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 The Terrace Transitional during CMS and state inspections, most recent first.
A resident with a history of thoracic vertebra fracture and other conditions experienced a delay in care after complaining of leg numbness and weakness. Despite initial exams showing no abnormalities, the resident later reported paralysis, which was not communicated to the provider. The resident was eventually sent to the ER with severe symptoms and diagnosed with serious conditions, highlighting a lapse in timely notification and response.
The facility failed to provide sufficient support personnel for food and nutrition services, resulting in delayed and cold meals for residents. Observations showed meals were served later than scheduled, with residents expressing dissatisfaction. The Dietary Manager suggested nursing staff delays, but observations indicated meals left the kitchen late. The administrator expected meals to be served within a 5-10 minute window of posted times, which was not achieved.
The facility did not follow its abuse prevention policy by failing to verify the licenses of two staff members before they began working with residents. Employee 1, a Nursing Assistant, started work without any record of license verification, while Employee 2, a CNA, had their license verified months after starting. Interviews with HR and the Administrator revealed inconsistencies in the verification process, with no explanation for the delays.
The facility was found to have insufficient nursing staff, resulting in delayed responses to call lights and unmet resident needs. Observations and interviews revealed that residents experienced long wait times for assistance, particularly during night shifts and weekends. Staff acknowledged the challenges of staffing shortages, with some being asked to work overtime. Resident council minutes also highlighted concerns about staffing levels and care quality.
The facility failed to provide timely and accurate laboratory services for three residents, leading to deficiencies in meeting their medical needs. A resident did not have a urinalysis completed as ordered, while another experienced multiple issues with laboratory tests not being performed, including TSH and Valproic Acid levels. A third resident faced delays in completing TSH and Lipid Panel tests, with no follow-up order for a TSH recheck as required.
The facility failed to provide palatable and properly heated meals to residents, with multiple complaints about bland, overcooked, and cold food. Observations confirmed the lack of a heating system during meal delivery, and resident council notes documented ongoing dissatisfaction. Despite new kitchen staff, issues persisted.
The facility failed to maintain an effective infection control program, as observed in improper medication handling by an RN and multiple instances of CNAs neglecting hand hygiene during meal services. A resident received medication touched by bare hands, and CNAs were seen handling meal trays and assisting residents without washing hands, despite being trained to do so.
A resident with multiple health issues was transferred to a hospital after a fall, but the facility failed to document the transfer in the medical record or communicate necessary information to the hospital. The resident returned with diagnoses of altered mental status and vertebral compression fractures. An interview revealed that required transfer documentation was not provided.
The facility failed to provide written information about the bed-hold policy to two residents during hospital transfers. One resident with multiple diagnoses was hospitalized after showing concerning symptoms, and another was transferred following a fall. In both cases, the bed-hold documentation was not found in their medical records, despite claims that it was sent with them.
A resident with multiple medical conditions was observed being pulled backwards in a shower chair, covered in towels with exposed buttocks, through a hallway by a CNA. The resident expressed this was not usual practice, preferring to be fully dressed post-shower. The DON confirmed this was not standard practice, highlighting a failure to maintain resident dignity.
The facility breached confidentiality by leaving computer screens open and a nurse report exposed on medication carts, revealing resident information. An LPN and an RN left screens unattended in the 200 hallway, and a nurse report was left face up for 15 minutes. The DON confirmed that such actions are against protocol.
A LTC facility failed to provide adequate supervision for two residents, leading to deficiencies. One resident, identified as a high elopement risk, left the facility unattended despite having a wander guard and lacked a smoking assessment. Another resident experienced an unwitnessed fall without receiving necessary neurological checks. The facility's policies on elopement and smoking were not effectively implemented, contributing to these deficiencies.
A resident with chronic pain and multiple health conditions did not receive prescribed gabapentin due to a missing prescription, leading to unmanaged severe pain. Despite having a care plan, the facility failed to ensure the medication was available, relying instead on alternative pain management methods.
Two residents in an LTC facility experienced medication management deficiencies. One resident received blood pressure medication outside of physician-ordered parameters due to staff confusion. Another resident missed multiple doses of Abilify and Torsemide due to dialysis scheduling conflicts, and was administered insulin outside prescribed parameters. Staff interviews confirmed these issues.
