A list of the most recent deficiencies for The Terrace. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-31 | 2024-02-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-07 | 2023-11-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-01 | 2023-11-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-26 | 2023-10-12 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-05-22 | 2023-06-09 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-12 | 2023-05-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-12 | 2023-05-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-12 | 2023-05-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-12 | 2023-05-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-04-12 | 2023-05-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-04-12 | 2023-05-05 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-04-12 | 2023-05-05 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-04-12 | 2023-05-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-12 | 2023-05-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-13 | 2023-02-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-13 | 2023-02-03 | Y |
| Keep all essential equipment working safely. | Health | 2023-01-13 | 2023-02-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-02 | 2022-09-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-02 | 2022-09-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-02 | 2022-09-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-29 | 2022-07-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-06-29 | 2022-07-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-06-29 | 2022-07-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-29 | 2022-07-21 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-06-29 | 2022-07-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-06-29 | 2022-07-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-29 | 2022-07-21 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-06-29 | 2022-07-21 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2022-06-29 | 2022-07-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-29 | 2022-07-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-29 | 2022-07-21 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-05-31 | 2022-06-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-14 | 2022-05-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-14 | 2022-05-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-14 | 2022-05-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-17 | 2022-04-08 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-07-28 | 2021-09-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-28 | 2021-09-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-28 | 2021-09-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-28 | 2021-09-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-28 | 2021-09-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-07-28 | 2021-09-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-28 | 2021-09-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-28 | 2021-09-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-07-28 | 2021-09-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-07-28 | 2021-09-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-11 | 2021-03-19 | Y |
