Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 View Long Term Care Facility during CMS and state inspections, most recent first.
A comatose, fully dependent resident with chronic respiratory failure, prior intracerebral hemorrhage, and HTN had a care plan and Closet Care Plan requiring two-person assistance for overall rolling and bed mobility. Despite this, a CNA provided personal/incontinent care and rolled the resident in bed without a second staff member present, even though the CNA knew two-person assistance was required. During this one-person transfer, the resident rolled out of bed, fell to the floor, struck the head, and was later found on CT to have bilateral acute post-traumatic subdural hematomas, resulting in hospital admission to a trauma ICU.
A CNA physically struck a resident with multiple chronic conditions after the resident became agitated and struck the CNA during care. The CNA responded by grabbing the resident's wrist, slapping their face, and using profane language. The incident was witnessed by staff, confirmed by video surveillance, and resulted in a red mark on the resident's cheek. The event was determined to be physical and verbal abuse, with psychosocial harm identified.
A resident in an LTC facility was not administered a scheduled antiseizure medication, Briviact, due to a failure in communication and medication management processes. The resident missed five doses, resulting in seizure activity and hospitalization. The facility staff did not notify the provider of the medication's unavailability, and the pharmacy did not inform the provider of the limited supply dispensed.
A resident with a history of epilepsy did not receive five doses of their prescribed anti-seizure medication, Briviact, due to it being unavailable. Despite the LPN's attempt to reorder the medication, it was not delivered, leading to the resident experiencing seizure activity and requiring hospital transfer. The incident highlighted a communication breakdown among staff regarding the urgency of the medication's availability.
Two residents in an LTC facility did not receive timely dental services, leading to deficiencies in their care. One resident, with cerebral palsy and epilepsy, was missing dentures since 2020 and did not receive follow-up appointments. Another resident, with dementia and epilepsy, experienced a delay in dental services upon admission and was not seen by a dentist until much later. The facility's policy required dental consults within 30 days of admission, which was not followed.
A resident with schizophrenia, alcohol abuse, and neutropenia was observed with dark brown debris under their fingernails while eating with their hands, indicating a failure in providing necessary grooming and personal hygiene services. Despite facility policies requiring nail care on bath days and as needed, the assigned CNA did not perform this care, which was recognized as an infection control issue by the nursing staff and DON.
A resident with paraplegia and moderate cognitive impairment sustained a toe injury due to the absence of a required calf board in their wheelchair, as per their care plan. The CNA assigned to the resident did not check the care plan, resulting in the resident's foot falling off the wheelchair pedal and causing injury. Staff interviews confirmed the care plan violation, highlighting the need for adherence to care plans to prevent such incidents.
Failure to Follow Two-Person Bed Mobility Care Plan Resulting in Resident Fall and Head Trauma
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment remained as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents. Facility policy required development and use of a comprehensive care plan and a Closet Care Plan, which was to be checked and followed by all caregivers before providing care. The Closet Care Plan for Resident #1, who was comatose and fully dependent for rolling bed mobility, specified that two staff members were required for overall rolling and bed mobility. Resident #1 had diagnoses including chronic respiratory failure, nontraumatic intracerebral hemorrhage, and hypertension. The Minimum Data Set dated 07/23/2025 documented that the resident was comatose and dependent for rolling from lying on the back to either side, requiring the assistance of two or more helpers. The Closet Care Plan dated 07/29/2025 reiterated that two staff members were required for bed mobility (overall rolling). These documents were available in the resident’s room and, per policy, were to be followed by all caregivers assigned to the resident. On 09/17/2025, Certified Nurse Aide (CNA) #1 provided personal/incontinent care to Resident #1 alone, without obtaining the required assistance of a second staff member, despite being aware that the resident required two-person assistance for rolling. While CNA #1 was rolling the resident, the resident fell out of bed to the floor. CNA #1 attempted but was unable to stop the fall, and no other staff were present in the room at the time. The resident struck the head on the floor and was subsequently evaluated at the hospital, where a CT scan showed bilateral acute post-traumatic subdural hematomas, and the resident was admitted to the trauma intensive care unit. The Medical Director stated that the acute subdural hematomas were likely the result of the fall and that the fall caused harm to the resident.
