Terrace Glen Village

In the surveyor’s words

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

• Actual harm, isolatedF686Jun 29, 2023

  Based on clinical record review, observations, Resident Representative and staff interviews and facility policy review, the facility staff failed to prevent an unstageable pressure ulcer from forming on a heel requiring debridement (the removal of dead (necrotic) or infected skin tissue to help a wound heal) and caused increased pain for 1 of 1 residents reviewed for pressure ulcers (Resident #9). The facility reported a census 36. Findings Include: The MDS (Minimum Data Set) Assessment identifies the definition of Pressure Ulcers: Stage I - An intact skin with non-blanchable redness of a localized area usually over a bony prominence. […]

• Actual harm, isolatedF689Jun 29, 2023

  Based on clinical record review, observation, Resident Representative and staff interviews, and facility policy review, the facility staff failed to ensure safe transport of a resident in a wheelchair, resulting in a fracture of the right tibia and fibula, bruising, swelling, and increased pain to the leg, and the resident transferred to the hospital for treatment for 1 of 3 residents reviewed for accidents (Resident #7). The facility reported a census of 36. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 scored 00 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognition impairment. […]

• Actual harm, isolatedF690Jun 29, 2023

  Based on clinical record review, observation, staff interviews, and facility policy review, the facility failed to thoroughly assess, monitor, and promptly act upon changes in condition in a resident's vital signs and clinical presentation resulting in the resident's transfer to the hospital, diagnosis of septic shock related to a urinary tract infection (UTI), and intravenous (IV) antibiotic use in the hospital for one of two residents reviewed for catheters (Resident #30). The facility reported a census of 36 residents. Findings Include: 1. The Significant Change Minimum Data Set (MDS) for Resident #30 dated 1/27/23 lacked documentation of a Brief Interview for Mental Status (BIMS) score, and lacked evaluation of the resident's cognitive skills for daily decision making. […]

• Actual harm, isolatedF689May 4, 2022

  Based on clinical record review, facility investigation review and staff interviews, the facility failed to protect residents from accidents that caused injury when wheelchair foot pedals were not in place during transport for 2 of 2 residents reviewed (Resident #1 and Resident #6). The facility reported a census of 30 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had diagnoses of non-Alzheimer's dementia, [CONDITION(S)] and presence of right artificial knee joint. The MDS further documented a Brief Interview for Mental Status (BIMS) score of 0 indicating severely impaired cognition and Resident #1 required supervision for locomotion on and off the unit and required extensive assistance of 2 staff for transfers. […]

• No harm, potential for more than minimal, patternF641Nov 19, 2025

  Based on clinical record review, staff interview, facility policy review and guidance from the 2025 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately code medications on the Minimum Data Set (MDS) assessment for 4 of 15 residents reviewed for MDS Assessment accuracy (Resident #2, #3, #12, #34). The facility reported a census of 38 residents.Findings include:1.The Medication Administration Record (MAR) for August of 2025 for Resident #2 documented that the resident received aspirin, 81 mg (milligram) and Clopidogrel (also known as Plavix), 75 mg (both medications are classified as anti-platelet medications) daily throughout the month. […]