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 Gardens during CMS and state inspections, most recent first.
Late quarterly MDS assessments were identified for four residents. An LPN verified that the assessments for residents with significant cognitive impairment and multiple medical diagnoses were completed after the required timeframe, including residents with dementia, diabetes, stroke history, behavioral symptoms, and other complex conditions. The RAI Manual 3.0 requires quarterly assessments to be completed every 92 days and within 14 days of the ARD.
Delayed Completion of MDS Assessments: The facility failed to complete timely MDS assessments for three residents. One resident with severe cognitive impairment and extensive dependence for ADLs had an annual MDS left incomplete beyond the required timeframe, and two admitted residents with significant medical diagnoses and varying levels of cognitive and functional impairment also had admission MDS assessments started but not finished on time. An MDS nurse verified the delayed completion for all three residents.
Late completion of significant change MDS assessments. Three residents had significant changes in condition, including ADL decline and hospice enrollment, but the MDS assessments were completed after the required timeframe. One resident had severe cognitive impairment with extensive ADL dependence, another had dementia and hospice election, and a third had MS, malnutrition, and hospice admission; an LPN verified the assessments were completed late.
Failure to conduct quarterly care conferences for three residents. A resident with multiple chronic conditions, another resident with MS and malnutrition, and a third resident with CVA-related hemiplegia and multiple cardiac and pulmonary diagnoses had only limited documented care conferences despite MDS findings showing significant assistance needs; the LSW verified the incomplete conference records.
Staff did not follow enhanced barrier precautions during incontinence and wound care for a resident with multiple wounds. Both a CNA and an LPN failed to wear gowns during high-contact care activities, despite facility policy requiring gown and glove use for residents with chronic wounds.
A resident was inappropriately administered Adderall for sleep apnea, a non-recognized use, leading to fatigue and therapy participation issues. The medication was initially given in the evening, causing increased exhaustion. After family concerns, the administration time was changed to the morning with an indication for ADHD. Staff interviews confirmed the inappropriate use and administration timing.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to timely complete quarterly MDS assessments for four residents out of 24 reviewed. Resident #44 had diagnoses including paraplegia, vascular dementia, cognitive communication deficit, type II diabetes mellitus, acute respiratory failure with hypoxia, major depressive disorder, delusional disorder, anxiety disorder, and a complete traumatic amputation between the left hip and knee. The resident’s quarterly MDS had an ARD of 03/03/25 and was completed on 03/18/25, and an LPN verified that it was completed late. Resident #76 had diagnoses including Alzheimer’s disease, depression, type II diabetes mellitus, a fracture of the lower end of the right radius, and major depressive disorder. That resident’s quarterly MDS had an ARD of 04/11/25 and was completed on 04/28/25, which the LPN also verified was late. Resident #14 had diagnoses including Alzheimer’s disease, vascular dementia, psychotic disorder with delusions due to a known physiological condition, type II diabetes mellitus, cerebral infarction, unspecified mood disorder, and anxiety disorder. The quarterly MDS for this resident had an ARD of 10/27/25 and a completion date of 11/11/25, and the LPN verified it was completed late. Resident #09 had diagnoses including encephalopathy, aphasia, dysarthria and anarthria, orthostatic hypotension, hypertension, atrial fibrillation, cerebral infarction, anxiety disorder, depression, type two diabetes mellitus without complications, vascular dementia, and heart failure. The quarterly MDS dated 11/13/25 was not completed until 12/01/25, and the MDS nurse verified the assessment was not completed until that date. The RAI Manual 3.0 states quarterly assessments must be completed every 92 days and within 14 days from the ARD.
Delayed Completion of MDS Assessments
Penalty
Summary
The facility failed to timely complete comprehensive MDS assessments for three residents. Resident #04 was admitted with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction, intractable epilepsy, aphasia following cerebral infarction, anemia, hypertension, cerebral infarction, encephalopathy, depression, type 2 diabetes mellitus, hyperlipidemia, hypertensive heart disease, and chronic respiratory failure with hypoxia. The annual MDS assessment was started but not completed until more than two weeks later. The resident was identified as having severely impaired cognition and was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility, and transfer. An MDS nurse verified that the annual assessment was not completed until the later date. Resident #07 was admitted with diagnoses including type 2 diabetes mellitus with skin ulcer, cellulitis, unspecified dementia, cerebrovascular disease-related cognitive symptoms, major depressive disorder, anxiety, Alzheimer's disease, chronic kidney disease, congestive heart failure, acute respiratory failure with hypoxia, ischemic cardiomyopathy, malnutrition, metabolic encephalopathy, hypothyroidism, hyperlipidemia, and peripheral vascular disease. The admission MDS assessment was started but not completed until several days later. The resident was cognitively intact and required varying levels of assistance, including supervision for eating, oral hygiene, and personal hygiene; substantial/maximal assistance for toileting, bathing, and lower body dressing; and partial/moderate assistance for upper body dressing, bed mobility, and transfer. Resident #81 was admitted with diagnoses including type 2 diabetes mellitus with ketoacidosis, cerebral infarction, hyperlipidemia, hypertension, acute kidney failure, edema, and chronic kidney disease. The admission MDS assessment was started but not completed until several days later. The resident had moderately impaired cognition and required supervision for eating, oral hygiene, and personal hygiene; partial/moderate assistance for toileting, bathing, upper body dressing, and bed mobility; and substantial/maximal assistance for lower body dressing and transfer. An MDS nurse verified the completion dates for both residents.
