Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Terrace Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
A resident’s grievance about the heater and his roommate was not documented on the grievance log, and the DON confirmed she received a 6-page grievance but had not specifically discussed it with the resident or kept him apprised of progress toward resolution. The resident reported he had spoken with the Social Services Director but had not heard back and felt there was no follow-through.
Care plan not revised for oxygen administration. Two residents had physician orders for specific O2 flow rates and humidification, but observations showed one resident receiving O2 at a higher rate with an empty humidity bottle and self-adjusting his O2, while another resident was also receiving O2 at a higher rate with the concentrator out of reach and the resident's daughter adjusting or removing the O2. The care plans included oxygen as ordered but did not address these resident or family actions.
A resident on hospice did not receive medications and comfort kit orders as directed by the hospice physician, and the facility kept discontinued meds active without documented justification. In a separate observation, an LPN administered meds via G-tube without checking residuals, without flushing the tube, and by pushing the meds in rather than allowing gravity flow, despite the resident’s order requiring residual checks before meds and flushes.
A resident had ongoing significant weight loss over several months, dropping from 124.2 pounds to 108.1 pounds, while the chart showed no timely RD notification after the weight-loss change in condition was identified. Dietary notes documented continued decline and that the resident was not receiving oral supplements, and the first supplement order was not entered until much later. Staff and the RD gave conflicting accounts about notification and when nutrition support should have started.
Medication Storage Not Kept Secure: Medications were observed left unattended on top of a med cart and later left in the cart drawer while an LPN administered medications to residents. Staff stated the medications should not have been left on the cart, and the DON stated medications should not be left on medication carts.
A resident with frequent skin tears and bruising did not have a comprehensive care plan addressing skin integrity. Observations and staff interviews confirmed the resident's ongoing skin issues, yet the care plan lacked documentation for skin integrity, contrary to facility policy.
The facility failed to follow physician orders for a resident's wound care and another's pain management. A resident's bandage was not changed as prescribed, and another resident received pain medication outside the prescribed parameters. The DON acknowledged the lapses and emphasized the need for adherence to orders.
A resident with a skin condition did not receive the required daily wound care, as evidenced by a bandage dated several days prior. Despite physician orders for daily treatment, the Treatment Administration Record inaccurately documented that wound care was performed. The DON confirmed that the nursing staff had documented wound care without actually performing it, failing to maintain accurate medical records.
The facility failed to ensure proper infection control practices, as an LPN did not wear PPE while adjusting IV tubing for a resident under enhanced barrier precautions, and another LPN did not follow hand hygiene protocols during wound care. These actions were contrary to the facility's policies on infection prevention.
A resident's legal representative requested medical records in January 2024 but did not receive them by April 2024, despite multiple follow-ups. The facility's policy requires records to be provided within 48 hours, but delays occurred due to the process involving corporate legal review.
Failure to Document and Resolve Resident Grievance
Penalty
Summary
The facility failed to make prompt efforts to resolve grievances and to keep the resident appropriately apprised of progress toward resolution for one resident reviewed for grievances. Review of the Grievance/Complaint Log from February 2026 through April 2026 showed no grievance filed by or on behalf of the resident, yet the resident stated during interview that he had spoken with the Social Services Director about the heater and his roommate but had not heard back and felt he received only lip service with no follow-through. The DON later stated she had received a 6-page grievance for the resident on April 13, 2026, confirmed it had not been documented on the Grievance/Complaint Log, and stated she had not specifically discussed the grievance with the resident or her efforts to address or resolve it. The facility policy required prompt efforts to resolve grievances and keeping the individual filing the grievance apprised of progress toward resolution and providing a written decision.
Care Plan Not Revised for Oxygen Administration
Penalty
Summary
The facility failed to ensure the care plan was revised for oxygen administration for 2 residents reviewed for respiratory care. Resident #116 had a physician order for oxygen at 5 liters per minute via nasal cannula with humidification when on concentrator, and may be without humidification when on a tank every shift. During observation, the resident was in bed receiving oxygen at 4 liters per minute via nasal cannula with an empty humidity bottle. The comprehensive care plan addressed potential complications of respiratory distress related to COPD and pneumonia and included administration of oxygen as ordered, but it did not include an intervention to address the resident adjusting his own oxygen levels. An LPN stated that he adjusts his oxygen levels as he sees fit and has been using oxygen for a long time. Resident #71 had a physician order for oxygen at 2 liters per minute via nasal cannula with humidification when on concentrator, and may be without humidification when on a tank every shift. During observations, the resident was in bed receiving oxygen at 4 liters per minute via nasal cannula, and the oxygen concentrator was on the right side of the bed outside of the resident's reach. The comprehensive care plan addressed potential complications of respiratory distress related to rhinovirus and a history of pneumonia and included administration of oxygen as ordered, but it did not include an intervention for adjustment or removal of oxygen by the resident's representative. An LPN stated that the resident's daughter would come in and adjust the oxygen and sometimes remove it, despite prior education that this should not happen.
