What is MAIN STREET TERRACE CARE CENTER's CMS rating?

MAIN STREET TERRACE CARE CENTER has a four-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does MAIN STREET TERRACE CARE CENTER have?

MAIN STREET TERRACE CARE CENTER has 28 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at MAIN STREET TERRACE CARE CENTER?

MAIN STREET TERRACE CARE CENTER has a three-star staffing rating from CMS with 0.54 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is MAIN STREET TERRACE CARE CENTER located?

MAIN STREET TERRACE CARE CENTER is located in LANCASTER, OH. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does MAIN STREET TERRACE CARE CENTER have?

MAIN STREET TERRACE CARE CENTER has 50 certified beds.

Who owns MAIN STREET TERRACE CARE CENTER?

MAIN STREET TERRACE CARE CENTER is a for profit - corporation facility and operates independently (not part of a chain).

Is MAIN STREET TERRACE CARE CENTER safe?

MAIN STREET TERRACE CARE CENTER has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Do nurses at MAIN STREET TERRACE CARE CENTER stick around?

MAIN STREET TERRACE CARE CENTER has low staff turnover at 27%, which means caregivers stay longer and know residents better.

Was MAIN STREET TERRACE CARE CENTER ever fined?

No, MAIN STREET TERRACE CARE CENTER has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Is MAIN STREET TERRACE CARE CENTER on any federal watch list?

No, MAIN STREET TERRACE CARE CENTER is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at MAIN STREET TERRACE CARE CENTER?

Medicare inspectors have found 28 deficiencies at MAIN STREET TERRACE CARE CENTER: 1 serious, 27 moderate. Each deficiency represents a violation of federal nursing home requirements.

How does MAIN STREET TERRACE CARE CENTER compare to other nursing homes?

MAIN STREET TERRACE CARE CENTER has a 4-star overall rating, placing it above average compared to other nursing homes in OH. Higher-rated facilities typically have better inspection results and staffing levels.

MAIN STREET TERRACE CARE CENTER

Name: MAIN STREET TERRACE CARE CENTER
Address: 1318 E MAIN STREET, LANCASTER, OH, 43130, US
Telephone: (740) 653-8767
Rating: 4.0

1318 E MAIN STREET, LANCASTER, OH 43130 · (740) 653-8767

For profit - Corporation 50 Beds Independent Data: November 2025

Trust Grade

68/100

#287 of 913 in OH

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MAIN STREET TERRACE CARE CENTER nursing home in LANCASTER, OH - Photo 1 of 2

MAIN STREET TERRACE CARE CENTER nursing home in LANCASTER, OH - Photo 2 of 2

Photo by Main Street Terrace Care Center

Last Inspection: October 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Main Street Terrace Care Center in Lancaster, Ohio has a Trust Grade of C+, indicating that it is slightly above average among nursing homes. It ranks #1 out of 9 facilities in Fairfield County and #287 out of 913 in Ohio, placing it in the top half of all nursing homes in the state. The facility is showing signs of improvement, with the number of issues decreasing from 12 in 2022 to 8 in 2024. Staffing ratings are average, with a turnover rate of 27%, which is much better than the Ohio average of 49%, suggesting that staff are relatively stable and familiar with the residents. However, there have been serious concerns, such as a resident suffering from worsening pressure ulcers due to inadequate treatment and failures in infection control during a COVID-19 outbreak, affecting multiple residents. Overall, while there are strengths, such as a good quality measure rating and no fines, families should weigh these against the notable incidents of care deficiencies.

Trust Score: C+
In Ohio: #287/913
Safety Record: Moderate
Inspections: Getting Better
Staff Stability: 27% annual turnover. Excellent stability, 21 points below Ohio's 48% average. Staff who stay learn residents' needs.
Penalties: No fines on record. Clean compliance history, better than most Ohio facilities.
Skilled Nurses: Each resident gets 32 minutes of Registered Nurse (RN) attention daily — about average for Ohio. RNs are the most trained staff who monitor for health changes.
Violations: 28 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★★☆

4.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★★

5.0

Care Quality

★★★☆☆

3.0

Inspection Score

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Stable

2022: 12 issues

2024: 8 issues

The Good

5-Star Quality Measures · Strong clinical quality outcomes
Low Staff Turnover (27%) · Staff stability means consistent care
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover is low (27%)
21 points below Ohio average of 48%

Facility shows strength in quality measures, staff retention, fire safety.

The Bad

No Significant Concerns Identified

This facility shows no red flags. Among Ohio's 100 nursing homes, only 1% achieve this.