Staff-to-Resident Physical and Verbal Abuse Incident
Penalty
Summary
On 12/08/2025, a certified nurse aide (CNA) was observed on video surveillance striking a resident in the face, resulting in a red mark on the resident's cheek. The incident occurred after the resident, who had a history of alcoholic cirrhosis, chronic kidney disease, and chronic obstructive pulmonary disease, became agitated and attempted to self-transfer from a recliner. The resident, who was moderately cognitively impaired and known to display verbal and physical aggression, struck the CNA during an attempt to reposition them. In response, the CNA grabbed the resident's wrist and slapped them in the face. The CNA was also witnessed using profane language directed at the resident during the altercation. Multiple staff interviews confirmed the sequence of events, with several staff members hearing or witnessing the slap and the use of inappropriate language. The CNA admitted to reacting physically after being struck by the resident and acknowledged that their response was inappropriate. The incident was immediately reported by the CNA to the supervising nurse, and the resident was subsequently assessed for injuries. The red mark on the resident's cheek resolved by the following day, and no additional injuries or changes in behavior were documented in the days following the incident. The facility's abuse prevention policy defined physical abuse as the willful infliction of injury, including hitting and slapping. The investigation concluded that physical abuse had occurred, as the CNA's actions met the definition of abuse. The incident was corroborated by video evidence and staff interviews, which consistently described the CNA's response as unacceptable and constituting physical and verbal abuse. The resident was monitored for psychosocial harm, and although no lasting injury or behavioral changes were documented, the event was determined to have caused psychosocial harm according to the reasonable person concept.
Failure to Administer Antiseizure Medication Leads to Resident Hospitalization
Penalty
Summary
The facility failed to effectively implement processes to acquire, dispense, and administer medications to meet the needs of each resident, specifically for Resident #260, who was not administered a regularly scheduled controlled antiseizure medication, Briviact, as ordered. This resulted in the resident missing a total of five doses, leading to seizure activity and subsequent hospitalization. The facility staff did not notify the provider of the medication's unavailability, and the pharmacy provider did not inform the medical provider that only a 14-day supply was dispensed instead of the 30-day supply ordered. Resident #260 had a medical history that included cerebral infarction, epilepsy, and metabolic encephalopathy, and was severely cognitively impaired. The resident's active physician's orders required Briviact 50 mg to be administered twice daily. However, due to insurance stipulations, the pharmacy sent only a 14-day supply, and the medication ran out on 4/19/24. Despite the medication being ordered through the electronic medication administration record on 4/16/24, the provider did not renew the prescription, assuming a 30-day supply had been dispensed. Interviews with facility staff revealed a breakdown in communication and responsibility. Licensed Practical Nurse #1, who administered the last dose, assumed the issue was being handled by the team leader and the doctor. Registered Nurse #1, the team leader, was unaware of the medication shortage until after the seizure occurred. The pharmacy consultant and the medical director indicated that the facility should have communicated the medication's unavailability to the provider. The lack of communication and failure to follow established procedures for medication reordering and notification contributed to the deficiency.