The facility failed to ensure proper storage and labeling of medications. An insulin vial exceeded its expiration date, and a glargine insulin pen lacked an open date. A nurse administered medication from a bubble pack that had been improperly taped back. Additionally, an intravenous antibiotic was left unattended on a medication cart. The DON confirmed these practices were against protocol.
A facility failed to establish an antibiotic stewardship program, leading to a deficiency in monitoring antibiotic use. A resident with recurrent UTIs was prescribed prophylactic antibiotics, but staff were unaware of the specific reasons for the prescription, and there was no supporting documentation from a urologist. Interviews revealed a lack of clarity and communication regarding the antibiotic regimen, highlighting the facility's failure to implement a comprehensive program.
Delay in Care for Resident with Leg Paralysis
Penalty
Summary
A delay in care was identified for a resident who complained of leg numbness and weakness. The resident, who had a history of a wedge compression fracture of the thoracic vertebra, multiple rib fractures, muscle weakness, cognitive communication deficit, and schizophrenia, was admitted to the facility and later discharged with these diagnoses. On June 26, 2024, a provider conducted a cranial nerve and neurological exam due to the resident's complaints of being unable to move or feel their legs, but no abnormalities were noted at that time. However, on June 29, 2024, licensed practical nurses documented the resident's complaints of lower extremity paralysis, but there was no evidence that the provider was informed of this change in condition. The situation escalated when, on June 30, 2024, a registered nurse documented that the resident was seen by a provider and sent to the emergency room due to hypoxia, nausea, and new onset paralysis of the lower extremities. The resident was diagnosed with cauda equina compression, epidural abscess, and osteomyelitis of the thoracic vertebra during a five-day hospital admission. Interviews with the facility's administrator and nurse practitioner revealed a lack of documentation regarding the resident's condition on June 29, 2024, and uncertainty about the resident's symptoms. The nurse practitioner noted that the resident's condition worsened suddenly, leading to the decision to send them to the hospital, but there was no prior notification of the change in condition.
Insufficient Support Personnel in Food and Nutrition Services
Penalty
Summary
The facility was found to have insufficient support personnel to effectively manage the food and nutrition services, leading to delays in meal service and resident dissatisfaction. Surveyors observed that meals were consistently served later than the posted meal times, with residents receiving their food cold. Multiple resident complaints were documented, both through direct interviews and in resident council notes, indicating that meals were not served hot and were often delayed. Specific observations noted that meal service in the dining room and hallways did not align with the scheduled times, with significant delays in serving residents in different halls. Interviews with residents and staff further highlighted the issue, with residents expressing dissatisfaction with the temperature and timing of their meals. The Dietary Manager claimed that meals were delivered from the kitchen on time, suggesting that delays might be due to nursing staff being behind on passing trays. However, observations contradicted this claim, showing that meals left the kitchen after the scheduled times. The facility administrator acknowledged the expectation for meals to be served within a 5-10 minute window of the posted times, which was not being met.
Failure to Verify Employee Licenses Before Resident Interaction
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents. Specifically, the facility did not adhere to its abuse policy by failing to screen prospective employees' licenses before they began working with residents. This deficiency was identified in the cases of two staff members. Employee 1, a Nursing Assistant, was hired and began working without any record of their license being checked to verify that a previous license had not been obtained. Employee 2, a Certified Nursing Assistant, had their license verified several months after starting work, contrary to the facility's policy. Interviews with the Human Resources (HR) department and the Administrator (ADM) revealed inconsistencies in the verification process. The HR department stated that license or certification verification was supposed to be completed upon hire and before employees worked with residents. However, there was no proof of license verification for Employee 1, and Employee 2's license was verified months after they started working. The ADM confirmed that the HR department was responsible for verifying licenses and that this should occur before employees accessed computers or worked with residents. The ADM was unable to explain why the verification process was delayed or incomplete for these employees.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of its residents, as evidenced by observations, interviews, and record reviews. Specifically, call lights were observed to be unanswered for extended periods, with some residents waiting up to 30 minutes or more for assistance. This delay in response was noted across multiple rooms and times, indicating a systemic issue rather than isolated incidents. Residents expressed dissatisfaction with the long wait times, particularly during night shifts and weekends, when staffing appeared to be more strained. Interviews with residents revealed a consistent pattern of complaints regarding the timeliness of staff responses to call lights. Several residents reported waiting for assistance with personal care needs, such as changing wet briefs, which were not addressed promptly, leading to discomfort and distress. The residents also noted that the staff seemed overworked and unable to provide adequate care, with some residents resorting to calling the front desk for help when call lights went unanswered. Staff interviews corroborated the residents' concerns, with several staff members acknowledging the challenges posed by staffing shortages. Registered nurses and CNAs reported being asked to work overtime and cover additional shifts due to the lack of sufficient staff. The absence of management during weekends further exacerbated the issue, as staff struggled to manage the workload and respond to residents' needs in a timely manner. The facility's resident council minutes also highlighted ongoing concerns about staffing levels and the impact on care quality, particularly during night shifts.