The Ugly 28 deficiencies on record

1 actual harm

Oct 2024 8 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The deterioration of the pressure ulcer was a result of the facility not implementing effective and timely treatment. This affected one resident (#45) of one resident reviewed for pressure ulcers. The facility census was 49 residents. Findings include: Review of the medical record for Resident #45 revealed an admission date of 09/25/24 with diagnoses including cerebral infarction, encounter for surgical aftercare following surgery on the digestive system, hemiplegia and hemiparesis, and history of pulmonary embolism. Review of the baseline care plan for Resident #45 dated 09/25/24 revealed the resident had a stage III pressure ulcer to the sacrum with the intervention to provide wound care/treatment per physician order. Review of the monthly physician's orders for Resident #45 revealed an order dated 09/25/24 to apply house barrier cream to buttocks and peri area every shift. Review of the pressure ulcer risk assessment for Resident #45 dated 09/26/24 revealed the resident was at high risk for skin breakdown. Review of the admission assessment for Resident #45 dated 09/26/24 revealed the resident had a Stage III pressure ulcer to the sacrum which measured 5.0 centimeters (cm) length by 5.0 cm width with 0.1 in depth with a scant amount of sanguineous (bloody) drainage and a pink, healthy wound bed. There was no dressing or wound treatment ordered for the pressure ulcer. The resident only had an order to apply house barrier cream to the buttocks and peri area. Review of the Minimum Data Set (MDS) assessment for Resident #45 dated 10/01/24 revealed the resident was cognitively intact, was totally dependent on staff for bathing, hygiene, bed mobility, and transfers, and was coded for the presence of stage III pressure ulcer upon admission to the facility. Review of the weekly skin assessment for Resident #45 dated 10/03/24 revealed the resident's pressure ulcer to the sacrum was now classified as an unstageable pressure ulcer and measured 4.8 cm length by 3.0 cm width with 0.2 cm in depth with a moderate amount of sanguineous drainage and the presence of slough wound bed. The new treatment order was to cleanse the wound with normal saline and apply Mesalt and a dry dressing to the wound bed. Review of the wound physician note for Resident #45 per Wound Physician (WP) #81 dated 10/03/24 revealed the resident had an unstageable (due to necrosis) sacral full thickness pressure ulcer which measured 4.8 cm length by 3.0 cm width with 0.2 cm in depth with a moderate amount of serous exudate, 20 percent (%) thick adherent devitalized necrotic tissue and 30 % slough (yellow/white material which consists of dead cells that accumulate in the wound bed). The new treatment order was to cleanse the wound with normal saline, apply Mesalt, and cover with a dry dressing. Review of the monthly physician's orders for Resident #45 revealed an order dated 10/03/24 to cleanse the sacral wound with normal saline, apply Mesalt, and cover with a dry dressing daily and as needed. Interview on 10/22/24 at 11:41 AM with the Resident #45 confirmed she had a pressure ulcer to her sacrum which required daily wound care. At the time of the interview, Resident #45 declined observation of wound care because the wound was located on the sacrum/buttocks area. Interview on 10/22/24 at 3:19 P.M. with the Director of Nursing (DON) confirmed Resident #45 was admitted with a Stage III pressure ulcer to the sacrum on 09/25/24. The DON confirmed the facility nurse did not contact the physician to obtain an appropriate treatment order, and the wound was noted to have worsened/deteriorated on 10/03/24 to an unstageable pressure ulcer with the presence of slough and necrotic tissue. Interview on 10/22/24 at 4:09 P.M. with the Assistant Director of Nursing (ADON) revealed she completed the wound assessment for Resident #45 on 09/26/24 and she did not contact the physician to obtain an appropriate treatment order for the resident's sacral ulcer which she had classified as a Stage III upon admission. The ADON confirmed there was no order implemented upon admission to cleanse Resident #45's pressure ulcer and/or to apply a treatment to promote wound healing and a dressing to cover the wound. Interview on 10/23/24 at 9:56 A.M. with State Tested Nursing Assistant (STNA) #7 revealed if a resident had a pressure ulcer, she would not apply house barrier cream to the ulcer but would notify the nurse so the nurse could assess the wound and see if it needed a dressing and/or a treatment to be done by the nurses. Interview on 10/23/24 at 10:05 A.M. with Registered Nurse (RN) #1 revealed she completed skin assessments on residents admitted to the facility over the weekends and after hours. RN #1 confirmed she was able to stage pressure ulcer injuries and utilized the resources provided in the medication room which included a staging chart. RN #1 revealed she reviewed the wound measurements and descriptions for Resident #45's admission skin assessment dated [DATE] and verified she would have staged the resident's wound as a Stage III pressure ulcer on 09/26/24, but she then would have notified the physician for an appropriate treatment to promote healing of the wound. RN #1 confirmed house barrier cream was not an appropriate wound treatment for a Stage III pressure ulcer. Interview on 10/24/24 at 6:46 A.M. via telephone with WP #81 revealed he would have ordered triad hydrophilic for Resident #45's Stage III pressure ulcer upon admission, and house barrier cream utilized by the facility was not an appropriate treatment order. WP #81 further confirmed when he first saw the wound on 10/03/24, it presented as unstageable pressure ulcer with slough and necrotic tissue and he ordered a more aggressive treatment, cleanse with normal saline, apply Mesalt, and cover with a dry dressing, because the wound had worsened. Review of the facility undated policy titled Skin Protocol revealed house barrier cream would be used as a preventative measure on the buttocks or