Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Terrace View Care Center during CMS and state inspections, most recent first.
Medication storage and labeling were not maintained for a medication cart and medication room. An RN verified inhalation vials were not kept in their foil pouches, an oral med was stored with ophthalmic meds and control solutions, and opened Tubersol and latanoprost lacked opened dates. In addition, a diclofenac label for one resident did not match the MD order, and a baclofen bubble pack label for another resident showed 10 mg one tablet TID instead of the ordered 5 mg dose.
A facility failed to follow infection control practices during contact isolation, laundry handling, clean linen storage, and resident meal-area safety. A resident on C. diff isolation had a visitor in the room who wore a gown but no gloves and touched the bed while placing personal items on it; a housekeeper sorted soiled linens without a gown; employee personal belongings were stored with clean resident linens; and a urinal filled with urine was placed near a resident’s cupcake. The DON, IP, and other staff acknowledged the observations.
Incomplete bed inspections and inaccurate entrapment assessments were found for residents using side rails and bariatric beds. A resident with bilateral half rails had an incorrect safety assessment that listed the wrong rail type and an inappropriate zone, another resident had no documented physician order or entrapment assessment for the rails, and residents on bariatric beds lacked documented bedframe and mattress measurements and entrapment zone measurements in the maintenance records. Staff confirmed the maintenance department was responsible for the inspections and that the required measurements were not documented.
A resident who lacked decision-making capacity and had a physician order for a CPAP for obstructive sleep apnea used their own CPAP device in the facility, but staff failed to document this equipment on the admission inventory or on any Personal Inventory Update forms, contrary to facility policy. An LVN who handled both admission and discharge confirmed the CPAP was the resident’s own device and was sent home at discharge but acknowledged it was never itemized and could not recall the specific type of CPAP or other belongings returned. The DON stated staff were expected to record all personal items at admission, update, and discharge, yet the CPAP was absent from all inventory records, leading to a complaint from the resident’s representative that a different CPAP machine was received after discharge.
A resident was observed in bed with bilateral half side rails elevated, but the medical record did not show informed consent for side rail use. The resident’s H&P showed capacity to understand and make decisions, and an LVN verified the record lacked the required side rail documentation, including informed consent, while the DON later confirmed the findings.
A resident was observed with multiple medications at bedside, including inhalers, eyedrops, vitamins, and several topical and oral OTC products. Although the resident said he self-administered them and staff were aware, the resident’s self-administration screen showed he was not mentally able to self-administer medications, and the chart lacked MD orders and a care plan authorizing self-administration. The DON and an LPN verified the findings.
A resident receiving mirtazapine and trazodone for major depressive disorder did not have documented evidence that NPI were attempted before the meds were given. The care plan listed approaches such as calm redirection, refocusing, and providing assistance and encouragement, but the MAR and record review did not show these interventions were used prior to administration. An RN acknowledged the missing documentation, and the DON verified the findings.
A resident with a Level 1 PASRR screening positive for serious mental illness did not receive the required Level II mental health evaluation. Records showed the evaluation was not scheduled because facility staff were unresponsive to communication attempts, and the MDS Coordinator later verified the Level II was not completed and was unaware of the notice sent to the facility.
The facility failed to develop comprehensive care plans for two residents’ individual needs. One resident kept medications at the bedside, ordered meds online, and self-administered inhaler, eye drops, and vitamins, but the care plan did not address this behavior or self-administration. Another resident had a Permacath for dialysis and orders for enhanced barrier precautions and dialysis 3 times weekly, but the care plan did not address the Permacath or related emergency care needs.
Low Air Loss Mattress Set Incorrectly for a Resident at Risk for Skin Breakdown. A resident with no decision-making capacity, total dependence for mobility, and a history of healed buttock sores was observed on a bariatric bed with an LAL mattress set to static mode with lock-out on. Staff interviews confirmed the mattress should have been in alternating mode for pressure redistribution, and an LPN noted the resident also had buttock redness and was receiving treatment.
Missing Ordered Bilateral Floor Mats: A resident with Alzheimer's disease, dementia, severe cognitive impairment, poor safety awareness, and a prior fall incident was observed in bed with only one floor mat in place, despite a physician order and care plan for bilateral floor mats at bedside for safety. CNAs recalled the resident used bilateral floor mats, and an RN verified the mats should be in place at all times when the resident was in bed.
Failure to Implement RD Nutritional Recommendations: A resident with ESRD on dialysis and no decision-making capacity had an RD assessment showing a low BMI for age and recommending Cholecalciferol, Vitamin C, and Prostat SF. The order summary, MAR, and progress notes showed no physician order or documentation that the MD was notified, and an RN verified the recommendations were not followed through.
A resident admitted with a PICC line had no documented external catheter length or arm circumference measurements upon admission. The physician ordered weekly arm circumference and catheter length checks, and the care plan included those interventions, but the progress note, IV MAR, and medical record did not show the baseline measurements. An RN verified the missing documentation and stated the measurements should have been completed on admission.
Unlabeled and Undated Oxygen Tubing: A resident receiving oxygen at 3 LPM via CPAP mask was observed with oxygen tubing that was unlabeled and undated. The resident had orders for continuous oxygen and for tubing changes weekly and as needed, and the care plan included oxygen administration and weekly tubing changes. An LVN and an RN both acknowledged the tubing should have been labeled and dated for infection control purposes.
Inadequate pain management was identified for two residents. One resident received oxycodone-acetaminophen for pain ratings that included 0/10, and the MAR showed missing non-pharmacological interventions, sedation checks, and BP/apical pulse monitoring despite physician orders. A second resident had a pain order that did not match the facility’s standard pain scale, and hydrocodone-acetaminophen was administered for a pain level below the ordered PRN threshold.
Incomplete Dialysis Emergency Kit at Bedside: A resident with ESRD and a central venous dialysis catheter had a bedside dialysis emergency kit that was supposed to include supplies for bleeding control, including a clamp if pressure dressing was ineffective. During observation, the kit contained gauze and paper tape but no scissor clamp, and both an LVN and RN acknowledged the kit was incomplete.
A resident was observed in bed with bilateral half side rails elevated, but the record did not show a physician order, side rail assessment, care plan intervention, or documented least restrictive alternatives before use. The resident’s H&P showed capacity to understand and make decisions, and an LVN and the DON later verified the findings.
A resident’s chart showed that the pharmacy consultant recommended trying or documenting non-pharmacological interventions before giving psychotropic medications, but the MAR and record review found no evidence these interventions were attempted before mirtazapine and trazodone were administered. Facility P&P required documented trials of alternatives and use of non-pharmacological approaches unless contraindicated, and an RN acknowledged the interventions should have been provided.
A resident's pain monitoring record was inaccurate because the MAR documented zero pain for every shift while PRN pain meds were given for reported pain levels of 5 to 7. The DON confirmed that the highest pain level for each shift should have been charted, but the record instead showed no pain despite multiple doses of tramadol HCl and hydrocodone-acetaminophen for pain.
