Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Terraces At The Clare during CMS and state inspections, most recent first.
A resident with dementia and moderate cognitive impairment was found with a blanket tied to the bed frame across the chest, despite no restraint order, assessment, or care plan in the record. A CNA admitted she tied the blanket to keep the resident from getting up and potentially falling, and staff later described the blanket as tightly secured and functioning as a restraint. The LPN and DON both acknowledged that tying the blanket to the bed was not appropriate and constituted a restraint.
Surveyors found that the facility did not properly label or date prepared foods, stored perishable items at unsafe temperatures, and allowed kitchen staff with facial hair to work without beard restraints. These actions were not in accordance with facility policies and had the potential to affect 47 residents receiving oral diets.
The facility did not adequately assess or report positive Legionella findings in its water system to the local health department, despite ongoing positive test results and continued use of affected water sources for drinking and care activities. Staff and leadership were aware of the contamination but lacked documentation of risk assessments, public health notification, or consistent provision of alternative water sources, resulting in potential exposure for all residents.
The facility did not perform a thorough risk assessment to identify why Legionella continued to grow and spread in its water system, despite ongoing positive test results in several rooms. Actions taken were limited to periodic flushing, temperature checks, and installing water filters, with incomplete documentation and inconsistent follow-through on consultant recommendations. There was no evidence of regular review meetings, comprehensive testing, or notification to families, and the issue persisted for over a year, potentially affecting all residents.
A resident dependent on staff for all ADLs and prescribed continuous oxygen at 1 LPM was found receiving oxygen at 2 LPM, contrary to the physician's order. The oxygen concentrator was not within the resident's reach, and staff failed to ensure the correct flow rate was maintained, resulting in improper respiratory care.
A resident receiving Diazepam for anxiety did not have accurate records maintained for their controlled substance medication. A discrepancy was found between the number of tablets in the medication card and the controlled drug record, and a nurse failed to properly document administration on the accountability form, resulting in a lack of proper medication accountability.
A resident with severe dementia was found with unexplained bruises, but the LTC facility failed to conduct a thorough investigation to rule out abuse. The investigation lacked complete documentation, including statements from key staff and details of the incident. The DON allowed a new nurse to document under her name, causing inaccuracies. The facility's internal policies on abuse investigation were not followed, leaving the incident unresolved.
A resident with severe dementia was found with bruises, prompting an abuse investigation. The facility's documentation was incomplete and not readily accessible, with confusion over staff documentation and missing statements. The Director of Nursing allowed a new nurse to document under her name, leading to inaccuracies. The Administrator acknowledged the incomplete records, highlighting a failure to maintain professional standards.
The facility failed to ensure staff signed the Narcotic Shift Count Log Sheet at the beginning and end of their shifts and prevented pre-signing. This affected five residents who required controlled medications, revealing discrepancies in documentation and adherence to policy.
Resident restrained with blanket tied to bed frame
Penalty
Summary
The facility failed to ensure a resident was free from physical restraints when a blanket was tied to the frame of the resident’s bed across the chest. The resident, R1, was a female with diagnoses including unspecified dementia with behavioral disturbance, congestive heart failure, atrial fibrillation, hypertension, hypothyroidism, Meniere’s disease, major depressive disorder with psychotic symptoms, and anxiety disorder. Her MDS documented a BIMS score of 10, indicating moderate cognitive impairment. Her record did not contain an assessment, physician’s order, or care plan for a restraint. According to the incident report and staff statements, a CNA tied the resident’s blanket to the bed frame in an effort to prevent the resident from getting up independently and potentially falling. The CNA acknowledged prior education on abuse prevention and understood that physical restraints are considered abuse. The CNA also reported that she informed the nurse on duty of her actions. The facility’s investigation concluded that the CNA deliberately tried to physically restrain the resident and that the CNA was no longer employed. Other staff described finding the blanket tied to the bed frame when the resident was being gotten up in the morning. One CNA stated the blanket was tied so tightly she could not untie it and had to get the nurse. The LPN stated the blanket was tied at the level of the resident’s chest and that anything tied on the bed that impedes movement is a restraint. The DON stated the CNA said she tied one side of the blanket to the bed and tucked the other side in to prevent the resident from falling. The resident was unable to explain what happened when interviewed.