peri area to prevent rashes or excoriation due to incontinence. Staff should contact the wound physician for wound orders and treatment for actual pressure ulcers. Review of online information from the NPUAP at chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://cdn.ymaws.com/npiap.com/resource/resmgr/2014_guideline.pdf on 10/28/24 on page 93 revealed the facility staff should implement treatments to prevent contamination of the pressure ulcer. Pressure ulcers near the anus were subject to contamination, especially by bacteria from the colon. Meticulous skin cleansing and use of dressings or topical agents to prevent exposure to fecal matter were needed. Further review on page 588 revealed wound dressings were a central component of pressure ulcer care and wound healing was optimized when the wound was kept in a moist environment. Occlusive or semi-occlusive wound dressings that maintained wound bed moisture promoted re-epithelialization and wound closure. Wound dressings for pressure ulcers would improve wound healing time, absorb blood and tissue exudate, minimize pain associated with application and removal, absorb and control malodor, reduce injury to periwound skin.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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2. Review of the medical record for Resident #46 revealed an admission date of 02/07/24 with diagnoses including metabolic encephalopathy, type two diabetes, obstructive uropathy, and benign prostatic hypertrophy (BPH.) Review of the care plan for Resident #46 initiated 02/07/24 revealed the resident had the potential for infection related to the presence of an indwelling urinary catheter. Interventions included to monitor lab results by obtaining urinalysis, culture, and sensitivity specimens for testing per physician's order, and reporting results to the physician. Review of a laboratory report for Resident #46 dated 07/25/24 revealed the urinalysis was abnormal and indicated a level greater than 100,000 mixed pathogens and was probably a contaminated sample. Review of the progress notes for Resident #46 for July 2024 revealed they did not include notification to the physician of the abnormal urinalysis result dated 07/25/24. Interview on 10/23/24 at 9:38 A.M. with Registered Nurse (RN) #18 confirmed Resident #46 had abnormal urinalysis test resulted on 07/25/24 and the facility failed to notify the resident's physician. Based 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. Findings include: 1.Review of the medical record for Resident #38 revealed an admission date of 04/10/24 with diagnoses including acute respiratory failure with hypoxia, morbid obesity, and congestive heart failure. Review of the care plan for Resident #38 initiated 04/10/24 revealed the resident had a potential for fluid volume deficit related to diuretic use. Interventions included to monitor and document the resident's weight and report weight changes to the physician. Review of the weight record for Resident #38 revealed the resident weighed 289 pounds (lbs) on 04/10/24 and on 04/17/24 the resident weighed 294.8 lbs. Review of the weight record for Resident #38 revealed on 05/07/24 the resident weighed 304 lbs. and on 05/17/24 the resident weighed 296.4 lbs. Review of the weight record for Resident #38 revealed on 06/04/24 the resident weighed 309.4 lbs. and on 06/11/24 the resident weighed 302 lbs. Review of the weight record for Resident #38 revealed on 07/11/24 the resident weighed 303.2 lbs. and on 08/02/24 the resident weight 313.6 lbs. Review of the weight record for Resident #38 revealed on 08/02/24 the resident weighed 313.6 lbs. and on 09/04/24 the resident weighed 301.5 lbs. Review of the progress notes for Resident #38 dated 04/10/24 to 09/04/24 revealed the notes did not include documentation of physician notification of the resident's weight fluctuations. Review of the Minimum Data Set (MDS) assessment for Resident #38 dated 08/29/24 revealed the resident was cognitively intact. Interview on 10/23/24 at 7:49 A.M. with Director of Nursing (DON) confirmed Resident #38's weight fluctuations had not been reported to the resident's attending physician. Interview with the DON further confirmed Resident #38's weight changes should be reported to the physician particularly due to the resident's diuretic use and diagnosis of congestive heart failure.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based 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. Findings include: Review of the medical record for Resident #22 revealed an admission date of 06/01/23 with diagnoses including dementia, major depressive disorder, type two diabetes, atherosclerotic heart disease, hypertension, and hypothyroidism. Review of the care plan for Resident #22 initiated 06/01/23 revealed the resident required the assistance of one staff with personal hygiene and oral care. Review of the Minimum Data Set (MDS) assessment for Resident #22 dated 08/16/24 revealed the resident had mild cognitive impairment and was to receive supervision/touching assistance with oral care. Review of the physician's orders for Resident #22 revealed an order dated 10/01/24 for denture care completed after each meal and at bedtime. The dentures were to be cleaned with a denture brush and antibacterial soap, four times daily. Review of the ADL Task Log for Resident #22 dated 10/01/24 to 10/22/24 revealed the resident had a total of 88 opportunities that staff were to assist with denture care. Of those 88 opportunities for denture care, there were only 43 times that the resident's dentures were documented as being cleaned. Resident #22 was not interviewable. Interview on 10/21/24 at 12:16 P.M. with Resident #22's representative confirmed they had to speak with the facility management because the resident's dentures were not not always clean when they came to visit. Interview on 10/24/24 at 9:46 A.M. with State Tested Nurse Aide (STNA) #8 confirmed the aides recorded ADL care on the ADL Task Log in the electronic medical record. STNA #8 confirmed if Resident #22's denture care was not signed off in the ADL Task Log it wasn't done. Interview on 10/24/24 at 9:57 A.M. with Director of Nursing (DON) confirmed the ADL Task Log in the electronic medical record would be the only location in which ADL care was documented. The DON confirmed the facility had no documentation that staff cleaned Resident #22's dentures four times daily as ordered.