Deficiencies per Year
8
6
4
2
0
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Biennial Survey
Census: 55
Capacity: 62
Deficiencies: 7
Oct 21, 2025
Visit Reason
The inspection was a biennial survey to assess compliance with the Assisted Housing Program Licensing Rule for Residential Care Facilities.
Findings
The facility was found non-compliant with multiple provisions including inadequate training of unlicensed assistive personnel on diabetes management and breathing apparatus use, improperly labeled medications, expired and discontinued medications not removed from use, failure to discard perishable foods within required timeframes, lack of routine maintenance in interior areas, and failure to have heating systems inspected and tagged annually.
Severity Breakdown
Class III: 4
Class II: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Unlicensed assistive personnel were not trained by a registered nurse in diabetes management for 2 of 6 employee records reviewed. | Class III |
| Medication was incorrectly labeled for 1 of 5 resident records reviewed. | Class III |
| Discontinued medication was not taken out of service and locked separately for 1 of 5 resident records reviewed. | Class III |
| Breathing apparatus training was not completed for 2 of 6 staff who assisted a resident with a hand-held bronchodilator. | — |
| Perishable foods were not discarded within 4 days of preparation. | Class II |
| Facility failed to show routine maintenance in interior areas; lint accumulation observed around dryer venting duct. | — |
| Heating systems were not tagged as inspected within the past 12 months. | Class III |
Report Facts
Employee records reviewed: 6
Resident records reviewed: 5
Medication administration dates: 4
Medication administration dates: 1
Medication administration dates: 3
Medication administration dates: 1
Total capacity: 62
Current census: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Loriman Looke | Administrator | Named as Administrator of the facility |
Inspection Report
Biennial Survey
Census: 55
Capacity: 62
Deficiencies: 7
Oct 21, 2025
Visit Reason
The visit was a biennial survey conducted to assess compliance with the Assisted Housing Program Licensing Rule for The Terraces facility.
Findings
The facility was found not in compliance with several provisions related to medications and treatments, including training of unlicensed assistive personnel, medication labeling, expired medications, breathing apparatus training, food storage, and physical plant standards. Multiple deficiencies were identified and plans of correction were implemented.
Severity Breakdown
Class III: 3
Class II: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Unlicensed assistive personnel were not trained by a registered professional nurse in the management of persons with diabetes. | Class III |
| Improperly labeled medications for 1 of 5 resident records reviewed. | Class III |
| Expired and discontinued medications were not removed from use and properly destroyed. | Class III |
| Failure to ensure breathing apparatus training was completed for 2 of 6 staff. | — |
| Failure to ensure perishable food was discarded within 4 days of preparation. | Class II |
| Facility failed to show routine maintenance in interior areas. | — |
| Heating systems were not tagged as inspected annually. | — |
Report Facts
Census: 55
Total Capacity: 62
Dates of training completion: Staff #2 completed training on 9/18/2025 and staff #5 on 9/24/2025
Dates of medication administration record entries: Staff #2 and #5 administered insulin on various dates in September 2025
Date of survey: Survey completion date 10/21/2025
Boiler inspection dates: Boilers inspected and tagged on 10/28/2025 and 10/29/2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Loriman Looke | Administrator | Named as Administrator and involved in confirmation of findings and corrective actions |
Inspection Report
Complaint Investigation
Capacity: 62
Deficiencies: 0
Dec 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation for The Terraces, a Level IV Residential Care Facility, under complaint investigations 2024-AHP-39394 and 2024-AHP-39353.
Findings
The facility was found to be in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV Residential Care Facilities and Infection Prevention and Control.
Complaint Details
Complaint investigations 2024-AHP-39394 and 2024-AHP-39353 were conducted; the facility was found in substantial compliance.
Inspection Report
Biennial Survey
Census: 46
Capacity: 62
Deficiencies: 2
Nov 1, 2023
Visit Reason
The inspection was a biennial survey to assess compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs for a Level IV Residential Care Facility.
Findings
The facility was found not in substantial compliance due to deficiencies in resident rights related to confidentiality and medication labeling. Specifically, three of four resident records lacked current written consent for release of information, and one medication container was incorrectly labeled.
Severity Breakdown
Class IV: 1
Class III: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Three out of four resident records did not contain a current written consent to release information. | Class IV |
| One medication container had incorrect labeling that did not match the physician's order. | Class III |
Report Facts
Resident records reviewed: 4
Residents without current consent: 3
Medication labeling errors: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Loriman Looke | Administrator | Named as Administrator and involved in exit interview confirming findings |
| Director of Residential Care | Interviewed and confirmed findings related to resident records | |
| CRMA | Confirmed medication labeling finding during survey |
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