Terrace View Gardens

In the surveyor’s words

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

• Actual harm, isolatedF689Nov 2, 2023

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to provide adequate supervision and monitoring for residents which resulted in actual harm to Resident #21 when the facility failed to observe the resident had a heating pad placed against her skin which caused burns to the resident's back and left shoulder. This affected one (Resident #21) of three residents reviewed for accidents. The facility census was 80. […]

• No harm, potential for more than minimal, widespreadF880Oct 31, 2021

  Based on observation, staff interview, review of online resources per the Centers for Disease Control (CDC) and the Center for Medicare and Medicaid Services (CMS), and review of facility policy, the facility failed to ensure staff wore eye protection and mask correctly in resident areas to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect 75 of 75 residents. The facility census was 75. Findings include: Observation on 10/29/21 at 8:55 A.M., Receptionist #125 was seated at the front desk behind a plexi-glass screen and wore an N95 facemask with eyeglasses. Licensed Practical Nurse (LPN) #488 was observed to wear an N95 facemask with no protective eyewear while preparing to administer medications to first floor residents. […]

• No harm, potential for more than minimal, patternF638Feb 26, 2026

  Based on medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to timely complete quarterly Minimum Data Set (MDS) assessments. This affected four residents (#44, #76, #14, and #09) out of 24 residents reviewed for MDS assessments. The facility census was 75.Findings include: 1. Medical record review for Resident #44 revealed an admission re-entry date of 03/01/22. Diagnoses include paraplegia, vascular dementia, cognitive communication deficit, type II diabetes mellitus, acute respiratory failure with hypoxia, major depressive disorder, delusional disorder, anxiety disorder, and complete traumatic amputation at level between left hip and knee. […]

• No harm, potential for more than minimal, isolatedF636Feb 26, 2026

  Based on medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to timely complete comprehensive Minimum Data Set (MDS) assessments. This affected three (#04, #07, and #81) out of 24 residents reviewed for assessments. The facility census was 75.Findings include:1. Review of the medical record for Resident #04 revealed an admission date of 01/16/25. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, other generalized epilepsy and epileptic syndromes intractable without status epilepticus, aphasia following cerebral infarction, iron deficiency anemia, hypertension, cerebral infarction, encephalopathy, vitamin d deficiency, depression, type two diabetes mellitus… […]

• No harm, potential for more than minimal, isolatedF637Feb 26, 2026

  Based on medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to timely complete significant change Minimum Data Set (MDS) assessments. This affected three residents (#48, #05, and #11) of four residents reviewed for a significant change. The facility census was 75.Findings include: 1.Medical record review for Resident #48 revealed an admission date of 05/23/23. Diagnoses included encephalopathy, dysphagia, aphasia, cognitive communication deficit, dementia, muscle weakness, chronic pulmonary embolism, and diabetes insipidus. Review of the most recent quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition. […]