Terrace View Gardens

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to timely complete quarterly Minimum Data Set (MDS) assessments. This affected four residents (#44, #76, #14, and #09) out of 24 residents reviewed for MDS assessments. The facility census was 75.Findings include: 1. Medical record review for Resident #44 revealed an admission re-entry date of 03/01/22. Diagnoses include paraplegia, vascular dementia, cognitive communication deficit, type II diabetes mellitus, acute respiratory failure with hypoxia, major depressive disorder, delusional disorder, anxiety disorder, and complete traumatic amputation at level between left hip and knee. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 was cognitively intact. The resident was supervision assistance for eating, and oral hygiene, and maximal assistance for toileting, dressing, and personal hygiene. The resident was documented as…

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 medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to timely complete comprehensive Minimum Data Set (MDS) assessments. This affected three (#04, #07, and #81) out of 24 residents reviewed for assessments. The facility census was 75.Findings include:1. Review of the medical record for Resident #04 revealed an admission date of 01/16/25. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, other generalized epilepsy and epileptic syndromes intractable without status epilepticus, aphasia following cerebral infarction, iron deficiency anemia, hypertension, cerebral infarction, encephalopathy, vitamin d deficiency, depression, type two diabetes mellitus without complications, hyperlipidemia, hypertensive heart disease without heart failure, and chronic respiratory failure with hypoxia.Review of the annual MDS assessment started on 01/27/26 for Resident #04 revealed the assessment was not completed until 02/12/26. Resident #04 was identified as having…

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 medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to timely complete significant change Minimum Data Set (MDS) assessments. This affected three residents (#48, #05, and #11) of four residents reviewed for a significant change. The facility census was 75.Findings include: 1.Medical record review for Resident #48 revealed an admission date of 05/23/23. Diagnoses included encephalopathy, dysphagia, aphasia, cognitive communication deficit, dementia, muscle weakness, chronic pulmonary embolism, and diabetes insipidus. Review of the most recent quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident was maximal assistance for eating, and upper body dressing, dependent for oral hygiene, toileting, bathing, lower body dressing, personal hygiene, transfers, and mobility in a manual wheelchair. Resident #48 was incontinent of bladder and bowel. Further review of Resident #48's record…

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 medical record review and staff interview, the facility failed to conduct quarterly care conferences. This affected three (#02, #11, and #68) out of three residents reviewed for care conferences. The facility census was 75.Findings include:1. Review of the medical record for Resident #02 revealed an admission date of 08/01/22. Diagnoses included type two diabetes mellitus without complications, major depressive disorder, hypertension, histoplasmosis, hypothyroidism, hyperlipidemia, anemia, obesity, tachycardia, peripheral vascular disease, post-traumatic stress disorder, anxiety disorder, heart failure, and obstructive sleep apnea.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #02 was cognitively intact. Resident #02 was assessed to require supervision for eating, partial/moderate assistance for oral hygiene, and upper body dressing, substantial/maximal assistance for toileting, bathing, lower body dressing, personal hygiene, and bed mobility, and was dependent…

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 facility policy review, the facility failed to ensure enhanced barrier precautions were followed during incontinence care. This affected one (#36) of three residents reviewed for incontinence care. The facility census was 72.Findings include:Review of the medical record for Resident #36 revealed an admission date of 04/24/25. Diagnoses included chronic kidney disease, depression, and transient ischemic attack (TIA).Review of the Five-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. This resident was assessed to require supervision with eating, dependent with toileting, transfers, and dressing, and substantial assistance with bathing.Review of section H for bowel and bladder of the Five-Day Medicare MDS assessment dated [DATE] revealed Resident #36 was always incontinent of bowel and bladder.Review of the physician orders for Resident #36 revealed no…