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based 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. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 04/10/24 with diagnoses including acute respiratory failure with hypoxia, hypertension, morbid obesity, and congestive heart failure. Review of the monthly physician's orders for Resident #38 revealed an order dated 06/12/24 for lisinopril (an anti-hypertensive medication) 2.5 milligrams (mg) once daily and an order dated 06/12/24 for spironolactone (a diuretic medication), and an order dated 10/06/24 to take full vital signs on a monthly basis, which included measuring blood pressure. Review of the vital sign records for Resident #38 dated 04/14/24 to 10/08/24 revealed monthly blood pressure checks were not completed in June, July, and August of 2024. There were no blood pressures completed from 05/10/24 to 09/10/24. Interview on 10/23/24 at 7:49 A.M. with the Director of Nursing (DON) confirmed the facility should have checked Resident #38's blood pressure at least monthly at a minimum but they had not checked the resident's blood pressure from 05/10/24 to 09/10/24. 2. Review of the medical record for Resident #29 revealed an admission date of 06/07/19 with diagnoses including Parkinson's disease, major depressive disorder, schizophrenia, depression, respiratory disorders, dysphagia, and hypertension. Review of the physician's orders for Resident #29 revealed an order dated 05/03/23 for the resident to have TED hose on in the morning and off at bedtime. Review of the care plan for Resident #29 dated 04/24/24 revealed the resident had impaired breathing problems and altered cardiac output related to atrioventricular block, bradycardia, hypertension, atrial fibrillation, asthma, and shortness of breath with exertion and sitting at rest at times. Interventions included the following: administer medications as ordered, allowing resident to perform activity at own rate, encourage fluid intake, labs as ordered, TED hose to lower bilateral extremities on in morning and off at bedtime. Review of the Minimum Data Set (MDS) assessment for Resident #29 dated 07/24/24 revealed the resident had intact cognition. Review of the Medication Administration Record (MAR) for Resident #29 revealed the MAR dated 10/22/24 was marked to indicate the resident's TED hose were in place. Observations on 10/21/24 at 11:43 A.M. and on 10/22/24 at 3:09 P.M. and 3:37 P.M. revealed Resident #29 did not have TED hose in place. Interview on 10/22/24 at 3:37 P.M. with State Tested Nursing Aide (STNA) #7 confirmed Resident #29 was not wearing her TED hose and had refused to wear them for a long time. STNA #7 could not recall the last time the resident wore the TED hose. Interview on 10/22/24 at 3:41 P.M. with Licensed Practical Nurse (LPN) #5 confirmed Resident #29 had a physician's order for TED hose, and she had marked Resident #29's MAR to indicate the resident was wearing the TED hose, but the resident was not wearing them.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based 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. Findings include: 1.Review of the medical record for Resident #15 revealed an admission date of 08/10/23 with diagnoses including dementia, expressive language disorder, major depressive disorder, gastro-esophageal disease, and chronic kidney disease. Review of the care plan for Resident #15 initiated 08/10/13 revealed it did not include the resident's risk for elopement or wandering behaviors. Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 07/25/24 revealed the resident had impaired cognition and had no wandering behaviors during the review period. Review of the progress note for Resident #15 dated 10/08/24 revealed the resident had increased confusion and was standing by exit doors. Staff redirected the resident back to her room and new orders were obtained for a Wanderguard to the right ankle due to exit seeking. Review of the physician's orders for Resident #15 revealed an order dated 10/08/24 for Wanderguard bracelet to the right ankle. Review of the medical record for Resident #15 revealed it did not include an assessment of the resident's risk for elopement. Interview on 10/23/24 at 8:34 A.M. with the Director of Nursing (DON) confirmed elopement risk assessments should be completed upon admission, quarterly, and with significant changes for all residents. The DON further confirmed the facility had not completed an elopement risk assessment for Resident #15 and the resident had exhibited recent exit-seeking behavior. Review of the facility policy titled Elopement undated revealed the facility would maintain the safety of all residents, minimize the potential of residents eloping from the facility, would determine which residents were at risk for elopement, and would prevent reoccurring elopements. The facility would assess all residents for elopement upon admission, quarterly, and with any significant changes. 