last entry date showed 4/29/25 at 2:30 AM with 40 tablets remaining. V2 stated the count was incorrect. On 4/30/25 at 2:14 PM, V2 (DON) stated that V9 (Registered Nurse) administered one dose of the Diazepam to R35. V2 stated when administered, the nurse will have to sign off that it was given on the controlled substance accountability form. V2 stated all controlled substances should be accounted for. V2 stated two nurses counting the narcotics at the beginning and end of shift. The…

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, interviews and records review the facility failed to complete a thorough investigation of the alleged injuries of unknown source to rule out physical abuse. This failure affected 1 (R1) out of 3 residents reviewed for abuse. Findings include: R1 subject of the incident is [AGE] years old currently a resident of facility. R1 was initially admitted on [DATE] with medical diagnosis that includes severe dementia, atherosclerotic heart disease of native coronary artery. R1's BIMS (Brief Interview of Mental Status) score is 1 out of 15, indicating R1's cognition is severely impaired. On 03/12/2025 at 11:17 AM, R1 was seen sitting inside her room. R1 was alert, unable to respond to questions within topic. R1 responded to all questions by saying okay. V3 (Registered Nurse) went inside R1's room to assess both arms and hands of R1. R1's left wrist and right hand noted to have small bruises and left eye that shows bruising and redness. V3 stated that bruising and redness on R1's left eye was there…

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 review of records and interviews the facility failed to maintain accurate and readily available resident records related to abuse investigation. This failure affected one resident (R1) out of 3 residents reviewed. Findings include: R1 subject of the incident is [AGE] years old currently a resident of facility. R1 was initially admitted on [DATE] with medical diagnosis that includes severe dementia, atherosclerotic heart disease of native coronary artery. R1 cognition is severely impaired with BIMS (Brief Interview of Mental Status) of 1. R1 was investigated by the facility related to bruises resident sustained that was identified on 02/04/2025. On 03/12/2025 at 11:17 AM, R1 was seen sitting inside her room. R1 was alert, unable to respond to questions within topic. Facility Final Report of R1's incident dated 02/04/2025 documents the following: Staff denies witnessing any incident during care but did mention that resident gets very stiff and resistant during transfer which might cause R1 to accidentally…

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 observations, interviews, and record review, the facility failed to ensure staff signed the Narcotic Shift Count Log Sheet at the beginning of the shift and at the end of the shift and failed to ensure staff did not sign the Narcotic Shift Count Log Sheet before the end of the shift. These failures affected 5 residents (R7, R29, R30, R50 and R51) reviewed for controlled medications in the total sample of 34 residents. Findings include: On 04/08/2024 at 11:02am during the medication cart observation with V3 (Licensed Practice Nurse) of the 10th floor medication cart, the 10th floor 04/2024 Narcotic Shift Count Log Sheet noted with missing signatures on shift 7A (am) - 7P (pm) columns 'ON' and 'OFF' on DATE: 3. This was pointed out to V3 (Licensed Practice Nurse). V3 stated whoever came in on 04/03/2024 did not sign the narc (narcotic) sheet. We (staff) are supposed to sign after the count. This surveyor requested V3 to provide a copy of the 10th floor 04/2024 Narcotic Shift Count Log Sheet. On 04/08/2024…

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 ensure treatment orders were in place for a resident with chronic wounds; failed to provide necessary care and services to promote wound healing; failed to ensure assessments are accurate; and failed to inform doctor of significant change within 24 hours per policy. These failures apply to 1 of 4 residents (R2) reviewed for wound management. Findings include: R2 is an [AGE] year old female, admitted to the facility on [DATE] with the following diagnoses: Bilateral Wound Debridement with Biopsy (8/12/23), Chronic Venous Hypertension (Idiopathic) with ulcer and inflammation of bilateral extremity, Cellulitis of right lower limb, Cellulitis of left lower limb, Peripheral Vascular Disease, Cerebrovascular Disease, Idiopathic Chronic Gout, Chronic Kidney Disease stage 3B, Hypoparathyroidism, Vitamin D Deficiency, Weakness, Muscle weakness, Anemia in Chronic Kidney Disease, Bell's Palsy, Localized edema, Obesity, Gastro-esophageal Reflux Disease without…

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.