Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 22, 2025
Visit Reason
The document is a plan of correction following a survey ending November 19, 2025, indicating acceptance of a credible allegation of substantial compliance.
Findings
The facility was certified in compliance effective December 11, 2025, based on acceptance of the plan of correction and substantial compliance. No specific deficiencies are detailed in this document.
Report Facts
Survey end date: Nov 19, 2025
Certification effective date: Dec 11, 2025
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 3
Nov 19, 2025
Visit Reason
The inspection was conducted as an annual recertification survey from November 17 through November 19, 2025, to assess compliance with federal regulations.
Findings
The facility was found deficient in multiple areas including accuracy of resident assessments, menu and nutritional adequacy, and food procurement and storage practices. Deficiencies involved inaccurate medication coding on Minimum Data Set assessments, failure to serve appropriate portions for modified diets, and improper labeling and dating of food items in storage.
Severity Breakdown
E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to accurately code medications on Minimum Data Set assessments for multiple residents. | E |
| Failure to serve appropriate portion sizes for pureed oatmeal and mechanical soft sausage for residents on modified diets. | E |
| Failure to properly label and date food stored in refrigerator, freezer, and dry goods storage areas. | E |
Report Facts
Resident census: 38
Residents reviewed for MDS accuracy: 15
Residents with inaccurate medication coding: 4
Modified diet residents with portion issues: 4
Food items improperly stored or labeled: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Named in findings related to food portion sizes, food storage, and corrective actions |
| Director of Nursing | Director of Nursing (DON) | Named in findings related to medication coding and corrective actions |
| Staff A | Observed preparing food during meal service related to portion size deficiency | |
| Staff B | Dietary Cook | Interviewed regarding preparation of pureed and mechanical soft diets |
| Administrator | Provided statement about MDS assessments process |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 21, 2024
Visit Reason
The document is a Plan of Correction submitted by the facility following a prior inspection, indicating acceptance of substantial compliance and certification effective October 10, 2024.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, resulting in certification of compliance effective October 10, 2024.
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 1
Oct 3, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey between September 30, 2024 and October 3, 2024.
Findings
The facility failed to notify the Office of the State Long-Term Care Ombudsman of a hospital transfer for one resident, violating notice requirements before transfer or discharge. The facility acknowledged the deficiency and implemented corrective actions including staff re-education and policy review.
Severity Breakdown
SS=B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify the Ombudsman of a hospital transfer for one resident as required by federal regulations. | SS=B |
Report Facts
Census: 38
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed failure to report hospital transfer and involved in re-education and corrective actions | |
| Admissions/Social Services Nurse | Re-educated on proper process for notifying Ombudsman of resident transfers and discharges | |
| Administrator | Provided explanation regarding lost reporting process and responsible for overall compliance |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 14, 2024
Visit Reason
An investigation of facility reported incident #121319-I was conducted from August 13, 2024 through August 14, 2024.
Findings
The facility was found in substantial compliance at the time of the investigation.
Complaint Details
Investigation was related to a facility reported incident #121319-I; the facility was found in substantial compliance.
Report Facts
Incident number: 121319
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 14, 2023
Visit Reason
An on-site revisit of the survey ending June 29, 2023 was conducted from August 09, 2023 to August 14, 2023 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility was found to be in substantial compliance effective August 01, 2023. The Denial of Payment for New Admits (DPNA) was not effectuated.
Inspection Report
Renewal
Census: 36
Deficiencies: 5
Jun 29, 2023
Visit Reason
The inspection was conducted as part of the facility's Recertification Survey and investigation of a Facility Self-Reported Incident #107684-I from June 26, 2023 to June 29, 2023.
Findings
The facility was found deficient in multiple areas including timely completion and submission of Minimum Data Set (MDS) assessments, care plan timing and revision, quality of care related to assessment and intervention following a resident injury, prevention and treatment of pressure ulcers, and free of accident hazards. The facility reported a census of 36 residents during the survey.
Complaint Details
The visit included investigation of a Facility Self-Reported Incident #107684-I which was substantiated.
