Main Street Terrace Care Center

Inspectors wroteBased on record review, review of policy, interview with the State Long Term Care Ombudsman and staff interview, the facility failed to notify the state long term care ombudsman of the transfer and/or discharge of three residents. This affected three (#60, #61, and #62) of three residents sampled for discharges/ hospitalizations. The facility census was 50.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure daily nurse staffing information was posted. This had the potential to affect 50 of 50 residents residing in the facility. The facility census was 50.

Inspectors wroteBased on observation, interview, and review of service report and email, the facility failed to maintain a clean stove hood in the kitchen. This had the potential to affect all 45 residents residing in the facility. The facility census was 45.

Inspectors wroteBased on closed record review, interview, and review of the facility's Beneficiary Notices, the facility failed to provide notification to residents and/or representative within 48 hours. This affected one resident, (#53), of three residents reviewed for Beneficiary Notification. The facility census was 45.

Inspectors wroteBased on record review, interview, review of a facility Self-Reported Incident (SRI), review of December 2025 In-service Sign Off, and review of the facility's Resident Safety policy, the facility failed to complete resident abuse in-service reeducation for an agency aide involved in an abuse allegation following the investigation. This affected one, (#06), of three residents reviewed for abuse. The facility census was 45.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure preadmission screening resident review (PASARR)'s were up dated with additional mental illness diagnoses. This affected three residents (#5, #8 and #23) of three residents reviewed for PASARR. The census was 45.

Inspectors wroteBased on record review, review of care plan, and interview, the facility failed to ensure monitoring was in place for the side effects of opioid medications. This affected one (#4) of five residents reviewed for unnecessary medications. The facility census was 45.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were provided a care conference quarterly. This affected one resident (#7) of one resident reviewed for care conferences. The facility census was 45.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure resident nebulizer equipment was stored in a safe and sanitary manner and not laying directly on their bed surface or bedside tablet. This affected two residents (Resident #01 and #23) of the three residents reviewed for oxygen. The facility census was 45.

Inspectors wroteBased on medical record review, staff interview, and observation the facility failed to ensure residents' pulse was monitored prior to administration of medication as well as pain medication had parameters in place related to the numeric pain scale. This affected two residents (#12 and #4) of the five residents reviewed for unnecessary medication. The facility census was 45.

Inspectors wroteBased on observation, food taste testing, and interview, the facility failed to prepare pureed foods in a way to maintain nutritious value and palatability. This affected three residents (#30, #35, and #42) of three residents on pureed diets. The facility census was 45.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were provided assistive devices as ordered. This affected one resident (#7) of one resident reviewed for assistive devices. The facility census was 45.

Inspectors wroteBased on medical record review, review of the facility policy, review of information from the National Pressure Ulcer Advisory Panel (NPUAP) and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer program to prevent the deterioration of a pressure ulcer for Resident #45. Actual Harm occurred on 10/03/24 when Resident #45, who was admitted to the facility with a Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) sacral pressure ulcer was assessed to have an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer with the presence of slough and necrotic tissue to the area. [...]

Inspectors wroteBased on medical record review, staff interview and review of the facility policy, the facility failed to complete comprehensive resident care plans. This affected four (Residents #9, # 15, #18, and #20) of 15 residents sampled. The facility census was 49 residents.

Inspectors wroteBased on observation, medical record review, staff interview and review of the facility policy, the facility failed to properly clean and disinfect glucometers after use. This affected one (Resident #9) of 12 facility-identified diabetic residents (#1, #7, #8, #9, #17, #19, #22, #23, #25, #27, #38, #45) who resided on the front hallway. The facility also failed to ensure staff practice proper infection control practices to prevent the potential spread of infection during wound care. This affected one (Resident #23) of one resident observed for wound care. The facility census was 49 residents.

Inspectors wroteBased on medical record review and staff interview the facility failed to notify the physician of significant weight changes for a resident with congestive heart failure and failed to notify the physician of abnormal urinalysis results. This affected two (Residents #38 and #46) of 15 residents sampled. The facility census was 49 residents.

Inspectors wroteBased on medical record review, family interview, and staff interview, the facility failed to assist all dependent residents with oral hygiene. This affected one (Resident #22) of one residents reviewed for activities of daily living (ADL) care. The facility census was 49 residents.