Late completion of significant change MDS assessments
Penalty
Summary
The facility failed to timely complete significant change MDS assessments for three residents when changes in condition were identified. Resident #48 had diagnoses including encephalopathy, dysphagia, aphasia, cognitive communication deficit, dementia, muscle weakness, chronic pulmonary embolism, and diabetes insipidus, and the record showed a significant change MDS was required because of a decline in several ADLs. That assessment had an ARD of 05/09/25 and was not completed until 05/26/25. An LPN verified that the assessment was completed late. Resident #05 had diagnoses including Alzheimer's disease, dementia, cognitive communication deficit, anxiety disorder, aphasia, vascular dementia, metabolic encephalopathy, and major depressive disorder. The record showed hospice services were elected, which triggered a significant change MDS; the assessment had an ARD of 01/05/26 and a completion date of 01/19/26. Resident #11 had diagnoses including non-active primary progressive multiple sclerosis, dysuria, protein-calorie malnutrition, hypothyroidism, hyperlipidemia, hypertension, anemia, and depression. Hospice admission effective 12/17/25 triggered a significant change MDS with a completion date of 01/14/26, and the assessment was not completed within 14 days of identifying the change as required by the RAI Manual 3.0.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conferences for three residents reviewed for care conferences. Medical record review and staff interview showed that Resident #02, admitted 08/01/22 with diagnoses including type 2 diabetes mellitus, major depressive disorder, hypertension, histoplasmosis, hypothyroidism, hyperlipidemia, anemia, obesity, tachycardia, peripheral vascular disease, PTSD, anxiety disorder, heart failure, and obstructive sleep apnea, had only three documented care conferences: 02/22/25, 08/25/25, and 02/18/26. The quarterly MDS assessment showed the resident was cognitively intact and required varying levels of assistance with eating, oral hygiene, dressing, toileting, bathing, personal hygiene, bed mobility, and transfer. LSW #603 verified the limited care conference documentation. Resident #11, admitted 09/09/22 with diagnoses including non-active primary progressive multiple sclerosis, dysuria, protein-calorie malnutrition, hypothyroidism, hyperlipidemia, hypertension, anemia, depression, and bilateral cataract extraction status, had only two documented care conferences: 06/24/25 and 09/18/25. The significant change MDS showed the resident was cognitively intact and required supervision for eating and oral hygiene, substantial/maximal assistance for dressing, personal hygiene, and bed mobility, and was dependent for toileting, bathing, and transfer. Resident #68, admitted 10/29/22 with diagnoses including cerebral infarction, left-sided hemiplegia and hemiparesis, epilepsy, atrial fibrillation, depression, hypertension, atherosclerotic heart disease, sleep apnea, BPH, non-Hodgkin lymphoma, acute pulmonary edema, hyperlipidemia, COPD, cardiomyopathy, and takotsubo syndrome, had only two documented care conferences: 02/22/25 and 07/03/25. The quarterly MDS showed the resident was cognitively intact and required assistance with eating, oral hygiene, bed mobility, toileting, dressing, personal hygiene, and transfer. LSW #603 verified the documented care conferences for both residents.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were followed during incontinence and wound care for a resident with multiple wounds. The resident, who had chronic kidney disease, depression, and a history of transient ischemic attack, was always incontinent of bowel and bladder and required substantial assistance with activities of daily living. Despite being on EBP due to multiple wounds, there were no physician orders for EBP in the resident's medical record. During observed incontinence care, a CNA did not apply a gown as required by EBP protocols. Additionally, during a subsequent wound care procedure, an LPN also failed to wear a gown while treating a wound that had been contaminated by a bowel movement. Both staff members confirmed in interviews that they did not use gowns during these high-contact care activities. Facility policy and best practice guidelines reviewed indicated that gown and glove use is required for residents with chronic wounds during high-contact care, such as dressing, bathing, hygiene, and wound care, but these protocols were not followed in the observed instances.
Inappropriate Administration of Adderall for Sleep Apnea
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, as evidenced by the administration of Adderall without an adequate indication for use. A resident was admitted with multiple diagnoses, including cerebral infarction, ADHD, anxiety disorder, congestive heart failure, and obstructive sleep apnea. The resident was prescribed Adderall, a central nervous system stimulant, with an indication for sleep apnea, which is not a recognized use for this medication. The medication was initially administered in the evening, leading to increased fatigue and difficulty participating in therapy sessions. Interviews with facility staff, including the administrator and pharmacist, confirmed that Adderall was inappropriately administered in the evening and that sleep apnea was not a valid indication for its use. The resident's family expressed concerns, prompting a change in the administration time to the morning and a subsequent change in the indication to ADHD. Despite these changes, the resident continued to experience symptoms of exhaustion and activity intolerance, which were reported to nursing staff. The deficiency was identified during a complaint investigation, highlighting non-compliance with regulations regarding unnecessary medications.
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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 Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridgetown Nursing And Rehabilitation Centre | 0.9 mi | ★★★★★ | 33 | 0 |
| Hillebrand Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Covenant Village Care Center | 1.7 mi | ★★★★★ | 6 | 0 |
| Edith Lane Of Cincinnati | 2 mi | ★★★★★ | 4 | 0 |
| Aventura At West Park | 2 mi | ★★★★★ | 2 | 0 |
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