Terrace Post Acute

In the surveyor’s words

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

• Immediate jeopardy, patternF684Apr 15, 2021

  Based on interview and record review, the facility failed to provide the necessary care and treatment in accordance with professional standards of practice by failing to ensure Registered Nurse 1 (RN1) thoroughly reviewed the discharge packet (a summary of treatments and medications a resident received at the General Acute Care Hospital to aid in the continuity of care) of one of three sampled residents (Resident 1) for verification of medication needs with Attending Physician 1 (AP1) upon the readmission. […]

• Immediate jeopardy, patternF760Apr 15, 2021

  Based on interview and record review, the facility failed to ensure all needed medications were ordered so that they could be administered to one of three sampled residents (Resident 1) upon readmission from 2/25/21 to 3/7/21. This deficient practice resulted in Resident 1 missing a total of 33 doses of medications, and missing a total of 44 blood sugar checks (a procedure that measures the amount of sugar in the blood) which could require the need for insulin (medication to lower the sugar level in the blood) to be given. This could have resulted in severe health complications possibly leading to hospitalization and/or death. […]

• Immediate jeopardy, isolatedF600Dec 14, 2022

  Based on interview and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) and Dietary Aid 1 (DA 1) did not act negligently (a situation in which not enough care or attention is provided to someone or something) towards one of five sampled residents (Resident 1), who was prescribed a regular, no salt added, soft and bite-size texture, regular consistency diet (a diet that contains food that is cut into smaller pieces, soft, easy to chew, with lower amounts of salt), and was at risk for aspiration (when something enters your airway or lungs), when: 1. […]

• Immediate jeopardy, isolatedF689Dec 14, 2022

  Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1), who was prescribed a regular, no salt added, soft and bite-size texture, regular consistency diet (a diet that contains food that is cut into smaller pieces, soft, easy to chew, with lower amounts of salt), and was at risk for aspiration (when something enters your airway or lungs), was provided with appropriate supervision to keep the resident free from accidents and hazards by failing to ensure Certified Nursing Assistant 1 (CNA 1) first verified with a licensed nurse, that the chef ' s salad (a salad of lettuce and other raw [crunchy] vegetables topped with slices of meat, cheese, croutons [bread that is hardened due to being fried or toasted], and hard-boiled eggs) prepared… […]

• Immediate jeopardy, isolatedF600Aug 9, 2022

  Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) who is legally blind with severely impaired cognition (mental action or process of acquiring knowledge and understanding), was kept free from sexual abuse by Resident 2. On 6/16/2022 at 3:00 a.m., Certified Nursing Assistant 1 (CNA 1) witnessed Resident 2 on top of Resident 1, Resident 2's pants were down to his knees while humping Resident 1's leg. Resident 1 was not evaluated by the facility for capacity to consent to sexual activity, and Resident 1 remained in the same room as Resident 2's until 6/23/2022. This deficient practice resulted to Resident 1 being subjected to a non-consensual sexual act by Resident 2 while under the care of the facility. […]