Hospice Orders Not Implemented and G-Tube Medication Administration Not Performed per Order
Penalty
Summary
The facility failed to ensure a resident receiving hospice services received the care and medications ordered by the hospice physician. Resident #117 had a hospice physician telephone/verbal order dated 12/8/2025 that discontinued Fleet enema, Citroma solution, aspirin, multivitamin, polyethylene glycol powder, and Voltaren arthritis pain gel, and added comfort kit medications including atropine drops, haloperidol liquid, lorazepam liquid, morphine concentrate, and ondansetron. However, review of the resident’s active physician orders on 3/18/2026 showed the discontinued medications were still active, and the comfort kit medications were not on the active order list. The resident’s record also showed a facility physician progress note on 1/5/2026 that addressed continuation of the arthritis pain gel but did not justify continuation of the other medications the hospice physician had ordered discontinued. The record contained no justification for not providing the comfort kit medications ordered by the hospice physician. During interview, the DON confirmed the hospice physician’s orders had not been implemented, the discontinued orders were still in effect, and the comfort kit medications had not been implemented. The facility physician stated he had not seen the hospice physician’s document and said he probably just wrote to continue the course. The facility also failed to administer gastrostomy tube medications according to the ordered procedure for another resident. Resident #151 had an order to check tube residual to verify placement prior to feeding, medication, and flush, and to hold feeding and notify the physician if residual was 100 mL or more. During observation of medication administration, the LPN did not verify tube placement by checking residual volume, did not flush the tube with water before giving medications, and pushed liquid medications into the gastrostomy tube with the syringe instead of allowing gravity flow. When the resident requested pain medication, the LPN again did not flush the tube, did not check residual volume, and pushed the medication into the tube. The LPN later stated she should not have pushed the medication in, should have let gravity flow it in, and should have checked for residual volume before giving the medications.
Failure to Maintain Resident Weight With Delayed Nutrition Intervention
Penalty
Summary
The facility failed to ensure acceptable nutritional status was maintained for a resident who experienced ongoing weight loss. Resident #68 weighed 124.2 pounds on 10/16/2025, 118.6 pounds on 11/6/2025, 109 pounds on 12/8/2025, 111 pounds on 1/7/2026, 107 pounds on 2/5/2026, and 108.1 pounds on 3/16/2026, reflecting a 12.96% loss from admission weight over the review period. The resident’s record showed a change in condition for weight loss beginning 1/6/2026, but there was no documentation that the Registered Dietitian was notified at that time. The resident’s dietary and nutritional notes documented continued weight loss and noted that the resident was not receiving oral nutritional supplements during the period of decline. A dietary note on 1/16/2026 described weight loss during the first two months in the facility and stated to continue monitoring. A nutritional progress note on 2/16/2026 identified significant weight loss and recommended a house nutritional supplement twice daily, and a 3/16/2026 note again recommended supplements. Physician orders showed the first supplement order was not entered until 3/16/2026, with no prior orders for nutritional supplements or appetite stimulant medications. During interviews, staff stated that significant weight loss should trigger notification of the MD, family, and RD, while the RD stated he was not specifically notified of the issue and that the supplement had not been started when he expected it to be.
Medication Storage Not Kept Secure
Penalty
Summary
The facility failed to ensure medications were stored in a safe and secure manner. During an observation on 3/16/2026 at 9:45 AM, three pills and two tablets were observed in a cup of medications on top of the medication cart with no staff present at the cart, while residents were passing by and staff were at the desk. Staff D, LPN, returned to the medication cart at 9:52 AM and later stated that the medications should not have been left on the cart and that the staff member had gone to answer the telephone and should have brought them along. During an observation on 3/19/2026 at 5:10 AM, Staff C, LPN, poured refrigerated liquid Gabapentin, removed 2.5 milliliters from the medication cup, and left the remaining medication on the medication cart while administering gastrostomy tube medications. Staff C then placed the liquid Gabapentin into the top drawer of the medication cart and continued administering medications to three residents with the liquid medication left in the drawer. Staff C later stated the medication should have been returned to the refrigerator and should not have been left on top of the cart or in the drawer. The DON stated that medications should not be left on medication carts.