The facility failed to complete the infection surveillance review using McGeer’s criteria for two residents when antibiotics were started. One resident received IV vancomycin for MRSA bacteremia secondary to a lumbar wound infection, and another resident received Diflucan for UTI and yeast infection of urine. The IP stated she reviewed new antibiotic orders and completed an Infection Surveillance Review form, but the February infection surveillance record did not show the review was done for either resident when therapy began.
Medication equipment and storage areas were not maintained safely. In Medication Cart A, the glucometer QC record did not match the glucometer serial number, strip lot number, or control solution range, and staff were unsure whether strip and control solution expiration was based on the box or 30/90 days after opening. In Medication Rooms A and B, the refrigerators used for meds had ice buildup, and one also had a brown stain on the freezer side.
A resident's fall risk assessment was completed with multiple inaccuracies, including failure to document two recent falls and omission of several high-risk medications the resident was prescribed. Both an LVN and the DON confirmed these errors, noting that the resident's fall risk score would have been higher if the assessment had been accurate.
A resident's medical record was found to have inaccurate documentation of neuro check intervals following an unwitnessed fall. The neuro checks, which should have transitioned from one-hour to two-hour intervals, were recorded with a one-hour delay, as confirmed by both an LVN and the DON during review.
A CNA tied a bed sheet around a resident's waist and secured it to a wheelchair, restricting the resident's movement without a physician's order or documented medical necessity. The resident, who had moderate cognitive impairment but was able to make decisions, was found by a representative unable to move freely and reported feeling scared. Facility policy requires restraints only with proper orders and consent, and no such documentation was found. Staff interviews confirmed the restraint and lack of appropriate reporting or alternative interventions.
The facility did not conduct or document required interviews with a resident and a CNA after an allegation that the resident was tied to a wheelchair and physically abused. Although the facility interviewed family members, assessed the resident for injuries, and obtained a written statement from the CNA, there was no evidence of direct interviews with the alleged victim or perpetrator, leaving the investigation incomplete.
A resident with moderate cognitive impairment was not provided timely physician notification or neurological monitoring after being found tied to a wheelchair with a bedsheet and following an unwitnessed fall resulting in discoloration on the thigh. Facility staff delayed reporting these incidents to the physician and the resident's representative, and did not initiate required neurological assessments, contrary to facility policy.
A facility failed to ensure proper care for residents by not obtaining physician orders for a resident's personal glucose monitoring device, not following transfer orders for another resident with heart failure, and not timely addressing low oxygen saturation levels for a resident dependent on supplemental oxygen. These deficiencies were acknowledged by the facility's staff, highlighting lapses in monitoring and communication.
The facility failed to document baseline measurements for PICC lines in two residents and did not label a PIV site for another resident, leading to potential delays in identifying complications. The DON confirmed these deficiencies, indicating a lapse in following facility policies.
The facility failed to provide safe respiratory care for two residents by not adhering to cleaning guidelines for respiratory equipment. One resident's BiPAP machine and another's CPAP machine were not cleaned as per guidelines, and equipment was improperly stored, risking contamination. Staff interviews confirmed the lack of adherence to cleaning protocols.
A facility failed to administer dexamethasone to a resident as per the physician's order, which required the medication to be given every other day in the morning with breakfast. The LVN administered the medication late and not with breakfast, as confirmed by a medical record review and acknowledged by the DON.
The facility failed to properly monitor and document the side effects of psychotropic medications for three residents. One resident was not monitored for orthostatic hypotension as required, while another had inaccurate blood pressure monitoring and lacked documentation of non-pharmacological interventions. A third resident had identical blood pressure readings recorded for different positions, indicating improper monitoring. The DON confirmed these deficiencies.
The facility failed to follow food safety guidelines by having seven cups of apple juice and one cup of yogurt unlabeled and undated in the walk-in refrigerator. The DSS confirmed these items were prepared the previous night and should have been labeled according to the facility's policy. This affected all 55 residents receiving food from the kitchen. The Administrator and DON were informed and acknowledged the deficiency.
The facility's assessment was found lacking in comprehensive planning and stakeholder involvement, as it did not include input from direct care staff, residents, or their families. It also failed to address necessary resources for weekend care, staff recruitment and retention strategies, and a contingency plan for staffing needs. The Administrator confirmed these deficiencies and was unaware of the updated CMS requirements.
The facility failed to ensure proper infection control practices, as staff did not perform hand hygiene after removing PPE in a room under Novel Respiratory Precaution. Additionally, a CNA did not follow enhanced barrier precautions for a resident with a PICC line, despite posted signage. The DON and other staff acknowledged these deficiencies.
A facility failed to accurately code the MDS for a resident receiving heparin for DVT prophylaxis. The resident's medical record showed a physician's order for the anticoagulant, but the Admission MDS did not reflect its use. The MDS Coordinator confirmed the error, and the DON acknowledged the findings.
A facility failed to offer and administer a pneumococcal conjugate vaccine to a resident, despite policy requirements. The resident's immunization record showed receipt of the Pneumonia 23 vaccine, but not the conjugate vaccine. The IP confirmed the oversight, and the DON acknowledged the vaccine should have been offered again.
A resident in an LTC facility exhibited aggressive behavior towards two other residents, involving verbal and physical abuse. The incidents were witnessed by staff, but there was inadequate documentation and monitoring of the affected residents. The facility's policies on preventing abuse were not effectively implemented, leading to room transfers for the affected residents.
A facility failed to report abuse incidents timely, as required by policy. In one case, a resident hit another's foot, and the initial report was incomplete, with additional details provided 48 hours later. In another case, a resident yelled and raised a walker at another, causing fear, but the incident was reported five days late. Staff misjudged the situation as incompatibility, contributing to reporting delays.
A facility failed to investigate and monitor alleged abuse incidents involving a resident who exhibited aggressive behavior towards two other residents. In one incident, a resident hit another's foot, and in another, the same resident yelled and raised a walker threateningly. The facility did not interview all relevant staff or ensure daily monitoring by the SSD, as required by policy. These failures posed a risk for unaddressed resident abuse.
Medication Storage and Labeling Errors
Penalty
Summary
Medication storage and labeling were not maintained in accordance with accepted professional principles in Medication Cart A and Medication Room A. During inspection of Medication Cart A with RN 3, two unit-dose vials of budesonide were not stored in the foil pouch, two unit-dose vials of ipratropium bromide and albuterol solution were not stored in the foil pouch, and a box of alendronate sodium was stored with cyclosporine ophthalmic emulsion and glucometer control solutions. RN 3 verified these findings. Drug label information reviewed for budesonide stated opened foil envelopes should be returned to the aluminum foil envelope to protect the unused ampules from light, and the label information for ipratropium bromide and albuterol solution stated to store in the pouch until time of use. In Medication Room A, an inspection with RN 2 found an opened bottle of Tubersol without an opened date and opened latanoprost eyedrops without an opened date. Drug label information reviewed for Tubersol stated a vial entered and in use for 30 days should be discarded, and the label information for latanoprost stated that once opened it may be stored at room temperature for six weeks. RN 2 verified both opened medications were missing opened dates. Medication labeling errors were also identified for two residents. During a medication administration observation for Resident 4, the diclofenac tube label did not match the physician's orders in the medical record. The pharmacy label stated diclofenac sodium 1% gel apply two grams to left elbow and left knee topically four times a day for pain management, while the order summary showed multiple diclofenac orders with different sites and amounts. For Resident 59, the baclofen bubble pack label stated baclofen 10 mg give one tablet by mouth three times a day, but the physician's order was for 0.5 tablet (5 mg) by mouth three times a day. LVN 1 verified the mismatch between the order and the bubble pack label, and the DON was later informed and verified the findings.
