Deficiency Records for The Terrace
Updated as of August 01, 2023
This is not the most recent data for The Terrace. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-04-27 | 2023-10-31 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-04-27 | 2023-10-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-27 | 2023-10-15 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-04-27 | 2023-10-15 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-04-27 | 2023-09-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-04-27 | 2023-08-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-27 | 2023-07-24 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-04-27 | 2023-07-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-27 | 2023-07-15 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-04-27 | 2023-06-15 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-05-22 | 2023-06-09 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-27 | 2023-06-01 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-04-27 | 2023-05-18 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-04-27 | 2023-05-18 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-04-27 | 2023-05-18 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-04-27 | 2023-05-18 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-04-27 | 2023-05-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-27 | 2023-05-17 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Use approved construction type or materials. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-04-27 | 2023-05-15 | N |
| 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 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-02-23 | 2021-03-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-11-24 | 2020-12-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-11-24 | 2020-12-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-08-19 | 2020-09-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-08-19 | 2020-09-04 | Y |