2. Review of the medical record for Resident #20 revealed an admission date of 12/14/22 with diagnoses including congestive heart failure, chronic kidney disease, and hypertensive heart disease. Review of the care plan for Resident #20 dated 03/12/24 revealed the resident had the potential for falls related to balance deficit, history of falls and noncompliance. Interventions included the following: half side rails to enhance independent bed mobility, assist in position for comfort as needed, anticipate needs as able, bed against wall, Dycem to reclining chair on top and under the pad to decrease the risk of sliding off seat, encourage non-skid footwear at all times, encourage to ask/use call light for assistance, call light within reach, low bed in low position while occupied, maintain uncluttered environment, mat to floor bedside bed, pressure alarm to chair to remind resident of need for assistance and alert staff resident may need assistance. Review of the Minimum Data Set (MDS) assessment for Resident #20 dated 08/30/24 revealed the resident had a moderate cognitive deficit. Review of the fall risk evaluation for Resident #20 dated 09/23/24 revealed the resident was at risk for falls. Review of the late entry progress note for Resident #20 dated 09/27/24 timed at 6:38 P.M. revealed on 09/23/24 at 10:00 A.M. a State Tested Nursing Assistant (STNA) notified the nurse the resident was on the floor in the shower room. Review of the Interdisciplinary Team (IDT) progress note for Resident #20 dated 09/30/24 at 9:38 A.M. revealed the fall on 09/23/24 occurred in the shower room when STNA #28 took Resident #20 into the shower room, transferred the resident to the commode and then left the shower room. Resident #20 stated she fell when trying to transfer herself off the commode. Resident #20 sustained no injuries and all staff were reeducated that residents cannot be left in the shower room without a staff member present. Interview on 10/22/24 at 11:51 A.M. with the Director of Nursing (DON) confirmed on 09/23/24 STNA #28 took Resident #20 to the shower room, transferred the resident to the commode and then left the shower room. The DON confirmed Resident #20 had an unwitnessed fall without injury while trying to self-transfer off the commode. The DON confirmed Resident #20, and all residents should not be left alone in the shower room. Review of the facility policy titled Managing Falls and Fall Risk dated March 2018 revealed the staff would identify interventions related to the resident's specific risks to try to prevent the resident from falling.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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Based 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. Review of the physician's orders for Resident #9 revealed an order dated 03/12/24 for the resident to receive Lantus insulin 20 units daily for DM via subcutaneous injection. Observation on 10/22/24 at 8:20 A.M. of insulin administration for Resident #9 per Registered Nurse (RN) #1 revealed the nurse dialed the pen to 20 units, cleansed the resident's abdomen, and injected the insulin. The nurse did not prime the insulin pen prior to administration. Interview on 10/22/24 at 8:25 A.M. with RN #1 confirmed she did not prime the insulin pen prior to insulin administration for Resident #9 and she should have done so according to the manufacturer's instructions. Review of the Lantus pen instructions for use last revised October 2021 revealed the nurse should remove the seal from the safety pen needle, attach the safety pen needle securely to the pen injector device by twisting clockwise until it stops, and then prime the pen injector device prior to administration.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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Based 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. Findings include: 1.Review of the medical record for Resident #18 revealed an admission date of 01/06/18 with diagnoses including hemiplegia and hemiparesis affecting right dominant side, major depressive disorder, dysphagia, aphasia, Parkinson's disease, and anxiety disorder. Review of the care plan for Resident #18 initiated 01/06/18 revealed it did not include a care plan for wandering, exit-seeking, or high risk for elopement. Review of the physician's orders for Resident #18 revealed an order dated 07/01/24 revealed for a Wanderguard to the right ankle for exit seeking. Review of the progress note for Resident #18 dated 07/01/24 revealed the resident had been attempting to exit seek out of the doors and a new order for a Wanderguard was received. Review of the progress notes for Resident #18 dated 08/31/24 and 09/03/24 revealed the resident was exit seeking but was redirected by staff. Review of the Minimum Data Set (MDS) assessment for Resident #18 dated 09/05/24 revealed the resident had severely impaired cognition and was coded for the presence of wandering during one to three days of the review period. Review of the progress notes for Resident #18 dated 09/28/24, 10/08/24, and 10/11/24 revealed the resident was wandering, but was redirected by staff. Interview on 10/23/24 at 7:47 A.M. with the Director of Nursing (DON) confirmed Resident #18's care plan did not address the resident's risk for elopement and/or wandering and exit-seeking behaviors. 2. Review of the medical record for Resident #15's medical revealed an admission date of 08/10/23 with diagnoses including dementia, expressive language disorder, major depressive disorder, gastro-esophageal disease, and chronic kidney disease. Review of the care plan for Resident #15 initiated 08/10/23 revealed it did not include a care plan for use of TED hose and/or a care plan for activities. Review of the physician's orders for Resident #15 revealed an order dated 03/15/24 for TED hose to be applied in the morning and removed at bedtime. Review of the MDS assessment for Resident #15 dated 07/25/24 revealed the resident had impaired cognition. Review of the activity assessment for Resident #15 dated 09/20/24 revealed the resident felt it was somewhat important for her to read and it was very important for her to listen to music, see animals, keep up with the news, participate in groups, do her favorite activities, go outside when the weather is good, and participate in religious services. Interview on 10/23/24 at 2:00 P.M. with the DON confirmed Resident #15's TED hose were not addressed in the plan of care. Interview on 10/23/24 at 2:40 P.M. with Activities Director (AD) #45 confirmed Social Services Director (SSD) #15 had been completing the activity care plans for the residents. Interview on 10/23/24 at 2:43 P.M. with SSD #15 confirmed there was no activity care plan for Resident #15. 