Infection control practices not followed with isolation, laundry, clean linen storage, and resident food area
Penalty
Summary
The facility failed to ensure infection control practices were followed during contact isolation care, laundry handling, linen storage, and resident meal-area safety. The facility’s infection control policies required standard precautions, contact precautions for residents with C. difficile, gown and glove use when indicated, hand hygiene, and separation of employee personal belongings from resident linen storage areas. The report identified multiple observations and interviews showing these practices were not consistently implemented. Resident 61 was on contact isolation for C. difficile with physician orders dated 2/12/26, including isolation until 2/17/26 at 2359 hours and discontinuation after three formed stools. The resident’s bowel record showed loose/diarrhea stools on 2/16/26, and the resident’s H&P stated the resident did not have the capacity to understand and make decisions. During observation, the resident’s responsible party was inside the room wearing a gown but no gloves, touching the resident’s bed, and placing a notebook and cellphone on the bed. The responsible party stated she had not been told to wear gloves, had used the room sanitizer when leaving, and had not been instructed that personal items could not be placed on the resident’s bed. During laundry services observation, a housekeeper was sorting soiled linens and trash linens in the soiled linen gate area while wearing gloves but not a protective gown. In the clean linen area, employee personal belongings were observed stored on a clean rack with resident blankets and tablecloths, including hair brushes, combs, cologne, lip balms, nail tools, lotion, eye drops, candy, coins, a labeled container, medications/supplements, salt, and office supplies. In addition, Resident 43 was observed lying in bed with a urinal filled with urine placed on the bedside table near the resident’s cupcake. Resident 43’s H&P showed the resident had the capacity to understand and make decisions.
Incomplete Bed Inspections and Incorrect Entrapment Assessments
Penalty
Summary
The facility failed to ensure that bed inspections and entrapment assessments were completed and documented for residents using side rails or bariatric beds. The report identified deficiencies for three sampled residents and one non-sampled resident: one resident on a bariatric bed, two residents with bilateral half side rails, and another resident on a bariatric bed. The facility’s Bed Inspection and Maintenance Policy stated that all beds, rails, mattresses, wheels, and controls were to be inspected routinely, with nursing completing visual safety checks each shift and maintenance completing monthly and quarterly inspections that included entrapment risks. For one resident on a bariatric bed with bilateral side rails for bed mobility and repositioning, the medical record showed a side rail safety assessment, but it did not include the bedframe length, mattress type, mattress height, or mattress length. The resident was observed in bed with bilateral side rails elevated and stated the rails were used for turning and repositioning. Facility staff confirmed the resident had a bariatric bed, and the Maintenance Director stated he was responsible for the bed inspection and entrapment assessment, but the monthly preventive maintenance record did not document the required bedframe and mattress measurements or the applicable entrapment zone measurements. For another resident with padded bilateral half side rails, the physician’s order and care plan addressed the use of the rails for bed mobility and repositioning, but the safety assessment was inaccurate. The assessment identified the bed system zones for 1/4 side rails on both sides rather than 1/2 side rails, and zone 5 was checked even though staff stated zone 5 applies to split side rails and the resident did not have split rails. For a third resident with bilateral half side rails, the medical record did not show a physician’s order for the rails and did not show documented evidence that an entrapment assessment had been completed. For the additional resident on a bariatric bed with a low air loss mattress and bilateral half side rails, the record also did not show documentation of the bedframe length, mattress type, mattress height, mattress length, or entrapment zone measurements during the bed inspection.
Failure to Document and Protect Resident’s CPAP as Personal Property
Penalty
Summary
The facility failed to protect a resident's personal property by not documenting the resident's CPAP machine on any inventory forms during admission or discharge. The facility's Personal Property policy required that residents' personal belongings and clothing be inventoried and documented upon admission and updated as necessary. The resident, who lacked capacity to understand and make decisions per a history and physical dated 12/19/25, was admitted with personal belongings documented only as jackets and shoes on the Resident's Clothing and Possessions form. A physician's order dated 2/6/26 directed the use of a CPAP device for obstructive sleep apnea, and the responsible party later complained that when the resident was transported home, a different CPAP machine was received than the one originally provided to the facility. During interviews and record review, LVN 1 confirmed that the resident used their own CPAP machine in the facility and that she was responsible for both the admission and discharge processes, including completing the Resident's Clothing and Possessions form at discharge. LVN 1 stated that staff were expected to record belongings on admission and use a Personal Inventory Update form, which includes fields for add/delete, description, serial number, and quantity, whenever new items or equipment were brought in or removed, and to itemize belongings returned at discharge. However, there was no documentation of the CPAP machine on the admission inventory, no Personal Inventory Update form completed, and no record of the CPAP or other belongings sent with the resident at discharge. LVN 1 acknowledged that the CPAP machine was sent with the resident but could not recall the type of CPAP or other items sent, and the DON confirmed that staff were expected to record each personal item at admission, update, and discharge.
Failure to Obtain Informed Consent for Side Rail Use
Penalty
Summary
The facility failed to ensure that Resident 43 remained free from accident hazards associated with the use of elevated side rails and failed to obtain informed consent for the use of bilateral upper side rails. The facility policy on Bed Safety and Bed Rails required that bed rails not be used unless criteria were met, including attempts at alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The policy also required staff to inform the resident or representative about the benefits and potential hazards of bed rails and to obtain informed consent before use. On 2/17/26, Resident 43 was observed lying in bed, awake, oriented to name, and verbally responsive, with bilateral half side rails elevated at the head of the bed. The resident had been admitted to the facility and the H&P dated 1/26/26 showed the resident had the capacity to understand and make decisions. Review of the medical record failed to show informed consent for the use of bilateral upper side rails. During a 2/18/26 observation, interview, and record review, LVN 3 verified the record did not contain informed consent for side rail use and stated there must be a rehab recommendation, physician order, side rail assessment, informed consent, and care plan to verify the need for side rails and prevent entrapment. The DON later verified these findings.
Unsafe Self-Administration of Medications at Bedside
Penalty
Summary
The facility failed to determine whether it was safe for one resident to self-administer medications left at bedside. The facility’s policy stated that residents may self-administer medication only when the IDT determines it is clinically appropriate and safe, the decision is documented in the medical record and care plan, and medications are stored securely. In this case, Resident 21 was observed with multiple medications at bedside, including an albuterol puff, Refresh eyedrops, ketorolac eyedrops, vitamins, and a black box containing additional medications and topical products. Resident 21 stated he administered the eyedrops and took the vitamin as needed, and said the nurses were aware he was administering the medications himself. However, the resident’s Medication Self-Administration Screen dated 5/2/25 showed he was not mentally able to self-administer medications and was not a candidate for self-administration. The medical record also did not contain physician orders for the medications found at bedside or orders authorizing self-administration, and there was no care plan addressing self-administration. LVN 3 and the DON verified these findings.