Deficiencies in Laboratory Services for Residents
Penalty
Summary
The facility failed to provide timely and accurate laboratory services for three residents, leading to deficiencies in meeting their medical needs. Resident 58, who was admitted with multiple diagnoses including bipolar disorder and a history of urinary tract infections, did not have a urinalysis with culture and sensitivity completed as ordered by the physician. Despite the order being marked as completed, the results were not found, and the Director of Nursing (DON) was unable to locate the lab results or relevant progress notes. Resident 22, with a complex medical history including hypothyroidism and epilepsy, experienced multiple issues with laboratory tests not being performed. A TSH test was not rechecked after an initial low result, and subsequent orders for CBC, CMP, and Valproic Acid levels were not completed due to issues such as insufficient specimens and incorrect tubes being sent to the laboratory. Despite attempts to notify the physician, there were no new orders or follow-ups to ensure the tests were completed. Resident 34, who had diagnoses including type 1 diabetes and Alzheimer's disease, also faced issues with laboratory orders not being completed in a timely manner. Orders for TSH and Lipid Panel tests were repeatedly not completed as scheduled, and there was a delay in collecting and reporting the results. Additionally, there was no follow-up order for a TSH recheck six weeks after the initial tests, as should have been done according to the facility's policy.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at an appetizing temperature for 10 out of 36 sampled residents. Multiple residents reported dissatisfaction with the quality of the food, citing issues such as blandness, overcooked meals, and food that was either too spicy or not served hot. Specific complaints included diarrhea and constipation linked to certain meals, and some residents resorted to having food brought in from outside the facility. Observations confirmed that meals were served without the use of a heating pellet system, which is intended to keep food warm during delivery. The facility's resident council notes from March to August 2024 consistently documented complaints about cold food and other issues such as items being out of stock. A test tray revealed that the food did not match the menu description and was of poor quality, with the meat being dry and chewy and the vegetables overcooked. Interviews with the Dietary Manager and the facility administrator highlighted that the pellet system was not consistently used, and there were logistical issues with the return of trays and availability of pellets. Despite recent efforts to improve food quality with new kitchen staff, the deficiency persisted.
Infection Control Deficiencies in Medication Handling and Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by two main deficiencies. Firstly, a registered nurse (RN) was observed handling medication improperly by touching a pill with bare hands after it was taped back into a bubble pack, and then administering it to a resident. The RN acknowledged the error, stating that the medication should have been discarded instead of being given to the resident. The Director of Nursing (DON) was unaware of this practice and confirmed that medications should not be taped back into bubble packs. Secondly, during meal services, multiple instances of improper hand hygiene were observed among certified nursing assistants (CNAs). CNAs were seen handling meal trays and assisting residents without performing hand hygiene before and after these tasks. This included touching food items, delivering trays, and assisting residents without washing hands, even when enhanced barrier precautions were required. Interviews with CNAs revealed that they were trained to perform hand hygiene in these situations, yet failed to adhere to these protocols during the observed meal services.