3. Review of the medical record for Resident #20 revealed an admission date of 12/14/22 with diagnoses including congestive heart failure, chronic kidney disease, major depressive disorder, chronic obstructive pulmonary disease, depression, atrial fibrillation and chronic respiratory failure with hypercapnia. Review of the MDS assessment for Resident #20 dated 08/30/24 revealed the resident had a moderate cognitive deficit and received oxygen. Review of physician's orders for Resident #20 revealed an order dated 01/11/23 for oxygen at two liters per nasal cannula to keep oxygen saturation above 90 percent (%) as needed for shortness of breath and to change oxygen tubing and water weekly. Review of the care plan for Resident #20 initiated 12/14/22 revealed it did not include a care plan which addressed the resident's use of supplemental oxygen. Interview on 10/22/24 at 10:49 A.M. with Registered Nurse (RN) #18 confirmed Resident #20 the facility had not developed a care plan regarding the resident's supplemental oxygen use as ordered by the physician. 4. Review of the medical record for Resident # 9 revealed an admission date of 03/05/24 with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus (DM), osteoarthritis, osteoporosis, anemia, dysphagia, anxiety disorder, major depressive disorder, Parkinson's disease, hypertension, and congestive heart failure. Review of the care plan for Resident #9 initiated 03/05/24 revealed the care plan did not address the resident's DM diagnosis and/or the resident's use of daily insulin. Review of the MDS assessment for Resident #9 dated 09/07/24 revealed the resident had no cognitive deficit, had DM as a current diagnosis, and received daily insulin injections. Interview on 10/22/24 at 4:35 P.M. with Licensed Practical Nurse (LPN) #14 confirmed Resident #9's care plan did not address the resident's DM diagnosis, nor did it address the resident's daily use of insulin. Review of the facility policy titled Comprehensive Person-Centered Care Plans dated March 2022 revealed the facility should develop and implement a comprehensive person-centered care plan for each resident that included measurable goals and timetables to meet the resident's physical, psychosocial and functional needs.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. 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. Review of the physician's orders for Resident #9 revealed an order dated 03/12/24 for the resident to receive Lantus insulin 20 units daily for DM via subcutaneous injection. Observation on 10/22/24 at 8:20 A.M. of insulin administration for Resident #9 per Registered Nurse (RN) #1 revealed the nurse checked the resident's blood sugar using a glucometer prior to insulin administration. RN #1 cleansed the resident's finger with an alcohol wipe and pierced the resident's finger with a lancet and obtained a drop of blood. RN #1 [NAME] cleansed the multi-use glucometer with an alcohol swab and placed the glucometer on the resident's dresser. RN #1 then exited the room to obtained the resident's insulin, returned to the room and injected the insulin, and then left the room and placed the glucometer inside the medication cart. Interview on 10/22/24 at 8:25 A.M. with RN #1 confirmed she cleaned the glucometer following obtaining Resident #9's blood sugar with an alcohol swab instead of using an approved disinfectant wipe. Review of the facility policy titled Glucometer Cleaning undated revealed after using the glucometer staff should clean and disinfect using a germicidal disinfectant wipe. 2. Review of the medical record for Resident #23 revealed an admission date of 01/26/21 with diagnoses cerebrovascular accident with left sided hemiplegia, diabetes mellitus, severe morbid obesity, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment for Resident #23 dated 09/24/24 revealed the resident had a severe cognitive deficit and required extensive assistance of two staff for bed mobility, transfers and toilet use. Review of the physician's orders for Resident #23 revealed an order dated 09/12/24 to cleanse wound to the left calf wound with normal saline (NS), apply calcium alginate the wound bed and wrap with Kerlix every shift and an order dated 10/04/24 to cleanse the left heel with normal saline, apply a crushed 500 milligram (mg) Flagyl tablet to the wound bed, apply calcium alginate to the wound bed, and wrap with Kerlix every shift. Observation of wound care on 10/23/24 at 11:18 A.M. for Resident #23 per RN #2 and the Director of Nursing (DON) revealed the nurses washed their hands and donned gloves. The DON held the resident's left leg while RN #2 removed the soiled dressings from the resident's leg exposing a left calf wound and a left heel wound. RN #2 attempted to pulled the calcium alginate off the left calf wound, but the calcium alginate was adhered to the wound and RN #2 doffed gloves, washed her hands and exited the room. RN #2 returned to Resident 23's room, washed hands and donned clean gloves. RN #2 used a syringe of NS to soak the calcium alginate to the resident's left calf and removed it. The DON instructed RN #2 to wash her hands. RN #2 removed her gloves, washed her hands, and donned clean gloves. RN #2 then used the same NS-soaked gauze which she had used on the left calf wound and cleansed the resident's left heel. RN #2 then washed her hands, donned clean gloves, applied crushed Flagyl and calcium alginate to the resident's left heel. RN #2 then washed her hands and donned a clean pair of gloves. The DON then washed her hands and donned a clean pair of while RN #2 wearing the same gloves opened three pieces of 2 X 2 calcium alginate and placed them on an ABD pad and placed over the left calf wound. RN #2 then wrapped the resident's left heel with Kerlix gauze and then used another roll of Kerlix to wrap the left calf. Interview on 10/23/24 at 11:47 A.M. with the DON confirmed RN #2 had not practiced proper control practices to prevent the spread of infection because she treated the two separate wounds as one wound and used contaminated gauze to cleans the resident's left heel. The DON further confirmed each wound should be treated separately to prevent cross-contamination.