Unnecessary Psychotropic Medication Use Without Documented Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure that one sampled resident was free from unnecessary psychotropic medications because the resident’s non-pharmacological interventions were not documented as attempted before administration of mirtazapine and trazodone for major depressive disorder. The resident was admitted and later readmitted to the facility, and an order dated 1/12/26 directed mirtazapine 15 mg at bedtime and trazodone 50 mg at bedtime. The care plan for these medications included non-pharmacological interventions such as approaching the resident calmly and unhurriedly, refocusing, redirection, and providing assistance and encouragement. The resident’s H&P dated 1/13/26 stated the resident had fluctuating capacity to understand and make decisions, and care was discussed with the spouse. Review of the January and February 2026 MAR and the medical record did not show documented evidence that non-pharmacological interventions were attempted before the medications were administered. During interview and concurrent record review, the RN acknowledged that non-pharmacological interventions should have been provided to evaluate the need for and limit use of the antidepressant medications. The DON was later informed and verified the findings.
PASRR Level II Evaluation Not Completed
Penalty
Summary
The facility failed to ensure PASRR was complete for one resident who was readmitted to the facility. The resident’s Level 1 PASRR screening dated 12/29/25 showed positive for serious mental illness and required a Level II mental health evaluation. A subsequent document dated 1/1/26 stated that a Level II Mental Health Evaluation was not scheduled because facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening, and the case was closed. During an interview and medical record review on 2/23/26, the MDS Coordinator stated she was responsible for following up on PASRR and that the MRD received documents from the California Department of Health Care Services and would notify her if follow-up was needed. She verified that the Level II Mental Health Evaluation for the resident was not completed and stated she was not aware of the Unable to Complete Level II Evaluation for Serious Mental Illness document sent to the facility. The DON was informed of the findings and acknowledged them.
Incomplete Care Plans for Medication Self-Administration and Permacath Care
Penalty
Summary
The facility failed to develop comprehensive care plans that reflected the individual care needs of two residents. For one resident, staff observed an albuterol inhaler, Refresh eyedrops, ketorolac eyedrops, and vitamins kept at the bedside in a black container or box. The resident stated he administered the eyedrops and took the vitamin as needed, and also stated the licensed nurses were aware he was self-administering the medications. An LVN stated the resident ordered his medications online and had previously had medications confiscated from him, and the DON later verified that the resident had been ordering medications online and keeping them at bedside. Review of the resident’s plan of care did not show a care plan problem addressing self-administration of medications or the behavior of ordering and keeping medications at bedside. For another resident, the medical record showed physician’s orders for enhanced barrier precautions due to the presence of a Permacath and for dialysis three times weekly. Review of that resident’s plan of care did not show a care plan developed to address the Permacath related to dialysis. During interview and record review, an LVN verified the resident had a Permacath for dialysis use and stated there should be a care plan to address the care and what to do during an emergency related to the Permacath. The Administrator and DON were informed of and acknowledged these findings.
Low Air Loss Mattress Set Incorrectly for Resident at Risk for Skin Breakdown
Penalty
Summary
The facility failed to ensure that Resident 61 received the necessary care and services related to a low air loss mattress ordered for skin management. Resident 61 had no capacity to understand and make decisions, was dependent with mobility, and had a history of pressure sores on the buttocks that were reported by the responsible party as healed. The resident’s physician ordered a bariatric bed with bilateral half siderails and a low air loss mattress every shift for skin management. During observation, Resident 61 was found sleeping on a bariatric bed with the low air loss mattress set to static mode, with the lock-out mode turned on and no green light for the soft-to-firm bars. The responsible party stated the licensed nurses had fixed the bed and that she did not know how to operate it. A licensed nurse later confirmed the mattress was on static mode and stated it should be set to alternating mode for proper air distribution and as a preventative measure. Additional staff interviews showed that the low air loss mattress was intended for residents with pressure injuries or who were immobile, and that the mattress setting should be monitored by licensed nurses. One licensed nurse stated the mattress should be in alternating mode and that static mode was used during resident care activities such as turning, cleaning, or transferring. Another licensed nurse stated the resident had redness on the buttock and was receiving treatment for the area. The Director of Nursing was informed and acknowledged the findings.
Missing Ordered Bilateral Floor Mats
Penalty
Summary
The facility failed to ensure Resident 7 was free from accident hazards when the physician-ordered bilateral floor mats were not consistently in place. The facility's policy on Floor Mat Safety and Use stated that floor mats must be non-slip, lay flat, remain clean and dry, and not create hazards or obstruct mobility devices. During the initial tour, Resident 7 was observed lying in bed with bilateral floor mats in place, but on a later observation the resident was in bed with only one floor mat on the left side of the bed. Resident 7 was admitted and later readmitted to the facility, had a care plan for high risk falls related to Alzheimer's disease and dementia, and the care plan included an adjustable bed in low position and bilateral floor mats at bedside for safety. The physician's order dated 1/12/26 directed the bed to remain low with bilateral floor mats due to poor safety awareness and to monitor placement every shift. The resident's history and physical noted fluctuating capacity to understand and make decisions, with care discussed with the spouse, and the admission MDS showed severe cognitive impairment and impairment to one lower extremity. CNA staff stated they recalled the resident had bilateral floor mats used for safety, and RN 1 verified that the resident had a prior fall incident and that bilateral floor mats should be in place at all times when the resident was in bed.
Failure to Implement RD Nutritional Recommendations
Penalty
Summary
The facility failed to ensure that one sampled resident with ESRD on renal dialysis received care and services to maintain acceptable nutritional status. The resident’s H&P showed no capacity to understand and make decisions. A nutritional assessment completed by the RD documented an IBW BMI of 23.1, noted as low for the resident’s age, and recommended Cholecalciferol 2,000 IU orally daily, Vitamin C 500 mg orally daily for 30 days, and Prostat SF 30 ml orally daily. Review of the January 2026 order summary report and MAR showed no physician order for Cholecalciferol, Vitamin C, or Prostat SF. The resident’s licensed progress notes also did not show documentation that the physician was notified of the RD’s recommendations. During interview and record review, RN 1 verified that there was no physician order and no documentation of physician notification, and stated licensed nurses were responsible for following through on RD recommendations within 24 hours. The DON was later informed and verified these findings.
PICC Line Measurements Not Documented on Admission
Penalty
Summary
The facility failed to provide the necessary care and services to maintain intravenous access for Resident 37 by not documenting the PICC line external catheter length and arm circumference measurements upon admission. Resident 37 was admitted with a PICC line in the left upper arm with double lumens, and a physician's order dated 1/23/26 directed staff to measure arm circumference and external catheter length every seven days. However, the licensed progress note dated 1/24/26 did not show documentation of the PICC line measurement and assessment when the resident was admitted to the facility. Review of the care plan initiated 1/26/26 showed interventions to measure arm circumference and external catheter length every seven days, but the IV Administration Record for January 2026 and the medical record did not show documented evidence that the catheter length above the insertion site and arm circumference were obtained upon admission. During an interview and concurrent record review on 2/19/26, RN 1 verified the record did not show these measurements and stated they should have been completed upon admission. RN 1 also stated the arm circumference measurement would indicate signs and symptoms of infection such as dislodgement, infiltration, swelling, and pain and would ensure baseline information was available. The DON was later informed and verified the findings.
