Terraces at the Clare

In the surveyor’s words

From the most serious findings on record at Terraces at the Clare, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 2, 2025

  Based on observations, interviews, and record reviews the facility failed to follow their policy and procedure for preventing foodborne illnesses to ensure foods in the walk-in coolers were properly labeled and dated when they were opened and prepared and discarded on the best by date. The facility also failed to ensure kitchen staff was wearing facial hair/beard restraint while in the kitchen and failed to ensure potentially hazardous refrigerated foods were stored at the appropriate temperatures. […]

• No harm, potential for more than minimal, widespreadF880May 2, 2025

  Based on observations, interviews, and record reviews, the facility failed to assess, ientify, and involve the local public health department to determine if their water management plan was adequate to prevent the growth of Legionella or other opportunistic waterborne pathogens. This failure affects five (R22, R28, R30, R204, and R209) out of a total sample of twelve residents reviewed and potentially affects all forty-eight residents residing in the facility. Findings: On 5/1/25 at 10:30 AM, V8 (Director of Plant Operations) stated that the expansion tank does not have enough air pressure and this could possibly cause growth of Legionella, and that the company will be coming next week Friday 5/9/25 to fix the tank, and the mixing valve will be fixed next week Monday or Tuesday 5/5/25 or… […]

• No harm, potential for more than minimal, widespreadF908May 2, 2025

  Based on observations, interviews, and record reviews, the facility failed to conduct a thorough risk assessment to identify why opportunistic waterborne Legionella could grow and spread in the facility water. This failure affects five (R22, R28, R30, R204, and R209) out of a total sample of twelve residents reviewed and potentially affects all forty-eight residents residing in the facility. Findings: On 4/30/25 at 10:39 AM, V8 (Director of Plant Operations) stated that he has been in this facility for almost two years and the facility checks for legionella quarterly. The testing was done on 3/26/25 and 4/18/25 with positive result in five rooms. […]

• No harm, potential for more than minimal, patternF755Apr 11, 2024

  Based on observations, interviews, and record review, the facility failed to ensure staff signed the Narcotic Shift Count Log Sheet at the beginning of the shift and at the end of the shift and failed to ensure staff did not sign the Narcotic Shift Count Log Sheet before the end of the shift. These failures affected 5 residents (R7, R29, R30, R50 and R51) reviewed for controlled medications in the total sample of 34 residents. Findings include: On 04/08/2024 at 11:02am during the medication cart observation with V3 (Licensed Practice Nurse) of the 10th floor medication cart, the 10th floor 04/2024 Narcotic Shift Count Log Sheet noted with missing signatures on shift 7A (am) - 7P (pm) columns 'ON' and 'OFF' on DATE: 3. This was pointed out to V3 (Licensed Practice Nurse). […]

• No harm, potential for more than minimal, isolatedF604Aug 9, 2026

  Based on interview and record review, the facility failed to ensure one resident (R1), in a sample of three residents reviewed for restraints was free of physical restraint unless medically necessary. R1 was physically restrained with a gait belt wrapped around R1 and a shower chair. This past noncompliance occurred from 6/30/26 to 7/3/26. Prior to the survey date of 8/9/25, the facility had taken the following action to correct the noncompliance: During weekly Resident at Risk meetings, the interdisciplinary Team reviewed the clinical record of residents with are unable to maintain upright posture while seated. […]