Failure to Follow Food Safety and Staff Hygiene Protocols
Penalty
Summary
The facility failed to adhere to its policies and procedures for preventing foodborne illnesses, as evidenced by improper labeling and dating of food items in the walk-in coolers. Surveyors observed containers of food, such as sliced liver and prepared cream cheese salmon, that were not labeled with preparation or use-by dates. Additionally, trays of prepared breakfast items, including berry cups, yogurt cups, hard-boiled eggs, and granola cups, were found without any indication of when they were prepared or when they should be used by. The Director of Dining confirmed that all perishable foods should be labeled and used or discarded within three days, and that expired foods must be discarded on the best by or use by date. Further deficiencies were noted in the storage of potentially hazardous foods at inappropriate temperatures. The main walk-in cooler was repeatedly found to be operating above the required temperature, with thermometer readings ranging from 47 to 59 degrees Fahrenheit, well above the policy-mandated maximum of 41 degrees Fahrenheit. Perishable items such as ranch and balsamic dressings and cooked pasta were stored in this cooler at temperatures exceeding 56 degrees Fahrenheit. The Registered Dietician confirmed that perishable foods should not be kept in the danger zone (above 41 degrees Fahrenheit) for more than four hours to prevent foodborne illness. Additionally, the facility failed to ensure that kitchen staff adhered to grooming policies designed to prevent contamination. Multiple staff members with facial hair were observed working in the kitchen without wearing beard restraints, only donning them after being observed by surveyors. The Director of Dining confirmed that all staff with hair or beards are required to wear appropriate restraints to prevent hair from contaminating food. These failures had the potential to affect 47 residents who were receiving oral diets at the time of the survey.
Failure to Assess and Report Legionella Risk in Facility Water System
Penalty
Summary
The facility failed to adequately assess, identify, and involve the local public health department regarding the adequacy of its water management plan to prevent the growth of Legionella or other waterborne pathogens. Despite positive Legionella test results in the facility's water system since 2023, there was no documentation of a comprehensive risk assessment or notification to the local health authority. The Infection Preventionist and Director of Nursing were aware of the positive results and monitored residents for respiratory symptoms, but could not provide documentation of risk assessments or confirm timely notification to public health authorities. The Administrator stated that the facility followed recommendations from an outside water management company, which included water flushing, but did not pursue further action or report findings to the health department due to the absence of confirmed resident cases of Legionella disease. Observations revealed that residents continued to use water from faucets in dining rooms and medication storage rooms for drinking, mouthwash, and showers, even in areas where Legionella had been detected. Staff, including CNAs, LPNs, and RNs, confirmed that water for drinking and medication administration was obtained from these sources. Although filters were reportedly provided for certain rooms and residents were instructed not to drink from sinks, there was no documentation that bottled water was supplied, and water coolers were filled from the same faucets with positive Legionella results. Laboratory results documented multiple positive Legionella findings in various rooms, with colony-forming units per milliliter (CFU/mL) ranging from 0.5 to 30. The facility's policies indicated a commitment to preventing water-borne contaminants, but there were gaps in implementation, including missed testing periods and lack of documentation for risk assessments and mitigation steps. The Medical Director was aware of the positive results but did not consider them harmful and relied on the water management team for guidance.
