The Terrace at Beverly Lake

Facility failed to document necessary care, services, and interventions in negotiated service agreements for 3 of 4 sampled residents, leaving them at risk for unmet needs and worsening health conditions.

The licensee failed to notify DOH Construction Review Services prior to renovating 16 common area bathrooms and to make the required payment for the review process.

The licensee failed to ensure one staff member completed First Aid training within 30 days of hire.

The licensee failed to investigate and document appropriate measures to prevent future falls, when three residents had falls. This is a recurring citation.

The facility failed to investigate and document appropriate measures to prevent future falls for 3 out of 3 residents who experienced falls, placing them at risk for harm.

Electrical outlets without faceplates in hallway near 206 and in RCC office.

Missing annual fire door inspection documentation; attic access open; fire doors propped open.

Missing documentation for required smoke detector sensitivity testing.

Laundry fire extinguisher not properly mounted.

Missing documentation for sprinkler system inspection, 3-year dry trip test, annual forward flow test, and quarterly inspections.

Facility is unable to provide documentation for the monthly carbon monoxide detector testing.

Fire extinguisher near laundry obstructed by storage.

Facility cannot provide documentation for the completion of twelve planned and unannounced fire drills in the previous 12 months.

Damaged power-strip in 2nd floor nursing office.

No documentation for annual fire resistance rated construction material inspection.

Facility is unable to provide documentation for the monthly 30 second activation test for the emergency lights.

Deficiencies in fire alarm inspection not corrected; missing monthly single station smoke alarm testing documentation.

Missing monthly and annual maintenance documentation for fire extinguishers.

No instructions posted within 6 feet of keypads for fire exits near the lobby and in the dining room.

Missing documentation for semi-annual kitchen suppression system servicing.

Facility is unable to provide documentation for the weekly inspections and Monthly 30 minute full load testing.

Manual pull station near basement elevator obstructed.

Exit sign hanging by wires in basement classroom.

Facility is unable to provide documentation for the annual 90 minute power test for the emergency lights.

Multiple fire-rated doors (2nd floor living room, near 214, room 114, near 113) failed to latch.

Combustible material stored against gas water heater in basement equipment room.

The licensee failed to ensure one staff member completed First Aid training within 30 days of hire. This is an uncorrected deficiency from June 23, 2025 and a recurring deficiency from April 23, 2025.

The licensee failed to ensure the Department of Health (DOH) Construction Review Services (CRS) reviewed plans prior to renovating 16 common area bathrooms. This is an uncorrected deficiency from June 23, 2025 and a recurring deficiency from April 23, 2025.

Facility failed to maintain a clean and safe environment in 8 common bathrooms and 1 hallway. Observations included dust, dried colored fluids, trash without bags, used tissues, and unconsumed food in common areas.