Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Terrace At Solarbron The during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and pressure ulcers experienced a decline in wound status, but the facility failed to notify the resident's POA representatives of the worsening coccyx wound and the development of new wounds on the left ankle and heel, despite documentation that the POAs were the primary health contacts. The facility did not have a policy for notifying representatives of changes in condition.
Two residents who were dependent on staff for bathing due to severe medical and cognitive conditions did not consistently receive or have documentation of daily bathing or showers. Care plans indicated the need for total assistance, but records showed missed or undocumented hygiene care, and there was no evidence of resident refusals. Staff confirmed that refusals should be documented, but this was not reflected in the records.
A facility failed to obtain immediate physician orders for a newly admitted resident's colostomy care. The resident, who was cognitively intact and had a colostomy, reported that while nurses provided care, CNAs were generally reluctant. Despite a care plan for ostomy care, no specific physician orders were documented, and an LPN confirmed that such orders should be established soon after admission.
The facility failed to follow infection control practices during wound care for a resident and while using a blood pressure monitor on two residents. During wound care, gloves were not changed or hands sanitized at appropriate times, putting a resident with venous ulcers at risk. Additionally, an LPN did not sanitize a blood pressure monitor between uses on two residents, contrary to facility policy requiring equipment cleaning between uses.
The facility was found to have pervasive odors, including marijuana and sewer gas, in various areas such as the Memory Care Unit and front lobby. Additionally, a resident's room had visible disrepair with dried smears and chipped paint. Despite existing cleaning protocols, these issues persisted, indicating a failure to maintain a clean and homelike environment.
A facility failed to provide a SNF-ABN and NOMNC to a resident who continued to reside in the facility after Medicare services ended. A review showed the necessary forms were not completed, and the Director of Nursing confirmed the absence of a policy for advanced beneficiary notice of non-coverage.
The facility failed to properly label medications on two medication carts. On the West Hall cart, ceftriaxone, lidocaine, and aspirin were unlabeled, while on the East Hall cart, two insulin pens lacked the resident's name. Staff confirmed the labeling errors, and the DON provided a policy outlining proper labeling requirements.
The facility failed to provide consistent bathing care to four residents, as revealed by a survey. Residents reported difficulties in receiving regular showers, and Point of Care documentation showed numerous days without recorded bathing. Grievances filed by families highlighted concerns about the lack of showers, yet inconsistencies persisted in the facility's records, with no refusals documented.
Failure to Notify Resident's POA of Wound Decline
Penalty
Summary
The facility failed to notify a resident's power of attorney (POA) representatives of a worsening pressure ulcer and the development of new wounds. The resident in question had multiple diagnoses, including paraplegia, dementia, and chronic conditions that increased the risk for skin breakdown. The care plans and clinical records indicated the resident was at high risk for pressure ulcers and had several wounds, including to the coccyx, left ankle, and left heel, with documented decline in wound status over time. Wound notes showed that the resident's husband was present and informed during some wound assessments, and the physician and spouse were notified of changes. However, there was no documentation that the resident's POA representatives, who were listed as the primary contacts for health and financial matters, were notified of the decline in the coccyx wound or the development of wounds on the left ankle and heel. The clinical record confirmed the absence of such notifications, despite the POAs being the designated representatives. During interviews, the Administrator acknowledged that the POA was not notified of the wound decline and that the facility did not have a policy regarding notification of a resident's representative about changes in condition. The lack of notification to the appropriate representatives constituted the deficiency identified in the report.
Failure to Provide and Document Daily Bathing Assistance for Dependent Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs), specifically bathing and showers, were provided and properly documented for residents who were unable to perform these tasks independently. For one resident with multiple complex medical conditions, including paraplegia, dementia, and a history of pressure ulcers, the clinical record and care plan indicated a need for total assistance with bathing. However, a review of the point of care documentation for July and August showed inconsistent entries for bathing, with several days lacking documentation of any bathing or shower, and no records indicating resident refusal. Similarly, another resident with severe cognitive impairment and total dependence for bathing had a care plan specifying preferred shower days. Documentation for July, August, and September revealed irregular entries for partial or complete bed baths and showers, with gaps in daily bathing records and no documentation of refusals. Staff interviews confirmed that refusals should be documented and reported, but no such documentation was found. The facility's policy required appropriate support and assistance with hygiene for residents unable to perform ADLs, but this was not consistently provided or recorded.
Lack of Immediate Physician Orders for Colostomy Care
Penalty
Summary
The facility failed to ensure that a newly admitted resident, identified as Resident D, had immediate physician orders for the care of a colostomy. Upon admission, Resident D, who had a colostomy and was cognitively intact, indicated that while nurses attended to his colostomy, CNAs were generally reluctant to provide care. A review of Resident D's clinical records and care plans revealed that although there was a care plan in place for ostomy care, there were no specific physician orders documented for the care of the colostomy in January and February. An LPN confirmed that orders for colostomy care should be established shortly after a resident's admission, typically requiring changes every 2 to 3 days. However, no policy was provided regarding the procedure for obtaining admitting physician orders.