Failure to Develop Comprehensive Care Plan for Skin Integrity
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with skin conditions. During an observation, the resident was found lying in bed with bruising and scabbed skin tears on the left arm. Interviews with staff revealed that the resident frequently experiences skin tears, occurring approximately once a week, due to the fragility of their skin. Despite these ongoing issues, a review of the resident's care plan showed no documentation or focus on skin integrity. Further examination of the resident's medical records indicated multiple instances of skin tears and bruising, including wounds on the left upper arm, left knee, and bilateral extremities. The facility's policy mandates a comprehensive assessment and care plan for each resident, which should include measurable objectives and timeframes to address identified needs. However, the care plan for this resident did not address the potential for skin integrity issues, as confirmed by the MDS and Care Plan Coordinator.
Failure to Follow Physician Orders for Wound Care and Pain Management
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders for a resident with a skin condition and another resident requiring pain management. For the resident with a skin condition, observations revealed that a bandage on the resident's left shin had not been changed since 9/27, despite physician orders to clean the area and apply Xeroform and Zinc daily. The resident was unaware of the cause of the injury and reported that no one had changed the bandage. The Director of Nursing (DON) confirmed the bandage was overdue for a change and acknowledged the expectation for nursing staff to follow physician orders. In the case of the resident requiring pain management, the facility failed to administer medication according to the prescribed parameters. The resident received Oxycodone for pain levels below the prescribed threshold of 7-10/10 on multiple occasions. The DON attributed this to a new nurse not following physician orders and emphasized the expectation for nurses to adhere to medication administration guidelines. The facility's policies on wound care and medication administration were not followed, leading to these deficiencies.
Inaccurate Documentation of Wound Care
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate for a resident with a skin condition. During observations on two consecutive days, the resident was seen with a bandage on his left shin dated several days prior, indicating that the wound care had not been performed as required. The resident confirmed that no one had come to change his bandage, despite physician orders specifying daily wound care treatment. Upon review of the Treatment Administration Record (TAR), it was documented that the resident received wound care on specific dates, which contradicted the resident's statement and observations. The Director of Nursing acknowledged that the nursing staff had inaccurately documented performing wound care when it had not been done, highlighting a failure in maintaining accurate medical records as per the facility's policy and procedure.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by staff during care activities for two residents. In the first instance, a Licensed Practical Nurse (LPN) did not wear gloves or a gown while adjusting the intravenous (IV) tubing for a resident who was under enhanced barrier precautions due to a left arm peripherally inserted central catheter (PICC). Despite signage indicating the need for gloves and a gown for high-contact care activities, the LPN entered the room without the required personal protective equipment (PPE) because the IV pump had been beeping for some time. In the second instance, another LPN performing wound care on a resident did not adhere to hand hygiene protocols. The LPN failed to change gloves or perform hand hygiene after removing a dressing and before cleaning the wound. Additionally, the LPN did not perform hand hygiene after removing gloves and before donning a new pair. The facility's policies on hand hygiene and wound care were not followed, as staff did not perform hand hygiene at critical points during the wound care process, which is essential to prevent the spread of infections.
Failure to Provide Medical Records in a Timely Manner
Penalty
Summary
The facility failed to ensure that a resident's legal representative received copies of the resident's medical records in a timely manner. Resident #1's daughter, who holds the Durable Power of Attorney, requested the medical records in January 2024 but had not received them by April 2024. Despite multiple follow-ups via email with the Admissions Assistant and the Director of Nursing, the records were not provided. The Administrator acknowledged the delay and stated that the facility's policy is to provide medical records within 48 hours of a request, but the process involves sending the request to corporate for legal review, which contributed to the delay. The Admissions Assistant confirmed that Resident #1's daughter had made the request at the beginning of the year and was directed to fill out a medical records request form. However, the records were still not provided, and the daughter continued to seek updates without success. The facility's policy, issued on 4/1/2022, mandates that medical records be accurately documented, readily accessible, and systematically organized, but this was not adhered to in this case.
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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.
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Nursing homes near Gainesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palm Garden Of Gainesville | 2.7 mi | ★★★★★ | 0 | 0 |
| Aviata At North Florida | 2.9 mi | ★★★★★ | 23 | 3 |
| Plaza Health And Rehab | 3.3 mi | ★★★★★ | 19 | 0 |
| Gainesville Health And Rehabilitation | 3.8 mi | ★★★★★ | 4 | 0 |
| Magnolia Ridge Health And Rehabilitation Center | 4.5 mi | ★★★★★ | 7 | 0 |
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