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 medical record review, staff interview, and review of a facility provided article, the facility failed to order and administer medication with an adequate indication for use and in the presence of adverse effects. This affected one (#2) of three residents reviewed for medications. The facility census was 78. Findings include: Review of the medical record revealed Resident #2 was admitted on [DATE] with diagnoses that included cerebral infarction, attention-deficit/hyperactivity disorder (ADHD), anxiety disorder, congestive heart failure, and obstructive sleep apnea. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. Review of a physician order dated 12/29/24 revealed Resident #2 was ordered amphetamine-dextroamphetamine (Adderall), a central nervous system stimulant, 30 milligram (mg) with instructions to give one tablet by mouth once a day for sleep apnea…

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 medical record review, and interview of facility staff, interview with eye surgery center staff, interview with resident's Power of Attorney (POA), the facility failed to ensure a resident eye surgery was rescheduled as needed. This affected one (#20) of one resident reviewed for eye care. The facility census was 73. Finding include: Review of medical record revealed Resident #20 had an admission date on 11/16/20, with diagnoses including: Down Syndrome, anxiety disorder, metabolic encephalopathy, and dementia. Review of Minimum Data Set assessment dated [DATE], revealed Resident #20 was severely cognitively impaired. Resident #20 was total dependent with one-person physical assist for all care. Review of plan of care dated 12/27/22 revealed Resident #20 was at risk for inability to focus on objects, discriminate color, adjust to changes in light and dark, decreased impaired vision related to highly impaired vision related to cataracts, progression of disease processes and other factors. She was often…

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 weekly menus, observations, resident and staff interviews, the facility failed to ensure the dining room was maintained in a clean and sanitary manner. This affected 20 residents (#3, #5, #7, #8, #9, #14, #17, #18, #20, #21, #37, #39, #43, #49, #50, #53, #56, #58, #60, and #69) observed in the dining room. The facility further failed to keep eight (#300, #302, #303, #306, #308, #312, #314, and #315) resident rooms on the 300 unit in a clean, sanitary and comfortable manner. The facility census was 76. Findings include: 1. Observation on 04/22/19 at 9:00 A.M., of Resident #18 and #39's floors revealed dark black skid marks across the floor. 2. Observation on 04/22/19 at 9:40 A.M., revealed Resident #53's privacy curtain had red and brown stains. 3. Observation on 04/22/19 at 10:00 A.M., revealed Resident #76s bathroom wall on the left side of the room had large dents and holes along with exposed drywall. The edges of the floors had dark black marks. Interview on 04/22/19 at 10:05 A.M., with…

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 medical record review, observation, and staff interview, the facility failed to ensure treatments were in place to prevent and promote healing of a pressure ulcer. This affected one (#44) of five residents reviewed for pressure ulcers. The facility census was 76. Findings include: Medical record review revealed Resident #44 was admitted to the facility on [DATE] with a re-entry date of 04/21/17. Diagnoses included cerebral infarction (stroke), diabetes, heart failure, and dementia. Review of care plan dated 04/30/17 revealed Resident #44 was at risk for alteration in skin integrity related to cerebral vascular accident, diabetes, dementia, incontinence, history of pressure areas, and mobility impairment. Interventions included assess for pain and provide treatment per physician orders, elevate heels when in bed as needed/tolerated, and pressure relieving boots as tolerated. Review of the annual minimum data set (MDS) assessment dated [DATE] revealed Resident #44 was severely impaired cognitively.…

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 medical record review, observation, staff interview and resident interview, the facility failed to administer oxygen therapy appropriately for one resident (#31) of one reviewed for respiratory services. The facility census was 76. Findings include: Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including, hemiplegia, paraplegia, obstructive sleep apnea, cerebral infarction (stroke), chronic obstructive pulmonary disease (COPD), and kidney failure. Review of Resident #31's physician orders dated 12/18/18, revealed an order for oxygen at 3 liters per minute, per nasal cannula. Review of most recent annual 04/05/19 comprehensive assessment revealed the resident was cognitively intact. The resident was noted to be receiving oxygen therapy at the facility. Observation of Resident #31 on 04/22/19 at 4:02 P.M., revealed the resident was receiving oxygen via nasal cannula at a rate of 4.5 liters per minute via nasal cannula. Observation of Resident #31 on…

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.