Terrace Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Terrace Health & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF760Dec 28, 2021

  Based on review of facility policy, clinical record review, facility documents and staff interview the facility failed to ensure that residents were free from any significant medication errors, resulting in actual harm by failing to provide [CONDITION(S)] medication, the resident having a [CONDITION(S)] and hospitalized for one of eight residents (Resident CR1). Findings include: Review of the facility policy, Missed Medication Incident, indicated that the facility defines medication error as any physician provider medication that is not administered to the resident as prescribed. […]

• Actual harm, isolatedF684Jun 8, 2021

  Based on observation, clinical record review, hospital record review and staff interviews, it was determined that the facility failed to ensure that residents received treatment and care in accordance with standards of practice and physicians' orders regarding wound vac placement and placement of a urinary catheter, resulting in harm of a lower back injury and a urethral tear, which required treatments for two of 17 residents reviewed (Resident R1 and R2). Findings Include: A clinical record review revealed that Resident R1 had been admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689Jun 8, 2021

  Based on observations, a review of clinical records, facility investigation reports and staff interviews, it was determined that the facility failed to provide necessary staff supervision and to maintain a resident's environment free of potential accident hazards, that increased the risk for injury and actual sustained injuries, requiring treatment from falls causing actual harm for three of 17 residents reviewed (Residents R2, R3, and R4). Findings include: A clinical record review revealed that Resident R2 was admitted to the facility on [DATE], with diagnoses which included, obstructive and reflux [CONDITION(S)] (when urine flow is obstructed which causes urine to back up and injure kidneys) and abnormal posture with contractures of bilateral lower extremities. […]

• Actual harm, isolatedF697Jun 8, 2021

  Based on review of policies, clinical records, and staff interviews, it was determined that the facility failed to make certain that proper pain management was provided for one of 17 residents (Resident R2), resulting in harm when the resident suffered severe pain during care and attempting to eat. Findings include: Review of the facility Pain Management and Assessment policy last reviewed on 2/26/21, indicated that a thorough assessment by observation and treatment and relief of pain including facial grimaces and guarding and unexplained behaviors will be observed. The basis for pain control includes resident needs. […]

• Actual harm, isolatedF726Jun 8, 2021

  Based on facility policy, clinical and facility record review and staff interview, it was determined that the facility failed to make certain that licensed nurses had the specific competencies and skills necessary to care for residents' with wound vac needs, urinary catheter needs, and use of positioning devices for Broda chairs causing actual harm for three of 17 residents reviewed (Resident R1, R2, and R3). Findings include: During an interview on 6/2/21, at 3:43 p.m. the Registered Nurse Corporate Clinical Specialist Employee E4 indicated that staff have training online through the Relias system and are required to be self-motivated to complete courses annually. […]