Unlabeled and Undated Oxygen Tubing
Penalty
Summary
The facility failed to provide necessary respiratory care and services for Resident 43 by not ensuring the resident’s oxygen tubing was labeled and dated. Resident 43 was observed lying in bed and receiving oxygen at 3 LPM via CPAP mask attached to the oxygen concentrator, and the oxygen tubing was noted to be undated and unlabeled during the initial tour of the facility. Resident 43 was admitted to the facility and had physician’s orders to change oxygen tubing every week and as needed, along with an order for oxygen administration via nasal cannula at three LPM continuously. The care plan identified the resident’s use of oxygen due to episodes of difficulty breathing and included interventions to administer oxygen as ordered and change the tubing weekly and as needed. During interviews, an LVN and an RN both acknowledged that the oxygen tubing should have been labeled and dated for infection control purposes, and the DON later verified the findings.
Inadequate Pain Assessment and Medication Administration
Penalty
Summary
Adequate pain management was not provided for a resident who had physician orders for acetaminophen for mild pain and oxycodone-acetaminophen for moderate to severe pain, along with orders to assess pain every shift using a specified pain scale, provide non-pharmacological interventions as needed, and monitor BP, apical pulse, respiratory rate, and sedation level when oxycodone-acetaminophen was given. Review of the MAR showed multiple administrations of oxycodone-acetaminophen for pain ratings ranging from 0/10 to 10/10. The record also showed that non-pharmacological interventions were not provided before several doses, sedation level was not monitored on multiple occasions, and BP and apical pulse were not monitored when the medication was administered. An RN confirmed the medication was given for 0/10 pain on some occasions and verified the missing interventions and monitoring. A second resident had an order for hydrocodone-acetaminophen 5-325 mg every four hours as needed for moderate to severe pain, defined in the order as 6-10/10, and also had an order to assess pain every shift using a pain scale of 0 for no pain, 1-4 for mild pain, 5-7 for moderate pain, and 8-10 for severe pain. The facility’s DON stated the facility used a different standardized pain scale of 1-3 for mild pain, 4-6 for moderate pain, and 7-10 for severe pain. The DON reviewed the record and verified that the resident’s ordered pain scale did not match the facility’s standard pain scale and should be revised. The MAR showed hydrocodone-acetaminophen was administered for a pain level of 5, which was below the ordered threshold of 6-10. The DON reviewed the MAR and verified the medication was given below the ordered pain parameter and should not have been administered for a pain level of 5 until the order was clarified.
Incomplete Dialysis Emergency Kit at Bedside
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met for one resident receiving dialysis care. The facility’s policy titled Dialysis Care, revised 5/11/25, directed staff to keep a dialysis emergency kit at the bedside in case of bleeding from the shunt site or dialysis catheter. Resident 9 was admitted with ESRD, had no capacity to understand and make decisions, and had a central vein catheter to the right upper chest. The resident’s care plan directed staff to apply a pressure dressing to a bleeding access site and, if ineffective, use a clamp to stop the bleeding and notify the physician immediately. The resident’s physician orders included inspection of the dialysis site every shift and keeping a pressure dressing at bedside. During an observation and concurrent interview, the dialysis emergency kit in the resident’s room was found in a labeled zip-lock bag and contained gauze dressing and paper tape, but no scissor clamp. LVN 1 verified the kit was incomplete and stated it did not include a clamp scissor. RN 1 was later informed and acknowledged that the dialysis kit should have included a clamp scissor, and the DON was also informed and verified the findings.
Missing Order and Assessment for Bilateral Side Rails
Penalty
Summary
The facility failed to ensure Resident 43 remained free from accident hazards associated with elevated side rails. During the initial tour, Resident 43 was observed lying in bed, awake, oriented to name, and verbally responsive, with bilateral half side rails elevated at the head of the bed. Resident 43 was admitted to the facility and had an H&P dated 1/26/26 showing capacity to understand and make decisions. Medical record review showed no physician order for bilateral half side rails on the 2/2026 Order Summary Report. The plan of care did not include an intervention for bilateral half side rails, and the record did not show that a side rail assessment was completed. There was also no documented evidence that least restrictive alternatives were attempted before the side rails were used. During interview and concurrent record review, LVN 3 acknowledged the findings and stated there should be a side rail recommendation from rehab, a physician's order, side rail assessment, informed consent, and care plan to verify the need for side rails and prevent entrapment. The DON later verified the findings.
Failure to Act on Pharmacy Consultant Recommendations for Psychotropic Medication Review
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant’s January 2026 drug regimen review recommendations were acted upon for Resident 7. The consultant recommended trying or documenting non-pharmacological interventions before medication administration, but review of the resident’s medical record showed no documented evidence that these interventions were attempted prior to administration of mirtazapine and trazodone. The resident had been admitted to the facility and later readmitted, and the history and physical noted fluctuating capacity to understand and make decisions, with care discussed with the spouse. Facility policies reviewed included a Psychoactive/Behavior Assessment policy stating that, before use of psychoactive medication, the interdisciplinary team should assess medical necessity and document a trial of alternatives, and a Psychotropic Medication Use policy stating that non-pharmacological approaches are used unless contraindicated and that residents on psychotropic medications receive gradual dose reductions coupled with non-pharmacological interventions unless clinically contraindicated. On interview, RN 1 acknowledged that the pharmacist reviews medications monthly, provides recommendations, and that licensed nurses follow through within 72 hours, and also stated that non-pharmacological interventions should have been provided to evaluate the need and limit use of the antidepressant medications. The DON was later informed and verified the findings.
Inaccurate Pain Level Documentation in Resident Record
Penalty
Summary
The facility failed to maintain an accurate medical record for one of 12 sampled residents, Resident 56, by not correctly documenting pain level monitoring for each shift. The facility's policy stated that documentation should be complete and accurate and should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Resident 56 had a physician's order dated 2/13/26 to monitor and assess pain every shift using a scale from 0 to 10, with higher scores indicating greater pain. Review of Resident 56's MAR for February 2026 showed pain was documented as zero for all day, evening, and night shifts since admission. However, the record also showed multiple administrations of PRN pain medication for reported pain levels of 5, 6, and 7, including tramadol HCl and hydrocodone-acetaminophen. During an interview and concurrent record review, the DON stated that the highest pain level for each shift should have been documented, and verified that the MAR showed zero pain while the resident received pain medication for pain levels five and above.