Failure to Conduct Comprehensive Risk Assessment for Legionella in Facility Water System
Penalty
Summary
The facility failed to conduct a thorough risk assessment to determine why opportunistic waterborne Legionella continued to grow and spread in the facility's water system. Despite ongoing positive Legionella test results in multiple rooms since 2023, the facility's actions were limited to periodic flushing, temperature monitoring, and the installation of water filters in affected rooms. Documentation revealed that only three rooms were retested in April, instead of the five recommended by the consultant, and there was no evidence of regular meetings to discuss results or perform comprehensive risk assessments. The Director of Plant Operations acknowledged that the expansion tank had insufficient air pressure, which could contribute to Legionella growth, and that cleaning of the mixing valve was performed without documentation. Interviews with facility staff indicated a lack of clarity and consistency in following the water management plan and consultant recommendations. The administrator was unsure why only three rooms were retested and admitted that positive findings were not reported to the local health authority, as no residents had tested positive for Legionella disease. There was also no documentation that residents' families were notified of the ongoing Legionella issue. The facility experienced a gap in water testing during a change in testing companies, and the water management company had only recommended flushing, with no further interventions until a plumber was called for mechanical inspection after two years of positive results. Water temperature logs showed variable temperatures in the affected rooms, with some readings within the range that supports Legionella growth. Laboratory results documented persistent low to high levels of Legionella in several rooms, with the highest recorded at 30 CFU/mL. The facility's policy stated a commitment to prevention and control of water-borne contaminants, but the lack of comprehensive risk assessment, incomplete testing, and insufficient documentation contributed to the ongoing deficiency affecting all residents in the facility.
Failure to Monitor and Administer Oxygen Therapy per Physician Order
Penalty
Summary
A deficiency occurred when a resident who was prescribed continuous oxygen therapy at 1 liter per minute (LPM) via nasal cannula was found to be receiving oxygen at a higher flow rate of 2 LPM. The oxygen concentrator was positioned behind the resident's wheelchair and was not within her reach. The resident, who is cognitively intact but dependent on staff for all activities of daily living, reported that staff typically check her oxygen in the morning and that she does not adjust the setting herself. However, there was inconsistency among nursing staff regarding the necessity of oxygen therapy for this resident, and the resident expressed confusion about why she was on oxygen. Upon review, a registered nurse confirmed that the physician's order specified 1 LPM and that there was no order to titrate the oxygen. The nurse adjusted the flow rate to the correct setting. The resident's clinical records indicated diagnoses including pneumonitis, congestive heart failure, and acute pulmonary edema, and her care needs required staff assistance for mobility and personal hygiene. The facility's policy requires verification and monitoring of oxygen administration according to physician orders, but this was not followed, resulting in the resident receiving an incorrect oxygen flow rate.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to maintain accurate records and accountability for controlled substances for one resident who was prescribed Diazepam for anxiety. During a narcotic reconciliation count on the tenth floor medication cart, it was observed that the Diazepam blister pack contained 39 half tablets, while the controlled drug record indicated that 40 half tablets should have remained. The last documented entry on the controlled drug record was inconsistent with the actual count in the medication card. The Director of Nursing confirmed that the count was incorrect. Interviews and record reviews revealed that a registered nurse had administered a dose of Diazepam to the resident, but the administration was not properly signed off on the controlled substance accountability form. Facility policy requires that all controlled substances be accounted for, with two nurses counting the medications at the beginning and end of each shift and documenting any discrepancies. The failure to accurately document and reconcile the controlled substance count resulted in a lack of accountability for the resident's medication.
Inadequate Investigation of Resident's Injuries
Penalty
Summary
The facility failed to conduct a thorough investigation into the alleged injuries of unknown source for a resident, R1, who was affected by this deficiency. R1, a resident with severe dementia and atherosclerotic heart disease, was found with bruises on her left wrist, right hand, and left eye. Despite the presence of these injuries, the facility did not adequately document or investigate the circumstances surrounding the bruises to rule out physical abuse. The investigation lacked critical details such as the time, date, and location of the incident, as well as statements from all relevant staff members. The investigation process was flawed, as evidenced by the lack of written statements from key staff members who were involved in R1's care. The Director of Nursing (V2) allowed a new nurse (V6) to document under her name, leading to inaccuracies and confusion in the documentation. Furthermore, the facility's administrator (V1) and the Assistant Director of Nursing (V7) were unable to provide complete and accessible documentation when requested. The investigation report concluded that the bruises might have been caused by R1's resistance during transfers and her medication, Plavix, but failed to provide evidence or identify the staff involved in these transfers. The facility's internal policies on abuse investigation were not followed, as the investigation did not include interviews with all staff who had direct knowledge of the incident or those who regularly cared for R1. The final report lacked essential information, such as the original allegation details and a comprehensive review of medical records and witness interviews. This deficiency highlights the facility's failure to ensure a proper and timely investigation into potential abuse, leaving the incident unresolved and inadequately addressed.