Infection Control Lapses in Wound Care and Equipment Cleaning
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for Resident 33 and while using medical equipment on Residents 13 and 16. During a wound care procedure, RN 2 and LPN 10 did not change gloves after cleaning a bedside table and before handling clean dressing supplies. Additionally, gloves were not changed or hands sanitized at appropriate times during the dressing change process. Resident 33, who was cognitively intact and had venous ulcers on both legs, was at risk due to these lapses in infection control. The facility's policy required hand hygiene with alcohol-based gel before and after handling dressings and after removing gloves, which was not followed. In another instance, LPN 9 failed to sanitize a blood pressure monitor between uses on different residents. The monitor was used on Resident 13 and then placed in a bag without being cleaned. It was later used on Resident 16 without prior sanitization. The facility's policy, aligned with CDC and OSHA standards, required that resident-care equipment be cleaned and disinfected between uses, which was not adhered to in this case.
Facility Fails to Maintain Sanitary Environment and Address Odors
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by multiple observations of pervasive odors and physical disrepair. On several occasions, surveyors noted an odor consistent with marijuana in the Memory Care Unit and East Hall Nurses Station. Additionally, the front lobby was reported to smell like sewer gas, which the Director of Nursing attributed to a backed-up trap, especially during rain. Interviews with staff revealed a lack of specific policies for controlling odors, with housekeeping and maintenance expected to address these issues as they arise. However, the presence of these odors suggests that the current measures were insufficient. Further observations revealed physical disrepair in a resident's room, where dried deep red smears, missing paint chips, and scuff marks were noted along the walls. Despite daily inspections and weekly deep cleaning protocols, these issues persisted, indicating a failure to maintain cleanliness and order as outlined in the facility's policy for a homelike environment. The Director of Nursing provided a policy emphasizing the importance of minimizing institutional odors and maintaining cleanliness, yet the observed conditions contradicted these standards.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility-Advanced Beneficiary Notice (SNF-ABN) and a Notice of Medicare Non-Coverage (NOMNC) to a resident who was discharged from Medicare services but continued to reside in the skilled nursing facility. On December 6, 2024, a review of the SNF Beneficiary Protection Notification Review Forms revealed that the form was blank regarding whether the resident received the necessary SNF-ABN and NOMNC forms. The review indicated that the resident's Medicare coverage ended on August 3, 2024, but the required documents (CMS 10055 and NOMNC 10123) were not signed by the resident or their representative. On December 10, 2024, the Director of Nursing stated that the facility did not have a policy related to advanced beneficiary notice of non-coverage and relied on instructions from the Center for Medicare and Medicaid Services website.
Medication Labeling Deficiency in Facility
Penalty
Summary
The facility failed to ensure proper labeling of medications on two medication carts, leading to a deficiency. On the West Hall medication cart, a vial of ceftriaxone injection, a vial of lidocaine with an open date, and a bottle of aspirin with an open date were observed without proper labeling. The Qualified Medication Aide (QMA) indicated that the ceftriaxone and lidocaine were removed from the Emergency Drug Kit (EDK) and should have had the resident's name written on them. The aspirin, brought in by a family member, also lacked the resident's name. On the East Hall medication cart, two insulin pens, Lantus Solostar and Humalog Kwikpen, were found with open dates but without the resident's name. The Licensed Practical Nurse (LPN) confirmed that these insulin pens belonged to a resident and should have been labeled accordingly. The Director of Nursing (DON) provided a Medication Labeling policy that outlined the requirements for labeling, which were not adhered to in these instances.
Failure to Provide Consistent Bathing Care
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care, specifically bathing, to four residents, as identified during a survey. Resident L reported difficulties in receiving regular showers, with inconsistencies noted in the Point of Care (POC) documentation for May, June, and July 2024. Despite a grievance filed by the family in June 2024, indicating that showers were not being done, the facility's records showed numerous days where no bathing was documented, and there was only one recorded refusal. Resident N, who resides in a locked dementia unit and is non-interviewable, also experienced lapses in bathing care. The POC history for May, June, and July 2024 revealed several days without recorded bathing, and a grievance from the family in May 2024 highlighted concerns about the lack of showers. Despite the grievance, the documentation continued to show gaps in bathing care, with no refusals noted in the clinical record. Resident Q and Resident P also faced similar issues with bathing care. Resident Q's records showed inconsistencies in the POC documentation, with several days lacking any recorded bathing. A grievance from Resident Q's family in May 2024 addressed concerns about shower schedules, yet the documentation did not reflect consistent care. Resident P, who was discharged in June 2024, had a grievance filed on the day of discharge, indicating a lack of showers for two weeks. The POC history for Resident P also showed numerous days without documented bathing, and no shower sheets were observed for May 2024.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Evansville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West River Health Campus | 1 mi | — | 1 | 0 |
| Park Terrace Village | 2.5 mi | — | 1 | 0 |
| River Bend Nursing And Rehabilitation | 4.4 mi | — | 23 | 0 |
| Parkview Care Center | 5.7 mi | — | 24 | 0 |
| Brickyard Healthcare - Woodbridge Care Center | 6.3 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.