Terrace Healthcare & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Mar 3, 2022

  Based on interview and record review, the facility failed to ensure residents were free from abuse and neglect when the facility accepted an individual from a nurse staffing agency without verifying the identity, licensure, and level II background screening, who was found not to be the person they presented to be, was not licensed as a practical nurse, and did not have a level II background screening, which resulted in a substantiated allegation of physical abuse due to the unlicensed person presenting as a practical nurse, when attempting to administer oral and intravenous (IV) medications, caused facial bruising and arm skin tear for 1 of 3 residents, Resident #2, and allowing an unlicensed person to provide nursing care and services over 33 shifts for 212 residents using a sample of 3… […]

• Immediate jeopardy, patternF607Mar 3, 2022

  Based on interview and record review, the facility failed to develop and implement policies and procedures to verify the identification, licensure, and background screenings for all agency nursing staff and to ensure the documentation of the agency staff were verified and maintained prior to having access to the residents and providing nursing care and services to 212 residents throughout their assignment at the facility. This facility failure resulted in Immediate Jeopardy. Findings include: Cross Reference to F600 and F835 Review of the Florida Department of Health (DOH) license verification on 3/2/2022 revealed Staff D did not have a current license for a Licensed Practical Nurse (LPN), Registered Nurse (RN) or certification for a Certified Nurse Assistant (CNA). […]

• Immediate jeopardy, patternF835Mar 3, 2022

  Based on interview and record review, the facility administration failed to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by not assuming full responsibility for the day to day operations of the facility ensuring the safety for 128 residents by not verifying identification, licensure and level II background screenings for agency nursing staff, which resulted in a substantiated allegation of physical abuse for 1 of 3 residents, Resident #2, and allowing an unlicensed person to provide nursing care and services over 33 shifts for 212 residents using a sample of 3 of 3 residents of the total 212 residents, Residents #2, #5, and #6. This facility failure resulted in Immediate Jeopardy. […]

• No harm, potential for more than minimal, widespreadF888May 27, 2022

  Based on interviews, document review, and review of facility policy, the facility failed to meet the requirement for 100% compliance that all staff have received at least one dose of a single-dose vaccine, or all doses of a multiple-dose COVID-19 vaccine series, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the Centers for Disease Control Prevention (CDC). One hundred twelve out of 156 current staff were either fully vaccinated against COVID-19 or had been granted an exemption or delay in accordance with CDC guidelines, for a compliance rate of 98.1%. […]

• No harm, potential for more than minimal, widespreadF761Jan 21, 2022

  Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles, and included the expiration date when applicable, in 6 of 7 medication carts. Findings: On 1/18/2022 at 9:05 AM, the surveyor observed Medication Cart #1 with Staff A, Licensed Practical Nurse (LPN), and found one opened bottle of [MEDICATION(S)] insulin with an opened date of 11/29/2021, one opened bottle of [MEDICATION(S)] insulin with an opened date of 11/29/2021, one opened [MEDICATION(S)] insulin pen with no opened or expiration dates, one opened [MEDICATION(S)] insulin pen with an opened date of 12/13/2021, one opened [MEDICATION(S)] pen with an opened date of 12/2/2021,… […]