Incomplete Abuse Investigation Documentation
Penalty
Summary
The facility failed to maintain accurate and readily accessible resident records related to an abuse investigation involving a resident with severe dementia and atherosclerotic heart disease. The resident, who is severely cognitively impaired, was found with bruises on her arms, which were identified on February 4, 2025. The facility's final report concluded that abuse was ruled out, attributing the bruises to the resident's medication and possible accidental injury during transfers. However, the investigation documentation was incomplete and not readily available when requested by surveyors. The investigation was conducted by the Director of Nursing (V2), but the documentation was not properly organized or accessible. The Administrator (V1) and V2 failed to provide complete written statements from all relevant staff, including the night nurse who first identified the bruises. Additionally, there was confusion regarding the documentation process, as V2 allowed a new nurse (V6) to document under her name, leading to inaccuracies in the records. The facility's incident audit report did not include all necessary documentation, and the notes related to the bruising incident were not found in the resident's records. The lack of proper documentation and organization of the investigation records hindered the facility's ability to demonstrate a thorough investigation into the resident's bruising. The Administrator acknowledged the incomplete documentation and the need for staff to document under their own names. Despite the Director of Nursing's claim that all written statements were provided, it was later revealed that additional statements existed but were not initially accessible. This deficiency highlights the facility's failure to adhere to professional standards in maintaining resident records and conducting a comprehensive abuse investigation.
Failure to Properly Document Narcotic Counts
Penalty
Summary
The facility failed to ensure that staff signed the Narcotic Shift Count Log Sheet at the beginning and end of their shifts and also failed to prevent staff from signing the log sheet before the end of their shifts. These deficiencies were observed during medication cart inspections on the 10th and 11th floors, where missing signatures were noted on specific dates. Licensed Practical Nurses (LPNs) acknowledged the missing signatures and stated that the staff responsible for those shifts did not sign the narcotic sheet as required. The Director of Nursing (DON) confirmed that the expectation is for staff to sign immediately after counting the controlled medications to acknowledge the count is correct. The surveyor and LPNs conducted reconciliations and physical counts of controlled medications for five residents, revealing discrepancies in the documentation process. The residents involved had various diagnoses requiring controlled medications such as Hydrocodone, Oxycodone, Dilaudid, Lorazepam, and Pregabalin. The facility's policy mandates that controlled substances be counted and signed for at the end of each shift by both the incoming and outgoing nurses, and any discrepancies should be reported to the DON. Further review of the Narcotic Shift Count Log Sheets showed instances of pre-signing before the end of the shift, which is against the facility's policy. The DON and Administrator confirmed that staff are not expected to pre-sign and should only sign once the count is verified. The facility had previously conducted an in-service education session emphasizing the importance of counting and signing narcotics at the beginning and end of each shift. Despite this, the deficiencies persisted, indicating a failure to adhere to established procedures for handling controlled substances.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warren Barr Gold Coast | 0.3 mi | ★★★★★ | 2 | 0 |
| Warren Barr Lincoln Park | 2.5 mi | ★★★★★ | 10 | 0 |
| Little Sisters Of The Poor | 2.5 mi | ★★★★★ | 0 | 0 |
| Landmark Of Lincoln Park Rehabilitation And Nursin | 2.7 mi | ★★★★★ | 4 | 0 |
| Avantara Lincoln Park | 2.7 mi | ★★★★★ | 9 | 0 |
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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 July 2026) and official state health department websites.