Inspection Report Summary
The most recent inspection on October 4, 2024, identified deficiencies related to care planning, treatment according to physician orders, medical record accuracy, and infection prevention practices. Earlier inspections showed similar issues with treatment and care consistency, medical record delays, infection control, medication storage, and food safety. Inspectors cited recurring themes in resident care coordination, documentation, and infection control measures. Complaint investigations were not listed in the available reports. The pattern of findings suggests ongoing challenges with care and documentation, with no clear improvement trend over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 4
Date: Oct 4, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, treatment, medical record accuracy, infection prevention, and care planning at Terrace Healthcare & Rehabilitation Center.
Findings
The facility was found deficient in developing comprehensive care plans for residents, ensuring treatment and care according to physician orders, maintaining accurate resident records, and implementing proper infection prevention and control practices including hand hygiene and use of personal protective equipment.
Deficiencies (4)
Failed to develop a comprehensive care plan for 1 of 4 residents reviewed for skin conditions, Resident #3.
Failed to ensure residents received treatment and care according to physician orders for 1 of 4 residents reviewed for skin condition, Resident #374, and for 1 of 3 residents reviewed for pain management, Resident #116.
Failed to ensure resident records were complete and accurate for 1 of 4 residents reviewed for skin conditions, Resident #374.
Failed to ensure staff performed hand hygiene while providing wound care for 1 of 4 residents reviewed for skin conditions, Resident #76, and failed to ensure staff used appropriate PPE while providing high-contact care for 1 of 6 residents reviewed, Resident #274.
Report Facts
Deficiencies cited: 4
Medication doses: 4
Wound care dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Wound Care Licensed Practical Nurse (LPN) | Interviewed regarding Resident #3's skin tears and hand hygiene practices during wound care. |
| Staff C | MDS and Care Plan Coordinator | Interviewed regarding Resident #3's care plan deficiencies. |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding wound care, medication administration errors, documentation inaccuracies, and infection control practices. |
| Staff A | Licensed Practical Nurse (LPN), Unit Manager | Observed and interviewed regarding failure to use PPE during IV tubing adjustment for Resident #274. |
| Infection Preventionist | Interviewed regarding staff compliance with gown use and hand hygiene. |
Inspection Report
Deficiencies: 1
Date: Apr 26, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding residents' access to their medical records, following a complaint about delayed provision of medical records for Resident #1.
Findings
The facility failed to provide copies of medical records in a timely manner for 1 of 3 residents reviewed, specifically Resident #1. Interviews and record reviews confirmed delays and communication issues in processing the medical records request.
Deficiencies (1)
Failure to ensure residents received copies of their medical records in a timely manner for 1 of 3 residents reviewed.
Inspection Report
Routine
Deficiencies: 6
Date: Jun 7, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, treatment, medication administration, infection control, and food safety at Terrace Healthcare & Rehabilitation Center.
Findings
The facility failed to provide appropriate treatment and care according to physician orders for multiple residents, including wound care, respiratory care, medication storage, food safety, and infection prevention. Documentation deficiencies and failure to follow physician orders were noted for wound care, oxygen administration, and use of compression stockings and podus boots. Food safety violations included unlabeled and improperly thawed food and uncovered food during transport. Infection control lapses included improper catheter bag placement.
Deficiencies (6)
Failure to provide treatments, wound care, and services according to physician orders for 4 of 8 residents.
Failure to provide safe and appropriate respiratory care consistent with professional standards for oxygen administration for 3 of 7 residents.
Failure to store medications under proper temperature for 1 of 4 medication carts.
Failure to ensure stored food is labeled and dated, thawed according to professional standards, and food is distributed safely.
Failure to maintain complete and accurate medical records for 7 of 12 residents.
Failure to prevent possible spread of infection related to improper catheter bag placement for 1 of 3 residents.
Report Facts
Residents affected: 4
Residents affected: 3
Medication carts observed: 4
Residents affected: 7
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Verified Resident #18's order for ace wraps and stated lack of application. |
| Director of Nursing (DON) | Acknowledged failure to follow orders for ace wraps, dressing changes, oxygen tubing changes, and compression stockings. | |
| Staff C | Licensed Practical Nurse (LPN) | Confirmed Resident #113 was not wearing compression stockings and should be. |
| Staff F | Noticed improperly stored Vancomycin bag in medication cart. | |
| Consultant Pharmacist | Confirmed Vancomycin must be refrigerated. | |
| Dietary Manager (DM) | Confirmed food safety violations including thawing and uncovered food during transport. | |
| Staff J | LPN Wound Care Nurse | Acknowledged documentation problems with wound care. |
| Staff N | Licensed Practical Nurse | Confirmed catheter bag was on floor without protective barrier. |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 6, 2023
Visit Reason
The inspection was conducted to assess compliance with nurse staffing posting requirements as part of a routine regulatory oversight visit.
Findings
The facility failed to ensure nurse staffing information was posted daily as required. Observations and interviews confirmed that staffing information was not posted over the weekend, contrary to facility policy.
Deficiencies (1)
Failed to post nurse staffing information daily as required by facility policy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding nurse staffing posting requirements. | |
| Staffing Coordinator | Interviewed regarding nurse staffing posting practices. |
Inspection Report
Routine
Deficiencies: 4
Date: Jan 21, 2022
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, medication storage, respiratory care, wound care, and food service in the nursing home.
Findings
The facility failed to provide appropriate wound care for residents, ensure continuous oxygen therapy as ordered, properly label and store medications including insulin and eye drops, and maintain proper food storage and distribution practices.
Deficiencies (4)
Failed to ensure residents received treatment and care for wounds in accordance with professional standards for 2 of 4 residents reviewed for skin conditions.
Failed to provide safe and appropriate respiratory care for a resident who needed oxygen therapy consistent with physician orders.
Failed to ensure drugs and biologicals were labeled and stored in accordance with professional principles, including expiration dates, in 6 of 7 medication carts.
Failed to ensure food was stored, distributed, and served in accordance with professional standards for food service.
Report Facts
Residents reviewed for skin conditions: 4
Total residents in sample: 54
Medication carts inspected: 7
Dressing change documentation gap: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Practical Nurse (LPN) | Stated lack of knowledge about dressing orders for Resident #113 |
| Director of Nursing (DON) | Stated expectation that staff complete physician orders for wound care and nursing staff should complete wound care as ordered | |
| Medical Doctor (MD) | Recommended dressing changes and antibiotics for Resident #113, noted wound deterioration | |
| Staff G | Licensed Practical Nurse (LPN) | Stated Resident #69's dressings were changed daily if time permitted |
| Staff A | Licensed Practical Nurse (LPN) | Verified Resident #63 was not receiving oxygen as ordered |
| Staff B | Licensed Practical Nurse (LPN) | Reported expired insulin and eye drops on medication carts |
| Staff F | Licensed Practical Nurse (LPN) | Reported insulin and eye drops should be labeled with opened and expiration dates |
| Staff E | Licensed Practical Nurse (LPN) | Reported insulin and eye drops should be labeled and discarded when expired |
| Staff C | Licensed Practical Nurse (LPN) | Reported insulin and eye drops should be dated when opened |
| Staff D | Licensed Practical Nurse (LPN) | Reported all insulins were expired and should be discarded |
| Kitchen Manager | Acknowledged food storage and meal distribution deficiencies |
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