Delayed Infection Surveillance Review for Antibiotic Use
Penalty
Summary
The facility failed to monitor and address antibiotic use for two residents who were started on antimicrobial therapy. For one resident, a physician order dated 2/3/26 directed vancomycin 1 gram IV every 36 hours for MRSA bacteremia secondary to a lumbar wound infection for 38 days, and the resident received doses on 2/4, 2/6, 2/7, 2/9, 2/10, 2/12, 2/13, 2/15, and 2/16/26. For another resident, physician orders dated 2/7/26 and 2/9/26 directed Diflucan 150 mg for UTI and then for yeast infection of urine, and the resident received the medication on 2/7/26 at 1720 and on 2/10, 2/11, and 2/12/26 at 0900. The facility’s Antibiotic Stewardship policy required staff to gather clinical information based on McGeer’s criteria before contacting the prescriber and to document appropriate indications for antibiotic use. During interview, the IP stated she reviewed new antibiotic orders, assessed residents, and completed an Infection Surveillance Review form to determine whether McGeer’s criteria were met, and that this review should be completed as soon as possible. However, the Infection Surveillance Review for February 2026 did not show that the review was completed for either resident when the antibiotics were started. The IP verified the findings, and the DON was informed and acknowledged them.
Medication Equipment and Refrigerator Storage Not Maintained Safely
Penalty
Summary
The facility failed to ensure the glucometer in Medication Cart A and the refrigerators used to store medications in Medication Rooms A and B were maintained in a safe operating condition. During inspection of Medication Cart A with RN 3, surveyors observed a glucometer quality control device, two bottles of glucometer strips, and normal and high control solutions. Facility records for blood glucose monitoring quality control did not match the glucometer serial number, the glucometer strip lot number, or the high control solution range shown on the strip bottle. The opened dates for the glucometer strips and control solutions were also reviewed, and RN 2 stated she was not sure whether the facility used the expiration dates on the box or 30 or 90 days from opening. RN 2 verified that the expiration dates documented on the quality control record were not 90 days from the opening date. The facility also failed to maintain the medication refrigerators in Medication Rooms A and B in proper condition. During inspection with RN 2, the refrigerator in Medication Room A was observed with ice buildup and a brown stain on the side of the freezer, and the refrigerator in Medication Room B was observed with ice buildup. The facility's policy stated nursing staff were responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. RN 2 stated licensed nurses could clean the refrigerators unless the issue was technical, in which case maintenance would be called. The Maintenance Director stated the maintenance department cleaned the medication refrigerators monthly, but licensed nurses could call maintenance before the scheduled cleaning.
Inaccurate Fall Risk Assessment for Resident
Penalty
Summary
The facility failed to accurately assess a resident for fall risk, as evidenced by multiple inaccuracies in the resident's Fall Risk Assessment. The assessment did not document two recent falls experienced by the resident—one unwitnessed fall in the facility and another in the community that resulted in severe injury, hospitalization, and subsequent admission to the facility. Additionally, the assessment failed to record several high-risk medications that the resident was prescribed, including a diuretic, antihypertensive, narcotic, and sedative. Both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed during interviews and medical record reviews that the Fall Risk Assessment contained these inaccuracies. They acknowledged that the resident's fall risk score would have been higher if the assessment had been completed accurately, reflecting the true number of falls and the medications taken. The facility's policy required staff to identify specific risks and causes to prevent falls, but this was not followed in this case.
Inaccurate Neuro Check Documentation Following Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate following an unwitnessed fall. According to the facility's policy, neuro assessments are required after any unwitnessed fall. Review of the resident's 72 Hour Neuro Check - List revealed that the time intervals between neuro checks were not accurately documented. Specifically, after the initial one-hour intervals, the transition to two-hour intervals was not correctly followed, resulting in all subsequent neuro check entries being delayed by one hour. During interviews and concurrent medical record reviews with both an LVN and the DON, it was confirmed that the neuro check documentation contained incorrect time entries. This inaccuracy in the resident's medical record meant that the required neuro assessments were not performed at the correct intervals as outlined in the facility's policy.
Resident Restrained with Bed Sheet Without Physician Order or Consent
Penalty
Summary
A certified nursing assistant (CNA) wrapped a bed sheet around a resident's waist and tied it behind the resident's wheelchair, preventing the resident from easily removing the material. This action was observed by the resident's representative, who found the resident in the dining room unable to move freely, with the CNA present and working on the computer. The resident reported feeling scared and called his son for help. The facility's policy and procedure (P&P) on the use of restraints specifies that restraints are only to be used for the safety and well-being of the resident, only after alternatives have been tried unsuccessfully, and only with a physician's order and consent. The P&P also defines a restraint as any device that the resident cannot remove in the same manner as applied, which restricts their ability to change position or place. Medical record review for the resident showed no documentation of a physician's order or any medical necessity for the use of physical restraints. The resident had a history of moderate cognitive impairment but was assessed as having the capacity to understand and make decisions. The CNA stated that the resident frequently got out of bed without assistance and was at risk of falling, and that the CNA needed to care for other residents. The CNA admitted to tying the resident to the wheelchair for safety reasons and acknowledged that this action was inappropriate and should have been reported to the charge nurse. Interviews with other staff confirmed the presence of the bed sheet tied around the resident in the wheelchair, though one licensed vocational nurse (LVN) did not check if the sheet was actually tied. The incident was reported to the charge nurse by both the resident's representative and the LVN. The director of nursing (DON) was informed and acknowledged the findings. There was no evidence that alternatives to restraint were attempted, nor was there documentation of required orders or consent for restraint use.
Failure to Interview Key Individuals in Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident. According to the facility's own policy, all persons involved in an alleged abuse incident, including the alleged victim and perpetrator, must be interviewed as part of the investigation. However, when a resident's representative reported that the resident was found tied to a wheelchair with a bedsheet and alleged that a CNA had hit and kicked him, the facility did not conduct or document interviews with either the resident or the CNA involved. The investigation documentation showed that the facility interviewed the resident's family member, assessed the resident for injuries, and interviewed staff from the relevant shift and those who had provided care in the preceding 72 hours. Despite these steps, there was no evidence that the resident (the alleged victim) was interviewed directly, nor was there documentation of an interview with the CNA (the alleged perpetrator). The DON acknowledged that a written statement from the CNA was obtained, but this was not equivalent to an interview, and no documentation was provided to confirm an interview with the resident. The resident involved had moderate cognitive impairment and required maximum staff assistance for activities of daily living, but was determined to have the capacity to understand and make decisions. The failure to interview both the alleged victim and perpetrator was contrary to the facility's policy and left the investigation incomplete, as key firsthand accounts were not obtained or documented.
Failure to Notify Physician and Conduct Monitoring After Resident Incidents
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for one resident. The facility did not ensure timely physician notification when a resident's representative reported that the resident was tied to a wheelchair with a bedsheet and alleged that a CNA hit and kicked the resident. The incident was reported to the primary care clinician approximately seven hours after it was brought to the attention of facility staff, despite facility policy requiring prompt notification in urgent situations. The Director of Nursing confirmed that the physician notification was not timely. Additionally, the facility did not notify the physician or the resident's representative when the resident was found on the floor with purplish discoloration on the left thigh, following an unwitnessed fall. Facility policy required follow-up and monitoring, including neurological assessments after unwitnessed falls or injuries involving possible head trauma. However, neither neurological monitoring nor timely notifications were conducted or documented. Both LVNs involved in the incident confirmed that the physician and resident representative were not notified, and neurological evaluation was not initiated. The resident involved had a history of moderate cognitive impairment and required maximum staff assistance for activities of daily living. Medical records indicated the resident was capable of understanding and making decisions. The failures to notify the physician and representative, and to conduct appropriate monitoring after significant incidents, were verified by the Director of Nursing and were not in accordance with the facility's policies and procedures.
