Terrace Post Acute: Incomplete Medical Exam at Admission - CA
The resident, identified in inspection records only as Resident 1, arrived at the facility on August 7, 2025, with three serious diagnoses: a broken left femur, respiratory failure, and metabolic encephalopathy, a condition in which the brain cannot function properly because the body's metabolism has broken down. Three days later, a federally mandated assessment tool confirmed what anyone reading the admission chart might have anticipated: the resident's cognition was moderately impaired. That same resident needed staff supervision to eat, brush their teeth, and manage personal hygiene. They needed maximum physical assistance to bathe, use the toilet, and dress their lower body.
The physician assistant had completed a History and Physical on August 8, one day after admission. The H&P is the document that is supposed to serve as the foundation for everything that follows, the diagnosis, the treatment plan, the coordination of care between departments. It contained no mental status assessment. None.
Inspectors reviewed the record on August 19 alongside the facility's Director of Nursing. The director looked at the H&P and said it was incomplete. The director went further: a resident's mental status is critical as a baseline when developing an appropriate plan of care.
That statement, offered by the facility's own top nursing official, is the clearest summary of what went wrong. The person responsible for overseeing nursing care at Terrace Post Acute confirmed, without apparent dispute, that the document guiding this resident's care was missing a piece the director described as critical.
The inspection was a complaint survey, meaning someone had contacted regulators about conditions at the facility before inspectors arrived. CMS classified the violation at the lowest level of harm, minimal harm or potential for actual harm, and noted that only a few residents were affected. Inspectors reviewed three residents' records and found the problem in one of them.
The practical consequences of a missing mental status baseline are not abstract. When a care team doesn't document where a resident's cognition starts, they have no reliable way to detect whether it declines. A resident with metabolic encephalopathy can improve as the underlying metabolic problem is treated, or they can worsen. Tracking that trajectory requires knowing where the person began. Without a documented baseline, a decline can look like stability, and a change that warrants immediate medical attention can go unnoticed until it becomes something worse.
Resident 1 needed help with nearly every basic function. That level of dependence, combined with moderate cognitive impairment and a brain condition linked directly to metabolic disruption, made a thorough mental status assessment at admission more urgent, not less. The physician assistant who completed the H&P left it out anyway.
The facility's own written policy, last reviewed in January 2025, required a physical examination with a written report either within five days before admission or within 72 hours after. The H&P was completed within that window. It was the contents of the exam, not its timing, that fell short.
What the inspection record does not say is whether anyone caught the omission before August 19, whether Resident 1's care plan was adjusted after the gap was identified, or whether the resident's condition changed during the nearly two weeks between admission and the inspection visit. Those answers are not in the report. What is in the report is that a resident arrived with a broken bone, failing lungs, and a brain that wasn't working properly, and the document meant to guide their care skipped the part about the brain.
The Director of Nursing, reviewing the record on the afternoon inspectors came to the facility, confirmed it should have been there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terrace Post Acute from 2025-08-19 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Terrace Post Acute in VAN NUYS, CA was cited for violations during a health inspection on August 19, 2025.
That same resident needed staff supervision to eat, brush their teeth, and manage personal hygiene.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.