General Information: TERRACE AT FLEMING ISLAND, THE
Nursing home name TERRACE AT FLEMING ISLAND, THE
Address1125 FLEMING PLANTATION BLVD
ORANGE PARK, FL 32003
Phone number (904) 213-8338
Located within a hospital No
Type of ownership For profit - Corporation
Owner operates multiple homesNo
Accept Medicare or Medicaid Medicare and Medicaid
Continue Care Retirement CommunityNo
Resident and family councils Both
Certified number of beds 108
Total number of residents 106
Perc of occupied beds 98
Sprinkler status Yes
Number of Facility Reported Incidents0
Number of Substantiated Complaints0
Number of Fines0
Total Amount of Fines$0
Total Number of Penalties0
Total Number of Penalties0
Ratings Summary: TERRACE AT FLEMING ISLAND, THE
Overall rating 5
5
Nursing Home Staffing 4
4
Registered Nurses only 3
3
Health Inspections 4
4
Quality Measures 5
5
Nursing Home Staffing Info: TERRACE AT FLEMING ISLAND, THE
National AverageFlorida AverageTERRACE AT FLEMING ISLAND, THE
Overall staff rating NA NA 4
4
Registered Nurses only rating NANA 3
3
Total Number of Residents NA NA 106
Total Number of Nurse Staff Hours per Resident per Day 4.11 hours 4.46 hours 3.83 hours
Total Number of Licensed Nurse Staff Hours per Resident per Day 1.64 hours 1.67 hours 1.2 hours
Registered Nurses Hours per Residents per Day 0.81 hours 0.71 hours 0.55 hours
Licensed Practical or Vacation Nurses Hours per Resident per Day 0.83 hours 0.96 hours 0.65 hours
Certified Nursing Assistants Hours per Residents per Day 2.47 hours 2.78 hours 2.63 hours
Physical Therapy Staffing Hours per Resident Per Day 0.1 hours 0.13 hours 0.05 hours
Health Survey: TERRACE AT FLEMING ISLAND, THE
Heath Survey Summary on 2013-12-19
Total Number of Health Deficiencies 2
Scope and Severity of most Severe Health Deficiency Isolated/Minimal harm or potential for actual harm
Heath Survey Summary on 2012-11-01
Total Number of Health Deficiencies 5
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Heath Survey Summary on 2011-08-04
Total Number of Health Deficiencies 5
Scope and Severity of most Severe Health Deficiency Isolated/Minimal harm or potential for actual harm
Health Survey Details: TERRACE AT FLEMING ISLAND, THE
Inspection Results: 12/19/2013
Corrected Deficiency Scope and Severity
01/19/2014 Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated/Minimal harm or potential for actual harm
01/19/2014 Provide care by qualified persons according to each resident's written plan of care. Isolated/Minimal harm or potential for actual harm
Inspection Results: 11/01/2012
Corrected Deficiency Scope and Severity
12/01/2012 Have a program that investigates, controls and keeps infection from spreading. Isolated/Minimal harm or potential for actual harm
12/01/2012 Store, cook, and serve food in a safe and clean way. Isolated/Minimal harm or potential for actual harm
12/01/2012 Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated/Minimal harm or potential for actual harm
12/01/2012 Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Isolated/Minimal harm or potential for actual harm
12/01/2012 Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern/Minimal harm or potential for actual harm
Inspection Results: 08/04/2011
Corrected Deficiency Scope and Severity
09/04/2011 Conduct initial and periodic assessments of each resident's functional capacity. Isolated/Minimal harm or potential for actual harm
09/04/2011 Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated/Minimal harm or potential for actual harm
09/04/2011 Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated/Minimal harm or potential for actual harm
09/04/2011 Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated/Minimal harm or potential for actual harm
09/04/2011 Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. Isolated/Minimal harm or potential for actual harm

Fire Safety Survey: TERRACE AT FLEMING ISLAND, THE
Fire Safety Survey Summary on 2013-12-19
Total Number of Fire SafetyDeficiencies 0
Scope and Severity of most Severe Health Deficiency
Fire Safety Survey Summary on 2012-10-31
Total Number of Fire SafetyDeficiencies 3
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Fire Safety Survey Summary on 2011-08-04
Total Number of Fire SafetyDeficiencies 0
Scope and Severity of most Severe Health Deficiency
Fire Safety Survey: TERRACE AT FLEMING ISLAND, THE
Fire Safety Survey Results: 10/31/2012
Corrected Deficiency Severity
12/01/2012 Properly installed electrical wiring and equipment. Pattern/Minimal harm or potential for actual harm
12/01/2012 Heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Pattern/Minimal harm or potential for actual harm
12/01/2012 Record of quarterly fire drills for each shift under varying conditions. Isolated/Minimal harm or potential for actual harm

Resident Complaints: TERRACE AT FLEMING ISLAND, THE
Date Complaint Substantiated: 09/21/2012
CorrectedCategoryDeficiencySeverity
10/21/20121) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. D

Quality Measures: TERRACE AT FLEMING ISLAND, THE
Quality Measures National Average Florida Average TERRACE AT FLEMING ISLAND, THE
Overall quality rating NA NA 5
5
Long-Stay Residents
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased 15.4% 13.2% 8.6%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain 8.3% 5.9% 6.3%
Percent of High Risk Long Stay Residents With Pressure Ulcers 6.1% 6.3% 7.2%
Percent of Long Stay Residents Who Lose Too Much Weight 7.2% 7.9% 3.8%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder 43.9% 48.1% 17.2%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder 3.2% 2.8% 1.6%
Percent of Long Stay Residents With a Urinary Tract Infection 6.2% 7.1% 3.0%
Percent of Long Stay Residents Who Have Depressive Symptoms 6.3% 2.7% 0.0%
Percent of Long Stay Residents Who Were Physically Restrained 1.4% 1.9% 6.6%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury 3.2% 2.6% 3.3%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine 92.7% 91.8% 98.5%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 94.3% 95.1% 100.0%
Percent of Long Stay Residents Who Received an Antipsychotic Medication 20.7% 21.7% 29.5%
Short-Stay Residents
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain 19.2% 16.7% 5.0%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened 1.2% 0.8% 0.0%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine 83.4% 84.8% 91.6%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 82.4% 86.6% 98.2%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication 2.6% 3.2% 0.4%

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