Deficiencies in Monitoring and Communication for Residents
Penalty
Summary
The facility failed to ensure proper care and management of a resident's blood glucose monitoring device. Resident 26, who has diabetes, was using a personal continuous blood sugar monitoring device, the Dexcom G6. Despite the resident managing the device independently, there was no physician's order or care plan documented for its use. The facility's staff, including the LVN and DON, acknowledged the absence of documentation and orders for the device, which could potentially lead to missed severe hypoglycemia or hyperglycemia occurrences. Another deficiency involved Resident 293, who was admitted with a diagnosis of Chronic Diastolic Heart Failure. The facility failed to follow the transfer orders from the acute care hospital, which included daily weight monitoring and a fluid restriction of 2,000 ml per day. There was no documentation that the attending physician was informed of these orders upon the resident's admission. Both the RN and DON confirmed the lack of communication and documentation regarding the transfer orders, which are crucial for managing the resident's condition. Resident 8, who was dependent on supplemental oxygen, experienced a deficiency in care when the facility failed to assess and notify the physician timely about low oxygen saturation levels. The resident's oxygen levels were documented below the physician-ordered threshold of 92% for several hours without any intervention or notification to the physician. The DON and RN acknowledged that the situation was not addressed until the resident's family member informed the staff, indicating a lapse in monitoring and communication regarding the resident's condition.
Deficiencies in IV Access Management
Penalty
Summary
The facility failed to provide necessary care and services for maintaining intravenous accesses for three residents. For two residents, the facility did not obtain and document baseline measurements of the PICC line external catheter and arm circumference upon admission. Resident 292, who had a PICC line on the left upper arm for IV antibiotic medication due to a blood infection, did not have these baseline measurements documented. Similarly, Resident 293, who had a PICC line on the right upper arm for IV antibiotic treatment following foot surgery, also lacked documented baseline measurements. Interviews with nursing staff confirmed the absence of these measurements, which are crucial for monitoring potential changes and complications. Additionally, the facility failed to label the PIV site for Resident 33 with the date, time, and initials of the licensed nurse who inserted it. Resident 33, who was receiving IV antibiotic treatment for a urinary tract infection, had a PIV site on the right arm that was not labeled, making it unclear when the PIV was inserted or when it needed to be changed. The nursing staff verified the absence of labeling and documentation in the medical record, which is necessary for ensuring timely care and communication among staff. The Director of Nursing (DON) acknowledged these deficiencies, confirming that the facility's policies and procedures were not followed. The lack of documentation and labeling could delay the identification of complications related to intravenous catheters, potentially impacting resident care.
Failure to Maintain Respiratory Equipment Cleanliness
Penalty
Summary
The facility failed to provide safe respiratory care services for two residents, Resident 8 and Resident 294, by not adhering to the manufacturer's guidelines and the facility's policies and procedures for cleaning and maintaining respiratory equipment. For Resident 8, the facility did not ensure that the non-invasive ventilator machine was cleaned according to the manufacturer's guidelines, nor did they ensure that the headgear and tubing were cleaned as per the facility's policies. Observations revealed that the nasal cannula tubing and BiPAP oxygen tubing were touching the ground, and there was no documentation of the cleaning of the BiPAP machine or the filter being checked. Resident 8, who was admitted with a diagnosis of COPD and required a non-invasive mechanical ventilator, had a care plan that failed to include interventions for the care and maintenance of the BiPAP device. Despite physician's orders for cleaning the headgear and tubing, there was no evidence that these were followed consistently. Interviews with staff, including an LVN and the DON, confirmed the lack of documentation and adherence to cleaning protocols, with the DON acknowledging the findings. For Resident 294, the facility did not ensure that the CPAP machine was cleaned according to the manufacturer's guidelines, and the mask and tubing were not stored properly when not in use. Observations showed the CPAP mask and tubing were placed on top of a drawer with the tubing touching the floor. The resident, who had a sleep disorder, was independent in using the CPAP machine, but there was no physician's order for cleaning the device weekly as directed by the user guide. Interviews with staff, including a CNA and an LVN, revealed that the licensed nurses were responsible for cleaning the CPAP machine, but there was no documentation of this being done, and the DON acknowledged the lack of compliance with the manufacturer's cleaning instructions.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of medications for a resident. Specifically, a Licensed Vocational Nurse (LVN) did not administer dexamethasone, a steroid medication, to Resident 542 as per the physician's order. The physician's order required the medication to be given every other day in the morning with breakfast. However, during a medication administration observation, it was noted that the dexamethasone was administered late and not with breakfast as prescribed. The medical record review confirmed that the dexamethasone was scheduled to be administered at 0715 hours with breakfast, which was served at 0815 hours. The LVN acknowledged that the medication was administered late, not in accordance with the physician's order. The Director of Nursing (DON) was informed of these findings and acknowledged the deficiency.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications and that proper monitoring and documentation were conducted. Resident 33 was prescribed sertraline for depression, with orders to monitor for side effects, including orthostatic hypotension. However, the facility did not document the blood pressure readings necessary to monitor for orthostatic hypotension, as confirmed by both RN 1 and the Director of Nursing (DON). Resident 36 was prescribed multiple psychotropic medications, including bupropion, desvenlafaxine, Depakote, and Seroquel, with specific orders to monitor for side effects and document non-pharmacological interventions. The facility failed to accurately monitor orthostatic blood pressures and did not document the implementation of non-pharmacological interventions for the resident's behavioral episodes. The DON confirmed that the facility did not follow the physician's orders for monitoring and documentation. Resident 27 was prescribed olanzapine, with orders to monitor orthostatic blood pressures weekly. The facility documented identical blood pressure readings for different positions, indicating improper monitoring. RN 1 and the DON acknowledged that the orthostatic blood pressure monitoring was not conducted correctly, which could have identified significant adverse reactions from the medication.
Unlabeled and Undated Food Items in Walk-in Refrigerator
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines as evidenced by the presence of seven cups of apple juice and one cup of yogurt that were unlabeled and undated inside the walk-in refrigerator. This oversight was identified during an initial tour of the kitchen, where the Dietary Services Supervisor (DSS) confirmed that the kitchen staff had prepared these items the previous night, and they should have been labeled and dated according to the facility's policy. The facility's policy, revised on January 1, 2018, mandates that any food removed from its original container must be properly labeled with the name of the food item and the date it was removed. The DSS acknowledged the failure to comply with this policy, which affected all 55 residents receiving food prepared in the kitchen. The Administrator and Director of Nursing (DON) were informed of these findings and acknowledged the deficiency.
Facility Assessment Lacks Comprehensive Planning and Stakeholder Involvement
Penalty
Summary
The facility failed to ensure that the Facility Assessment was comprehensive and up-to-date, as required by the revised CMS guidance. The assessment did not actively involve direct care staff, residents, their representatives, or family members in its development. Additionally, the assessment lacked details on the resources necessary to care for residents during weekends, a plan to maximize recruitment and retention of direct care staff, and a contingency plan for staffing needs. These omissions were identified during an interview and document review with the Administrator, who confirmed the deficiencies and acknowledged a lack of awareness of the updated CMS requirements. The Administrator verified that the Facility Assessment was outdated, having been last updated on 6/6/24, and did not reflect the new CMS guidance effective from 8/8/24. The absence of active involvement from key stakeholders and the lack of comprehensive planning for staffing and resource allocation could potentially impact the facility's ability to meet residents' care needs. The Administrator admitted that the assessment did not include necessary resources for weekend care or strategies for staff recruitment and retention, nor did it have a contingency plan for staffing needs outside of emergency situations.