Oct 2022 12 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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Based 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. Findings include: Review of the medical record for Resident #7 revealed an admission date of 02/23/22. A physician's order on 03/08/22 related to advance directives indicated to discontinue full code status and change status to Do Not Resuscitate Comfort Care-Arrest (DNRCC-Arrest). The physician had also, on 03/02/22, signed a DNRCC-Arrest form which was located in the resident's record. The form stated Do Not Resuscitate Comfort Care protocol would be implemented in the event of a cardiac arrest or a respiratory arrest. However, review of the facility report sheet (a list of all residents used by nurses to give report of resident status to the oncoming shift that included code status) revealed Resident #7 was listed as being a full code (resuscitative measures to be implemented in the event of cardiac or respiratory arrest). Review of the plan of care for Resident #7 revealed on 03/10/22 the plan noted the resident wished for a peaceful end (of life) without any extraordinary interventions. The goal was to follow supportive care/DNR wishes. On 10/18/22 at 11:00 A.M. interview with Acting Director of Nursing (DON) #509 revealed resident code status was documented in the paper (hard) chart, on the electronic physician's orders, and on the report sheet. She stated the report sheets were to be updated daily on the night shift with any changes. She confirmed the report sheet was not accurate for Resident #7 as it indicated the resident was a full code, when the resident had a physician's order for DNRCC-Arrest. She confirmed the report sheet should have been updated and was not. The DON revealed it was her expectation staff would check the resident's medical record to confirm code/advance directive status. Review of the facility undated policy titled Code Status Protocol revealed if a resident was found to be without respirations, pulse, or vital signs, nurse remained with resident while chart was verified by co-worker for code status on DNR form.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based 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. Findings include: 1. Review of the medical record for Resident #22 revealed an original admission date on 06/26/17 and a readmission date of 04/13/19. Resident #22 had diagnoses including Parkinson's disease, atrial fibrillation, chronic obstructive pulmonary disease (COPD), dehydration, abnormal weight loss, anorexia nervosa-restricting type, major depressive disorder, and cerebral infarction (stroke). Review of the care plan, dated 07/08/17 revealed Resident #22 had actual and potential for impaired skin integrity. Interventions included report any red or open areas as indicated. The resident also had a plan related to risk for altered nutrition and hydration. Interventions included notify the registered dietitian (RD) and physician (MD) of significant weight changes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/28/22 revealed Resident #22 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of three out of 15. The assessment revealed Resident #22 required total dependence from one to two staff for all activities of daily living (ADLs), except eating. The resident required supervision with set up help only with eating. The resident's weight was 159 pounds with no noted weight loss. No pressure ulcer areas were noted on the assessment. Review of weights dated from 07/01/22 to current (10/20/22) revealed Resident #22 weighed 165 pounds (lbs) on 07/10/22 and 155 lbs on 07/17/22, a weight loss of five percent (5%). Resident #22 weighed 156 lbs on 10/05/22 and 146 lbs on 10/20/22, a weight loss of five percent since 09/18/22, 7.5% since 07/24/22, and 10% since 04/28/22. Review of skin sweep assessments revealed Resident #22 developed a Stage III pressure ulcer to the coccyx on 09/28/22. Review of progress notes, from 07/01/22 to 10/20/22 revealed there was no documented evidence the physician or resident representative were notified of Resident #22's weight changes (loss) or the development of the new pressure ulcer area. Review of the current physician's orders for October 2022 revealed Resident #22 had the following orders in place: Remeron (anti-depressant) 7.5 milligrams (mg) one tablet daily for weight loss, Arginaid Extra Liquid (nutritional supplement) 240 milliliters (mL) daily to promote weight gain, Boost VHC Liquid (nutritional supplement) 120 mL twice daily, and skin assessment weekly (on day shift every Friday). Interview on 10/20/22 at 3:45 P.M. with Registered Nurse (RN) #502 confirmed neither the physician nor the resident's representative were notified of the new pressure ulcer identified on 09/28/22. Interview on 10/24/22 at 6:10 P.M. with the Director of Nursing (DON) confirmed there was no indication Resident #22's representative or physician were notified of the resident's changes in weight. Review of the undated facility policy titled Notification Of Changes Policy revealed requirements for notification of the resident, the resident representative and their physician included a significant change in the resident's physical, mental, or psychosocial status. 2. Review of the medical record for Resident #28 revealed an admission date of 07/01/21. Resident #28 had a diagnosis of dementia. Review of the MDS 3.0 assessment, dated 08/02/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The assessment revealed the resident required extensive assistance from staff for bed mobility and transfers and supervision with eating. The MDS reflected the resident had no weight loss and no pressure ulcers. Record review revealed a physician's order was noted, dated 09/24/22 for skin prep (forms a protective film to help reduce friction to the area) to heels at bedtime. Review of a skin sweep assessment revealed on 09/28/22 Resident #28 was had a blister on the right heel measuring 4.2 centimeters (cm) in length by 4.0 cm width. The area was noted to be unstageable (depth unable to be determined). There was no further description of the area. On 10/19/22 at 2:05 P.M. Resident #28 was observed to have a three cm long by 2.5 cm wide red/purple area on the right heel. The skin was intact. In addition, review of weight records revealed Resident #28 weighed 151 pounds on 09/10/22 and 142.2 pounds on 10/02/22. This represented an 8.8 pound, 5.8% significant weight loss in one month. Review of the facility provided matrix (required for the annual recertification survey by the State agency) noted Resident #28 had an unstageable pressure ulcer and weight loss. Record review revealed no documented evidence Resident #28's responsible party was notified of the significant weight loss. There was no evidence the responsible party was notified of the pressure ulcer on the heel until 10/12/22 at a care plan conference (2 weeks after the area was identified). In addition, record review revealed no evidence the physician was notified of the development of the pressure ulcer or significant weight loss. On 10/20/22 at 3:35 P.M. and 3:50 P.M. interview with Registered Nurse (RN) #502 confirmed there was no documented evidence Resident #28's responsible party was notified timely of the development of the pressure ulcer to the resident's heel or evidence the responsible party was notified of the significant weight loss. In addition, RN #502 verified there was no evidence the physician was notified of the pressure ulcer to the heel or the significant weight loss. Review of the facility undated policy titled Notification of Changes Policy revealed it was the policy of the facility that changes in a residents condition or treatment were immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate. The policy noted requirements for notification of resident, the resident representative, and their physician included a significant change in the resident's physical, mental, or psychosocial status and a need to alter treatment significantly (discontinue an existing form of treatment or commence a new form of treatment). Review of the facility undated Weight Loss Protocol revealed to notify the physician of any significant weight change.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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Based 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. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 04/01/22 with medical diagnoses including unspecified dementia, generalized anxiety disorder, paranoid schizophrenia, adjustment disorder with depressed mood, chronic myeloproliferative disease, and delirium due to a known physiological condition. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 04/01/22 revealed Resident #12 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 13 out of 15. The assessment revealed Resident #12 required limited to extensive assistance from one staff to complete activities of daily living (ADLs). Review of the beneficiary notices for Resident #12 revealed the resident was discontinued (cut) from therapy on 05/30/22 and remained in the facility. Record review revealed Resident #12 was not provided with an Advanced Beneficiary Notice (ABN) prior to therapy services being discontinued as required. Interview on 10/20/22 at 8:45 A.M. with Social Services (SS) #572 confirmed Resident #12 was not provided with an ABN. SS #572 indicated she did not know the notice was required. 2. Review of the medical record for Resident #28 revealed an admission date on 07/01/21 with medical diagnoses including COVID-19, rhabdomyolosis, osteoarthritis, unspecified dementia, scoliosis, and repeated falls. Review of the Medicare five day MDS 3.0 assessment, dated 08/11/22 revealed Resident #28 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of four out of 15. The assessment revealed Resident #28 required extensive assistance from one to two staff to complete ADL care. Review of the beneficiary notices for Resident #28 revealed the resident was discontinued (cut) from therapy on 08/10/22 and remained in the facility. Record review revealed Resident #28 was not provided with an Advanced Beneficiary Notice (ABN) prior to therapy services being discontinued as required. Interview on 10/20/22 at 8:45 A.M. with Social Services (SS) #572 confirmed Resident #12 was not provided with an ABN. SS #572 indicated she did not know the notice was required. A facility policy was requested during an interview with the Director of Nursing (DON). However, the facility did not have a policy related to ABN notices.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Review of the medical record for Resident #44 revealed an admission date of 09/08/22. Record review revealed the resident was transferred to the hospital on [DATE]. Review of the medical record for Resident #45 revealed an admission date of 01/24/18. Record review revealed the resident was transferred to the hospital on [DATE]. Record review revealed no evidence the State Long Term Care Ombudsman office had been notified of the facility initiated emergent transfers to the hospital as required (at least 30 days had passed since the transfers occurred). Interview with Social Service (SS) #572 on 10/25/22 at 11:18 A.M. revealed the State Long Term Care Ombudsman office had not been notified of any facility initiated emergent transfers in the past year. SS #572 confirmed the Ombudsman were to be notified of the transfers at least every 30 days.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