Inspectors wroteBased on medical record review, staff interview, and observation, the facility failed to perform regular resident blood pressure checks and failed to apply thromboembolic deterrent (TED) hose as ordered. This affected two (Resident #38 and #29) of 15 residents sampled. The facility census was 49 residents.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to assess residents for elopement risk. Additionally, the facility failed to ensure residents were properly supervised to prevent falls. This affected two (Residents #15 and #20) of six residents reviewed for accidents. The facility census was 49 residents.

Inspectors wroteBased on medical record review, observation, staff interview and manufacturer's instructions, the facility failed to ensure staff primed insulin needles prior to insulin administration. This affected one (Resident #9) of five residents observed for medication administration. The facility census was 49 residents. Findings Include: Review of the medical record for Resident #9 revealed an admission date of 03/05/24 with the diagnoses including chronic obstructive pulmonary disease, diabetes mellitus (DM), and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 09/07/24 revealed the resident had no cognitive deficit, had DM as a current diagnoses and received daily insulin injections. [...]

Inspectors wroteBased on observation, facility policy review and interview the facility failed to implement an effective infection control program and policies and procedures to prevent the spread of infection including COVID-19 in the facility. This had the potential to affect all 40 residents residing in the facility.

Inspectors wroteBased on record review, facility policy review and interview the facility failed to ensure the designated Infection Preventionist, Registered Nurse #504 worked at least part-time and was involved in the Quality Assessment and Assurance Program to report on the facility Infection Control and Prevention Program. This had the potential to affect all 40 residents residing in the facility.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure Resident #7's advance directive decision was accurately documented for staff providing care. This affected one resident (#7) of 16 residents reviewed for advance directives.

Inspectors wroteBased on observation, record review, interview and facility policy review the facility failed to ensure timely notification to the physician and resident representative related to the development of new pressure ulcer areas and/or significant weight loss. This affected two residents (#22 and #28) of two residents reviewed for notification.

Inspectors wroteBased on record review, facility policy review and interview the facility failed to provide an Advanced Beneficiary Notice (ABN) as required to Resident #12 and Resident #28 who were cut from Medicare Part A therapy services and remained in the facility. This affected two residents (#12 and #28) of three residents reviewed for beneficiary notices.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the State Long Term Care Ombudsman office was notified of facility initiated emergency transfers. This affected two residents (#44 and #45) of two residents reviewed requiring emergency transfers in the past three months.

Inspectors wroteBased on record review and staff interview the facility failed to complete a comprehensive (Minimum Data Set (MDS) 3.0) assessment within 14 days after admission. This affected one resident (#30) of 14 residents reviewed for comprehensive MDS 3.0 assessments.

Inspectors wroteBased on record review, facility policy review and interview the facility failed to ensure comprehensive care plans were developed and initiated for each resident. This affected three residents (#30, #39 and #43) of 14 residents reviewed for comprehensive care plans.

Inspectors wroteBased on observation, record review, facility policy review and interview the facility failed to ensure comprehensive care plans were revised following a change in condition for Resident #28 and Resident #32. This affected two residents (#28 and #32) of 14 residents reviewed for comprehensive care plans. Findings Include: 1. Review of the medical record for Resident #32 revealed an admission date on 08/13/21 with diagnoses including Alzheimer's Disease, unspecified displaced fracture of first cervical vertebra, pain, and other abnormalities of gait and mobility. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 08/22/22 revealed Resident #32 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of three out of 15. [...]

Inspectors wroteBased on observation, record review, facility policy review and interview the facility failed to monitor pressure ulcers for healing, complications, or changes in the wound characteristics. This affected two residents (#22 and #28) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to implement nutritional recommendations to prevent or monitor for weight loss for Resident #22 and Resident #28. This affected two residents (#22 and #28) of three residents reviewed for nutrition.

Inspectors wroteBased on record review, review of infection line listing reports, facility policy review and interview the facility failed to ensure antibiotic use protocols were followed to ensure the appropriate use of antibiotics. This affected two residents (#1 and #16) of two residents reviewed for urinary tract infections/antibiotic use.