Lack of Transfer Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to ensure proper documentation and communication during the transfer of a resident to a hospital. Specifically, for one resident, there was no transfer documentation in the medical record when the resident was transferred to the hospital. The resident, who had multiple diagnoses including neuropathy, asthma, and cognitive communication deficit, was found on the floor by a roommate after reportedly hitting her head. Emergency medical services were called, and the resident was transported to the hospital. Upon return from the hospital, the resident was diagnosed with altered mental status and compression fractures of the L5 and T12 vertebrae. An interview with the Corporate Resource Nurse revealed that typically, a face sheet, a list of medications, and a copy of the bed hold agreement should accompany a resident during a transfer. However, there was no information available regarding the transfer of this particular resident, indicating a lapse in the facility's protocol for documenting and communicating necessary information during resident transfers.
Failure to Provide Bed-Hold Policy Information
Penalty
Summary
The facility failed to provide written information to residents or their representatives regarding the duration of the state bed-hold policy during hospital transfers or therapeutic leaves. This deficiency was identified for two residents out of a sample of 36. Resident 56, who had multiple diagnoses including hemiplegia and type 2 diabetes, was transported to the hospital after exhibiting symptoms such as slurred speech and drowsiness. Despite the Corporate Resource Nurse's claim that a bed-hold form was included in the paperwork sent to the hospital, no such documentation was found in the resident's medical record. Similarly, Resident 8, with diagnoses including hereditary neuropathy and major depressive disorder, was transferred to the hospital after a fall that resulted in a compression fracture. The Corporate Resource Nurse stated that a packet containing the bed-hold agreement was given to EMS, but it was not returned with the resident from the hospital. In both cases, the absence of documentation in the medical records indicates a failure to comply with the requirement to inform residents or their representatives about the bed-hold policy.
Resident Dignity Compromised During Transport
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as observed during a survey. A resident, who had been admitted with multiple diagnoses including hemiplegia, type 2 diabetes, and cognitive communication deficit, was seen being pulled backwards in a shower chair by a CNA. The resident was covered in towels, with the sides of her buttocks exposed, as she was moved through the hallway. This incident occurred despite the resident's care plan indicating a need for staff assistance with bathing due to her medical conditions. During an interview, the resident expressed that this was the first time she had been transported in such a manner and stated a preference to be fully dressed after her shower before returning to her room. The CNA involved mentioned that it was common practice to transport residents covered in towels to prevent their clothes from getting wet. However, the Director of Nursing clarified that it was not standard practice for residents to be wheeled through the hallway in towels with sensitive areas exposed, indicating a deviation from the facility's expected procedures.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records for four out of 36 sampled residents. On multiple occasions, staff members left computer screens open on medication carts, exposing resident information. Specifically, an LPN left a computer screen open and unattended in the 200 hallway, with residents nearby. Similarly, an RN left a computer screen open while attending to a resident in a room, with another resident walking by the cart. Additionally, a nurse shift report containing resident information was left face up and unattended on a medication cart for 15 minutes, with a resident walking in the vicinity. The Director of Nursing acknowledged that computer screens should be locked when unattended and that resident information should not be left exposed.
Inadequate Supervision and Policy Implementation in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two residents. Resident 185, who was identified as a high risk for elopement, managed to leave the facility unattended despite having a wander guard. The resident had a history of attempting to leave the facility and had expressed a strong desire to leave, even threatening to exit through a window. Despite interventions such as verbal consent for a wander guard and education on safety, the resident was able to remove the wander guard multiple times. On one occasion, the resident left the facility with a friend and did not return until later that night, prompting a police search. The resident's care plan did not include a smoking assessment, and there was no care plan addressing smoking, despite the resident being a smoker. Another resident, Resident 59, experienced an unwitnessed fall and did not receive the necessary neurological checks afterward. The resident had a history of falls and was assessed as a high risk for falls. Despite this, after a fall in the shower, there were no neurological assessments documented in the resident's medical record. The facility's policy required neurological assessments for unwitnessed falls, but this was not followed in this case. The facility's policies on elopement and smoking were not adequately implemented, leading to these deficiencies. The elopement policy required individualized care plans and interventions for high-risk residents, which were not effectively executed for Resident 185. Similarly, the smoking policy required assessments and care plans for residents who smoked, which were not completed for Resident 185. These oversights contributed to the residents' unsafe situations and the facility's failure to prevent accidents.
