Terrace Post Acute
Inspection Findings
F-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure a resident on morphine sulfate (strong pain medication used to treat moderate to severe pain) was not administered the medication after it had expired for one of three sampled residents (Resident 1).This deficient practice resulted in Resident 1 receiving a medication after its expiration date and had the potential for the medication to be ineffective.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on [DATE REDACTED] with diagnoses that included quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs) and hypotension (low blood pressure- condition where the force of blood against the artery walls is lower than normal). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated [DATE REDACTED], the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 1 was totally dependent on staff with eating, oral hygiene, toileting hygiene, and personal hygiene.During a review of Resident 1's Order Summary Report, the Order Summary Report indicated an order for morphine sulfate oral solution 10 milligrams/5 milliliters (mg/mL- units of measurement), give five (5) ml by mouth every eight (8) hours as needed for leg/knee pain give for severe pain level 7-10/10 (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain), ordered [DATE REDACTED].During a concurrent observation and interview on [DATE REDACTED] at 2:25 p.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 1's morphine sulfate bottle. LVN 1 stated that Resident 1's morphine sulfate expired on [DATE REDACTED].During a review of Resident 1's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 7/2025, the MAR indicated morphine sulfate was administered to Resident 1 on [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED].During a concurrent interview and record review on [DATE REDACTED] at 3:26 p.m., with the Director of Nursing (DON), reviewed Resident 1's MAR for 7/2025. The DON stated Resident 1 was administered morphine sulfate on [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED]. The DON stated that morphine sulfate should not have been administered because Resident 1's morphine sulfate expired on [DATE REDACTED]. The DON stated that before licensed nurses administer any medication, licensed nurses should always check the expiration date of all medications being administered. The DON stated if licensed nurses find that a medication is expired during medication administration, the medication found to be expired should be removed from the medication cart and reordered from the pharmacy. The DON stated the expired medication should not be administered to the residents because an expired medication may not have the potency the medication needs to be effective.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, review date [DATE REDACTED], the policy indicated medications are administered in
a safe and timely manner, and as prescribed. The expiration/beyond use date on the medication label is checked prior to administering.
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.