Severity Breakdown
SS=D: 4
SS=G: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure timely completion and submission of MDS assessments for residents. | SS=D |
| Failure to update Care Plans to accurately reflect resident conditions including code status, antidepressant use, and pressure ulcers. | SS=D |
| Failure to assess and intervene appropriately following a resident injury during wheelchair transport. | SS=D |
| Failure to prevent an unstageable pressure ulcer from forming on a resident's heel requiring debridement and causing increased pain. | SS=D |
| Failure to ensure safe transport of residents in wheelchairs resulting in injury to a resident's leg. | SS=G |
Report Facts
Census: 36
Residents reviewed for assessment: 12
Residents reviewed for accident/injury: 12
Residents reviewed for pressure ulcers: 1
Residents reviewed for accident hazards: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nurse Aide (CNA) | Named in findings related to resident injury and pain management. |
| Staff H | Licensed Practical Nurse (LPN) | Named in findings related to resident injury assessment and reporting. |
| Staff J | Certified Nurse Aide (CNA) | Named in findings related to resident injury and wheelchair transport. |
| Staff B | Registered Nurse (RN) | Named in findings related to resident vital signs and infection control. |
| Director of Nursing (DON) | Interviewed regarding MDS completion expectations and pressure ulcer prevention. | |
| Admissions Coordinator | Interviewed regarding MDS completion timing and care plan updates. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 3, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and demonstrate compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective June 3, 2022.
Inspection Report
Re-Inspection
Census: 30
Deficiencies: 6
May 4, 2022
Visit Reason
The inspection was a Recertification Survey and investigation of multiple substantiated complaints and a facility self-reported incident conducted from April 25, 2022 to May 4, 2022.
Findings
The facility was found deficient in multiple areas including notice requirements before transfer/discharge, coordination of PASARR and assessments, development and implementation of comprehensive care plans, professional standards for services provided, psychotropic medication use, and food procurement and safety. The facility submitted plans of correction addressing these deficiencies.
Complaint Details
Complaints #91265-C, #92968-C, #97163-C, #98254-C, #100959-C were substantiated. Facility Self-Reported Incident #102083-1 was substantiated.
Severity Breakdown
SS=B: 1
SS=D: 2
SS=G: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Notice Requirements Before Transfer/Discharge not met as facility failed to notify the Long-Term Care Ombudsman for resident transfers and discharges. | SS=B |
| Coordination of PASARR and Assessments not met as facility failed to complete PASARR evaluations timely for residents with mental health diagnoses. | SS=D |
| Develop/Implement Comprehensive Care Plans not met as facility failed to complete follow-up assessments and care plans for residents at risk for falls and mental health conditions. | SS=D |
| Services Provided Meet Professional Standards not met due to failure to follow bowel monitoring protocol and wound treatment orders. | — |
| Free from Unnecessary Psychotropic Meds/PRN Use not met as facility failed to ensure PRN psychotropic medications had appropriate physician face-to-face evaluations and stop dates. | SS=G |
| Food Procurement, Store/Prepare/Serve-Sanitary not met as facility failed to maintain sanitary conditions and proper food storage and labeling. | — |
Report Facts
Deficiencies cited: 6
Census: 30
Completion date for plan of correction: Jun 3, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Responsible for notifying the LTC Ombudsman of hospitalizations and discharges. |
| Director of Nursing | Director of Nursing (DON) | Named in findings related to PASARR coordination, care plan development, psychotropic medication monitoring, and wound care. |
| Staff C | MDS Coordinator | Involved in care planning and fall prevention interventions. |
| Staff E | Dietary Aide | Involved in facility investigation related to resident injury. |
| Staff F | Certified Nursing Assistant (CNA) | Involved in facility investigation related to resident injury. |
| Staff G | Registered Nurse (RN) | Involved in facility investigation and pain medication administration. |
| Culinary Director | Culinary Director | Named in findings related to food safety and sanitation. |
Inspection Report
Abbreviated Survey
Census: 51
Deficiencies: 0
Nov 19, 2020
Visit Reason
A focused COVID-19 infection control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 51
Inspection Report
Abbreviated Survey
Census: 35
Deficiencies: 0
Jun 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 6/16/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Renewal
Census: 31
Deficiencies: 3
Feb 6, 2020
Visit Reason
The inspection was a recertification survey conducted from February 3 to February 6, 2020, to assess compliance with federal regulations for Terrace Glen Village.
Findings
The facility failed to complete comprehensive assessments after significant changes for 2 of 12 residents reviewed and failed to update care plans accordingly. Additionally, the facility did not provide services meeting professional standards for 1 of 12 residents. No negative outcomes or adverse effects were reported.
Severity Breakdown
Level B: 2
Level D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to complete a comprehensive assessment after a significant change for 2 of 12 residents reviewed. | Level B |
| Facility failed to update the comprehensive care plan for 2 of 12 residents reviewed. | Level B |
| Facility failed to provide services that met professional standards of quality for 1 of 12 residents reviewed. | Level D |
Report Facts
Residents reviewed: 12
Census: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luha | Executive Director | Signed the initial comments section of the report |
| Director of Nursing | Interviewed regarding care plan expectations and deficiencies |
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