Significant Medication Error Due to Unavailable Anti-Seizure Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of anti-seizure medication. Resident #260, who had a history of cerebral infarction, epilepsy, and metabolic encephalopathy, was not administered five doses of their prescribed anti-seizure medication, Briviact. This lapse occurred over several days, from April 19 to April 21, 2024, due to the medication being unavailable. The absence of this critical medication led to the resident experiencing seizure activity, necessitating their transfer to a hospital for evaluation and treatment. The issue began when the Licensed Practical Nurse (LPN) on duty administered the last available dose of Briviact on April 19, 2024, and noted the need for a reorder. Despite contacting the pharmacy, the medication was not delivered due to an insurance and provider issue. The LPN reported this to the team leader, but the medication remained unavailable over the weekend. The nursing staff assumed that the issue was being handled, but no further action was taken to ensure the medication was obtained, leading to the resident missing multiple doses. Interviews with various staff members, including Registered Nurses and the Medical Director, highlighted a breakdown in communication and responsibility. The staff acknowledged the importance of the medication and the risk of seizures if doses were missed. However, there was a failure to adequately communicate the urgency of the situation to the appropriate medical personnel, resulting in the resident's condition deteriorating to the point of requiring emergency medical intervention.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services to two residents, leading to deficiencies in their care. Resident #10, who has cerebral palsy, epilepsy, and neuromuscular dysfunction of the bladder, was missing dentures since October 2020 and did not receive timely follow-up appointments for denture replacement. Despite being cognitively intact and requiring supervision with oral hygiene, Resident #10 was not seen by the dentist from November 2022 to July 2024. The resident expressed difficulty in chewing and eating properly due to the absence of dentures, and there was no record of dental consults after October 2020. Resident #112, diagnosed with dementia, epilepsy, and glaucoma, experienced a delay in receiving routine dental services upon admission. The resident, who was edentulous and at risk of altered nutritional status, did not have a physician order for dental consults and was not seen by the dentist until January 2024, despite being admitted earlier. The resident expressed difficulty in chewing certain foods and was unaware of being on a special diet. There was no documentation of dental evaluations or refusals in the medical record prior to the January 2024 consult. The facility's policy required residents to be seen by the dentist within 30 days of admission and annually, but this was not adhered to for Residents #10 and #112. Interviews with staff revealed a lack of coordination and communication regarding dental consults and follow-ups. The Director of Nursing acknowledged the oversight and emphasized the importance of dental hygiene and dignity for the residents. The failure to ensure timely dental services highlights a deficiency in the facility's adherence to its own policies and procedures.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. Specifically, Resident #314 was observed with dark brown debris under their fingernails on both hands while eating with their hands. The facility's policies on Activities of Daily Living, Grooming, and Nail Care required that individual care plan interventions be developed and implemented, and that nail care be provided weekly on bath days and as needed. However, observations and interviews revealed that the assigned Certified Nurse Aide did not provide nail care to Resident #314 on the observed date, despite the resident's care plan indicating the need for assistance with grooming. Resident #314 had diagnoses including schizophrenia, alcohol abuse, and neutropenia, and was documented as moderately cognitively impaired, requiring supervision for personal hygiene and moderate assistance for bathing. Despite this, the resident was observed on multiple occasions with unclean nails while eating, which was acknowledged by the Certified Nurse Aide, Licensed Practical Nurse, and Registered Nurse as an infection control issue. The Director of Nursing also stated that staff were expected to perform basic activities of daily living, such as nail care, based on each resident's care plan, and emphasized the risk of infection from debris under nails while eating.
Failure to Implement Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident, leading to an injury. The incident involved a resident with diagnoses including diabetes mellitus, paraplegia, and traumatic brain injury, who had moderate cognitive impairment. The resident required assistance for wheelchair mobility and was care planned to have a calf support and bilateral extending leg rests when in their wheelchair. However, on the day of the incident, the Certified Nurse Aide (CNA) assigned to the resident did not utilize the calf board as per the care plan, resulting in the resident's foot falling off the wheelchair pedal and sustaining an injury to their toe. The incident occurred when the resident was self-propelling their wheelchair, and their foot fell off the pedal, causing the toenail on their big toe to become dislodged and bleed. The CNA admitted to not being aware of the requirement for a calf board and did not check the care plan posted in the resident's room before assisting them. The investigation revealed that the calf board was not present in the resident's room on the day of the incident, which was a violation of the care plan. Interviews with staff, including the Director of Rehab Services, LPN, and RN, confirmed that the calf board was not in place at the time of the incident, and the injury could have been prevented if the care plan had been followed. The staff were expected to read and follow the care plan, and the failure to do so resulted in the resident's injury. The Director of Nursing acknowledged the care plan violation and emphasized the importance of following care plans to prevent injuries.
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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 Buffalo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Catherine Laboure Health Care Center | 1 mi | ★★★★★ | 5 | 0 |
| Humboldt House Rehabilitation And Nursing Center | 1 mi | ★★★★★ | 28 | 1 |
| Delaware Oaks Center For Rehabilitation And Nursin | 2.1 mi | ★★★★★ | 2 | 0 |
| Buffalo Center For Rehabilitation And Nursing | 2.3 mi | ★★★★★ | 5 | 0 |
| Highpointe On Michigan Health Care Facility | 2.5 mi | ★★★★★ | 2 | 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.