Terrace Post Acute
Terrace Post Acute in VAN NUYS, CA — inspection on August 19, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 8/10/2025, the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired.
The MDS further indicated that Resident 1 needed supervision from staff with eating, oral hygiene and personal hygiene and maximum assistance from staff with toileting hygiene, shower or bathing and lower body dressing.
During a review of Resident 1's H&P dated 8/8/2025, the H&P did not include any documentation indicating that Resident 1's PA assessed Resident 1's mental status.
During a concurrent interview and record review on 8/19/2025 at 4:25 p.m., with the Director of Nursing (DON), the DON reviewed Resident 1's H&P dated 8/8/2025.
The DON stated that Resident 1's H&P was incomplete and that PA should have included a mental status assessment.
The DON further stated that the resident's mental status is critical as a baseline when developing an appropriate plan of care.
During a review of the facility's policy and procedures (P&P) titled Physician Services and Visit, last reviewed on 1/16/2025, indicated, Physician services include, but are not limited to the resident's attending physician participation in the resident's assessment and care planning, monitoring changes in resident's medical status, and providing consultation or treatment when called by the Facility, including but not limited to resident evaluations including a written report of a physical examination with 5 days prior to admission or within 72 hours following admission, Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.