Infection Control Deficiencies in Hand Hygiene and Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically in performing hand hygiene and following enhanced barrier precautions. Observations revealed that the Activity Assistant, CNA 7, and CNA 1 did not perform hand hygiene after removing personal protective equipment (PPE) upon exiting Room A, which was under Novel Respiratory Precaution. The Activity Assistant and CNAs acknowledged their failure to wash hands, which is a critical step in preventing the spread of infection as per the facility's policy. The Director of Staff Development (DSD) and the Administrator, along with the Director of Nursing (DON), were informed of these lapses and acknowledged the findings. Additionally, CNA 8 did not follow enhanced barrier precautions for Resident 294, who required such measures due to having a PICC line. Despite signage indicating the need for a gown and gloves during high-contact care, CNA 8 did not wear a gown while changing the resident's soiled briefs. CNA 8 was under the impression that the resident was no longer under isolation precautions, contrary to the posted signage and the resident's care plan. The DON confirmed that staff should be aware of and adhere to enhanced barrier precautions for residents like Resident 294.
Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded accurately for one resident, which could potentially impact the resident's individualized care plan. The medical record review for the resident revealed a physician's order for heparin, an anticoagulant medication, to be administered subcutaneously every 12 hours for deep vein thrombosis (DVT) prophylaxis. However, the resident's Admission MDS did not reflect the use of this anticoagulant medication. During an interview and concurrent medical record review, the MDS Coordinator confirmed the incorrect coding of the MDS assessment. The Director of Nursing (DON) was informed and acknowledged the findings.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a pneumococcal immunization was offered and administered to a resident, identified as Resident 15, who was reviewed for pneumococcal immunization. The facility's policy and procedure, revised in October 2019, required that all residents be offered pneumococcal vaccines to prevent pneumococcal infections. However, a review of Resident 15's immunization record showed that while the resident received the Pneumonia 23 vaccine in June 2015, there was no documented evidence of the administration of the pneumococcal conjugate vaccine. During an interview and concurrent closed medical record review, the Infection Preventionist (IP) confirmed that the admitting nurse should have offered the PCV20 vaccine to Resident 15 upon admission, but this was not done. The Director of Nursing (DON) acknowledged the findings and stated that the pneumococcal conjugate vaccine should have been offered again to Resident 15. The oversight in offering the vaccine placed the resident at risk of acquiring pneumococcal infection.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect the rights of residents from verbal and physical abuse by another resident, specifically involving two residents. On one occasion, a resident was assisted by two nursing aide students when another resident angrily demanded the first resident to leave the room and subsequently hit the resident's right foot. This incident was witnessed by the nursing aide students, and the affected resident was assessed for injuries and emotional distress, leading to a room transfer. In another incident, a resident was verbally abused by the same aggressive resident, who yelled and used profanity in a foreign language. The aggressive resident also raised his walker as if to hit the other resident, causing fear and emotional distress. The affected resident expressed feeling unsafe and was subsequently transferred to another room. Despite these incidents, there was a lack of proper documentation and monitoring by the facility staff, as noted in interviews with the staff and residents. The facility's policies and procedures on preventing abuse were not effectively implemented, as evidenced by the repeated aggressive behavior of the resident and the inadequate response by the staff. The staff failed to document the incidents properly and did not monitor the affected residents after the incidents, which could have prevented further harm. The facility's Director of Nursing and other staff members were aware of the incidents but did not take sufficient action to address the aggressive behavior and ensure the safety of all residents.
Failure to Timely Report Abuse Incidents
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act. This failure was evident in two incidents involving residents. In the first incident, Resident 1 hit Resident 2's right foot, as witnessed by two nurse aide students. Although Resident 2 was assessed with no physical injuries and was monitored for emotional distress, the initial report filed to the California Department of Public Health (CDPH) was incomplete and lacked a description of the incident. The additional information was only provided 48 hours after the incident, which was not in compliance with the facility's policy requiring immediate reporting. In the second incident, Resident 1 yelled and cursed at Resident 3, raising his walker as if to hit him. Resident 3 reported feeling scared and was transferred to another room. Despite this, the incident was not reported to the appropriate agencies, including the CDPH, the ombudsman office, and law enforcement, until five days later. The facility's policy mandates that such incidents be reported immediately, within two hours if they involve abuse or result in serious bodily injury, or within 24 hours otherwise. The delay in reporting these incidents posed a risk for resident abuse not being identified and reported, potentially leading to continued abuse. Interviews with the Director of Nursing (DON) and other staff confirmed the findings. The DON acknowledged the incomplete initial report and the delay in providing additional information. Furthermore, the DON and other staff members did not perceive the second incident as verbal abuse, attributing it to incompatibility between the residents. This misjudgment contributed to the failure to report the incident in a timely manner, as required by the facility's policy.
Failure to Investigate and Monitor Alleged Abuse Incidents
Penalty
Summary
The facility failed to investigate an allegation of abuse according to its policies and procedures, and did not adequately monitor residents involved in the incidents. Resident 1 was involved in two separate incidents of aggression towards other residents. In the first incident, Resident 1 hit Resident 2's foot, which was witnessed by two nurse aide students. Although Resident 2 was assessed for physical injuries and monitored for emotional distress, the facility did not interview all staff members who had contact with the residents during the period of the alleged incident, as required by the facility's policy. Additionally, the facility did not ensure that the Social Services Director (SSD) visited Residents 1 and 2 daily for 72 hours as part of the investigation process. In the second incident, Resident 1 yelled and cursed at Resident 3, raising his walker as if to hit him. Resident 3 reported feeling scared and was subsequently transferred to another room. Despite this report, the facility did not conduct a further investigation into the incident. The facility's failure to investigate these incidents thoroughly posed a risk for resident abuse not being identified and addressed, especially in a facility with a vulnerable resident population. The facility's documentation and interviews with staff confirmed these deficiencies. The Director of Nursing (DON) and the SSD acknowledged the lack of proper investigation and monitoring. The facility's failure to adhere to its own policies and procedures for investigating and monitoring alleged abuse incidents highlights significant gaps in ensuring resident safety and compliance with regulatory standards.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 5,650 citations issued within 25 miles in the last 12 months — including the 25 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fullerton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenfield Care Center Of Fullerton, Llc | 0 mi | ★★★★★ | 15 | 0 |
| The Pavilion At Sunny Hills | 0 mi | ★★★★★ | 7 | 0 |
| St Elizabeth Healthcare Center | 0.4 mi | ★★★★★ | 25 | 0 |
| Park Vista At Morningside | 1.2 mi | ★★★★★ | 21 | 0 |
| St. Catherine Healthcare | 1.7 mi | ★★★★★ | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.