Terrace Post Acute
Inspection Findings
F-Tag F0711
F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Based on interview and record review, the facility failed to ensure that a resident's physician assistant (PA a licensed healthcare professional who practices medicine on a team with physicians) completed a comprehensive History and Physical (H&P - a formal comprehensive assessment by a healthcare professional that involves a resident interview, physical examination and documentation of findings. The H&P serves as the foundation for diagnosing a resident's condition, formulating a treatment plan, and guiding subsequent medical care.) Examination for one of three sampled residents (Resident 1) by failing to include an assessment of mental status (assessment of a resident's mental capacity which includes cognition, mood behavior and perceptions). This deficient practice resulted in an incomplete evaluation of
the residents' overall condition, had the potential for inconsistent care coordination due to incomplete H&P and a delay in care and services.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 8/7/2025 with diagnoses that included nondisplaced intertrochanteric fracture of left femur (a break in the upper part of the of the left thigh bone), respiratory failure (a life threatening medical condition where your lungs can't get enough oxygen into the blood or remove enough carbon dioxide from the blood, preventing body organs from functioning properly) and metabolic encephalopathy (a condition where the brain cannot function properly because of a problem with
the body's metabolism [the process by which your body converts food and drinks into energy]). 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 REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Terrace Post Acute in VAN NUYS, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in VAN NUYS, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Terrace Post Acute or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.