Pennsylvania Department of Health
TERRACE HEALTH & REHAB CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

TERRACE HEALTH & REHAB CENTER
Inspection Results For:

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TERRACE HEALTH & REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on a revisit survey completed on September 1, 2026, it was determined that Terrace Health and Rehab Center corrected the deficiencies cited during the survey of July 23, 2026, under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities, however, has three continuing deficiencies under the requirements of the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of the facility's staffing worksheet and staff interview, it was determined that the facility failed to provide one Nurse Assistant (NA) per 10 residents on the daylight shift for two of six days (8/25/26 and 8/30/26) and one NA per 11 residents on the evening shift for five of six days (8/25/26, 8/27/26 through 8/30/26) as required.
Findings include:

A review of the facility's staffing worksheet for the time period of 8/25/26 through 8/30/26, revealed the following:
Daylight Shift
Date Census Actual Hours Hours Required
8/25/25 105 69.25 78.75
8/30/25 102 72.00 76.50
Evening Shift:
Date Census Actual Hours Hours Required
8/25/26 105 65.50 71.59
8/27/26 100 60.45 68.18
8/28/26 103 58.00 70.23
8/29/26 103 67.00 70.23
8/30/26 102 60.00 69.55
During an interview on 9/1/26 at 11:00 a.m., the Nursing Home Administrator confirmed that the facility failed to provide NA's on the above dates as required.

Plan of Correction - To be completed: 09/28/2026

The Staffing Coordinator/DON reviewed current census against nurse aide schedules and adjusted staffing assignments/shifts to meet the required ratios effective immediately, utilizing agency/pool staff to fill open shifts as needed.
DON/Administrator reviewed nurse aide staffing data across all shifts and units facility-wide to confirm the current compliance status.
The facility will implement an active nurse aide recruitment plan, including sign-on incentives, expanded advertising, partnership with local CNA training programs, and employee referral bonuses.
The Staffing Coordinator/Designee will audit daily nurse aide staffing ratios against census daily times 4 weeks, reporting compliance to the QAPI Committee for any further recommendations as necessary.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on a review of the facility's staffing worksheet and staff interview it was determined that the facility failed to provide one Licensed Practical Nurse (LPN) per 25 residents on the daylight shift for three of six days (8/28/26 through 8/30/26) and one LPN per 30 residents on the evening shift on one of six days (8/28/26)as required.
Findings include:

A review of the facility's staffing worksheet for the time period of 8/25/26, through 8/30/26, revealed the following:
Daylight shift
Date Census Actual Hours Hours Required
8/28/26 103 24.50 32.96
8/29/26 103 32.00 32.96
8/30/26 102 32.00 32.64
Evening shift
Date Census Actual Hours Hours Required
8/28/26 103 23.75 27.47
During an interview on 9/1/26 at 11:00 a.m. the Nursing Home Administrator confirmed that the facility failed to provide LPN's on the above days as required.

Plan of Correction - To be completed: 09/28/2026

DON/Staffing Coordinator reviewed and adjusted LPN schedules and assignments to meet required ratios effective immediately, utilizing agency LPN staff to fill open shifts as needed.
DON/Administrator reviewed LPN staffing data across all shifts and units facility-wide to confirm the current compliance status.
The facility implemented an active LPN recruitment plan, including sign-on incentives, expanded advertising, and employee referral bonuses.
The Staffing Coordinator/Designee will audit daily LPN staffing ratios daily times 4 weeks with results reported to the QAPI Committee, for any further recommendations as necessary.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of the facility's staffing worksheet and staff interview, it was determined that the facility failed to provide the minimum amount of 3.2 direct care hours per resident (PPD) on two of six days (8/25/26 and 8/30/26) as required.
Findings include:
A review of the facility's staffing worksheet for the time period of 8/25/26/26, though 8/30/26/26, revealed the following
8/25/26= 3.13 PPD.
8/30/26= 3.11 PPD.
During an interview of 9/1/26, at 11:00 a.m. the Nursing Home Administrator confirmed that the facility failed to provide the minimum 3.2 hours of direct resident care per resident on the above dates as required.

Plan of Correction - To be completed: 09/28/2026

DON/Staffing Coordinator recalculated required hours per resident day(HPPD) based on current census and adjusted the overall combined RN/LPN/CAN nursing schedule to meet the 3.2 HPPD minimum effective immediately.
Administrator/DON reviewed total combined nursing hours against daily census facility-wide for the full review period and on an ongoing basis to confirm HPPD compliance.
Developed a comprehensive staffing plan incorporating combined RN/LPN/CNA hours to ensure the 3.2 HPPD minimum is met daily, factoring in census fluctuations, with contingency coverage (agency, overtime, float pool) built into the plan.
Added a daily HPPD calculation to the daily staffing report reviewed by the Administrator/DON each morning, with an escalation protocol for any day trending below 3.2 HPPD.

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