Terrace at Bishop's Glen, The

In the surveyor’s words

From the most serious findings on record at Terrace at Bishop's Glen, The, in the surveyor’s own words.

• Actual harm, isolatedF760Nov 5, 2024

  Based on interviews, medical record review, facility documents review, and facility policy review, the facility failed to ensure residents were free from significant medication errors for one (Resident #1) of three residents reviewed for medication administration. This action resulted in Resident #1 requiring a transfer to a higher level of care and hospital admission. The findings include: A review of Resident #1's medical record revealed she was a [AGE] year-old female admitted to the facility with a diagnosis of chronic obstructive pulmonary disease, morbid obesity, muscle weakness, transient ischemic attacks, and dementia. […]

• No harm, potential for more than minimal, widespreadF812Mar 21, 2024

  Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all residents who consumed foods from the facility, by failing to 1) Seal and date mark open food products in the walk-in freezer, walk-in refrigerator, and open bundles of bread on the bread rack, and 2) Properly clean and sanitize the kitchen mixer, convection oven, fryer, oven tray lines and can opener pixel. Food handling and sanitation is important in health care settings serving nursing home residents. […]

• No harm, potential for more than minimal, widespreadF727Apr 7, 2022

  Based on observation, interview, record review, and facility assessment tool review, the facility failed to ensure a registered nurse (RN) worked at least 8 consecutive hours a day, seven days a week on four separate occasions. Registered nurses provide assessments, care to clinically complex patients and supervision to licensed practical nurses. The findings include: During a tour of the facility on 4/4/22 at 9:17 AM, the daily staffing sheet was observed posted at the nurse's station. There were no Registered Nurse (RN) hours listed on the daily staffing calculations. […]

• No harm, potential for more than minimal, isolatedF695Jun 11, 2025

  Based on observation, interview and record review, the facility failed to ensure that one (Resident #20) of seven residents receiving respiratory care was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan, by failing to ensure there was a physician's order for oxygen therapy and care of oxygen supplies. The findings include: A rview of Resident #20's medical record revealed that she was admitted to the facility on [DATE], with diagnoses including cerebral ischemia, diabetes mellitus type II, chronic obstructive pulmonary disease (COPD), unspecified asthma, acute on chronic respiratory failure, morbid obesity, muscle weakness, other abnormalities of gait and mobility, congestive heart failure, cognitive communication… […]

• No harm, potential for more than minimal, isolatedF812Jun 11, 2025

  Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to remove grease from fryers and failure to clean grease build-up and food debris inside and around both fish fryers. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 06/09/25 at 11:35 AM. […]