Failure to Provide Prescribed Medication for Pain Management
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically by not ensuring the availability of gabapentin for a resident with chronic pain. The resident, who had a history of acute on chronic combined systolic and diastolic heart failure, type 2 diabetes mellitus, morbid obesity, reduced mobility, and muscle weakness, was not administered gabapentin as prescribed on two occasions. The medication was not available because a prescription was needed from the pharmacy, as noted in the nursing progress notes. Interviews with the resident and staff revealed that the resident experienced severe pain, rated 10 out of 10, which disrupted her sleep and daily activities. Despite having a care plan in place to manage chronic pain, the resident did not receive the prescribed gabapentin, which was intended to manage her neuropathy. Other pain management interventions, such as cyclobenzaprine and a Lidocaine patch, were used, but the lack of gabapentin administration was a significant oversight in her care.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs, as evidenced by the administration of blood pressure medication outside of physician-ordered parameters for one resident and missed medication doses for another. Resident 22, who had multiple diagnoses including hypertension and schizophrenia, was administered Propranolol despite blood pressure readings being outside the specified parameters. Interviews with nursing staff revealed confusion and lack of understanding regarding the specific parameters, leading to improper administration of the medication. Resident 34, with diagnoses including type 1 diabetes and end-stage renal disease, missed multiple doses of Abilify and Torsemide due to being absent from the facility for scheduled dialysis. The facility failed to adjust medication administration times to accommodate the resident's dialysis schedule. Additionally, Resident 34 was administered insulin outside of the prescribed parameters, indicating a lack of adherence to physician orders. Interviews with facility staff, including the Corporate Resource Nurse, confirmed these deficiencies. The CRN acknowledged that the facility did not follow the insulin parameters and failed to communicate with the physician to adjust medication schedules for Resident 34. These actions and inactions led to the identified deficiencies in medication management for the residents involved.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the safe and secure storage of drugs and biologicals, as well as proper labeling in accordance with accepted professional principles. During an inspection of the medication cart in the 100 hallway, a Lispro insulin vial was found with an open date exceeding the 28-day expiration period, and a glargine insulin pen lacked an open or expiration date. A Registered Nurse (RN) acknowledged the oversight, stating that opened insulin should be discarded after 28 days. Additionally, a medication bubble pack was observed to have medication taped back in, which was then administered to a resident. The RN involved admitted that medications should not be taped back into bubble packs and should be discarded instead. Further observations revealed an intravenous antibiotic ball left unattended on top of the medication cart. The Director of Nursing (DON) confirmed that medications should not be left unattended at any time. These findings indicate lapses in medication management and storage protocols, which were acknowledged by the nursing staff and the DON during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. This deficiency was identified during a review of the care provided to a resident who was prescribed prophylactic antibiotics. The resident, who had a history of recurrent urinary tract infections (UTIs), was on antibiotic therapy as part of their care plan. However, staff were not aware of the specific reasons for the prophylactic antibiotic prescription, nor was there documentation from a urologist to support the use of Keflex for this purpose. Interviews with the Director of Nursing and the Corporate Resource Nurse revealed a lack of clarity and communication regarding the initiation of the antibiotic regimen. The Director of Nursing acknowledged the resident's history of recurrent UTIs but was unable to provide details about the last occurrence. The Corporate Resource Nurse was uncertain about which provider initiated the Keflex prescription and noted the absence of information from a urologist. This lack of awareness and documentation highlights the facility's failure to implement a comprehensive antibiotic stewardship program, leading to the deficiency noted in the report.
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 86 citations issued within 25 miles in the last 12 months — including the 2 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 Ogden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mt Ogden Health And Rehabilitation Center | 0 mi | ★★★★★ | 0 | 0 |
| Stonehenge Of Ogden | 1 mi | ★★★★★ | 0 | 0 |
| South Ogden Post-acute (cascades At South Ogden) | 1.1 mi | ★★★★★ | 14 | 0 |
| Mountain View Health Services | 1.7 mi | — | 14 | 1 |
| Pine View Transitional Rehab | 1.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Terrace Transitional.
100% money-back within 48 hours.
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.