The Terrace Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at The Terrace Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF640Mar 4, 2025

  Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to electronically transmit the discharge assessment within 14 days for one (1) resident, Resident (R) 19. R19's discharge date was 11/14/2024, but R19's Minimum Data Set (MDS) was not transmitted until 03/02/2025. The findings include: Review of the Resident Assessment Instrument (RAI) Manual, dated 10/2024, revealed the MDS completion date must be no later than seven (7) days from the Event Date for a Death in Facility Assessment. […]

• No harm, potential for more than minimal, isolatedF656Feb 13, 2024

  Based on interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan (CCP) for one (1) of sixteen (16) sampled residents, (Resident #3). On [DATE] at 10:25 AM, State Registered Nurse Aide (SRNA) #12 failed to follow the intervention in place on Resident #3's CCP that stated Resident #3 was a two (2) person assist for bed mobility for bottom to top and side to side changes, and as a result, SRNA #12 caused Resident #3 to roll out of the bed and on to the floor. […]

• No harm, potential for more than minimal, isolatedF689Feb 13, 2024

  Based on interview, record review, and review of the facility's policy, it was determined the facility failed to provide supervision to each resident to prevent avoidable accidents for one (1) of sixteen (16) sampled residents, (Resident #3). On [DATE] at 10:25 AM, State Registered Nurse Aide (SRNA) #12 failed to follow the intervention in place on Resident #3's Comprehensive Care Plan (CCP) that stated Resident #3 was a two (2) person assist for bed mobility for bottom to top and side to side changes, and as a result, SRNA #12 caused Resident #3 to roll out of the bed and onto the floor. […]

• No harm, potential for more than minimal, isolatedF637Apr 22, 2021

  Based on observation, interview, record review, facility policy review, and a review of the Minimum Data Set (MDS) reference manual, the facility failed to ensure a comprehensive MDS was completed within fourteen days after a significant change in status for one (1) of six (6) sampled residents (Resident #2). The facility failed to conduct a significant change MDS when Resident #2 was discharged from hospice (end of life care) program, and admitted into a Palliative Care program. […]