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Based 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. Findings include: Review of the medical record for Resident #30 revealed an admission date of 09/27/22. The resident had diagnoses including end stage renal disease with hemodialysis, chronic pain, and rheumatoid arthritis. The resident had a physician's order for hemodialysis three times weekly and was on a renal diet. Record review revealed there was no evidence a comprehensive Minimum Data Set (MDS) 3.0 assessment had been completed for Resident #30 since admission. Interview with the Administrator on 10/25/22 at 9:25 A.M. confirmed the MDS 3.0 assessment had not been completed for the resident. The Administrator revealed the Director of Nursing, Assistant Director of Nursing, and the MDS nurse had all quit working at the facility around mid September 2022.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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3. Review of the medical record for Resident #39 revealed an admission date on 09/06/22 with diagnoses including unspecified dementia without behavioral disturbance and unspecified psychosis not due to a substance or known physiological condition. Review of the Medicare five day Minimum Data Set (MDS) 3.0 assessment, dated 09/13/22 revealed Resident #39 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of three out of 15. The assessment revealed Resident #39 required limited assistance from one to two staff to complete bed mobility, transfers, ambulation/mobility, and dressing tasks. The resident required extensive assistance from one staff to complete hygiene and toileting tasks. The assessment revealed Resident #39 was administered daily antipsychotic and antidepressant medications. Review of the plan of care, dated 09/14/22 revealed neither Resident #39's diagnosis of dementia or use of psychoactive medications were addressed in the care plan. Review of the current physician orders, dated October 2022 revealed Resident #39 had the following orders: palliative care with contracted Hospice, monitor behaviors (refusing medications, resisting care for hygiene, agitation, and tearful/withdrawn), Seroquel (an antipsychotic medication) 25 milligrams (mg) daily related to psychotic disorder, and Sertraline Hydrochloride (an antidepressant medication) 25 mg daily for depression. Interview on 10/25/22 at 9:25 A.M. with the Administrator confirmed Resident #39's care plan did not address dementia or use of psychoactive medications. The Administrator indicated the Director of Nursing (DON), Assistant Director of Nursing (ADON), and MDS nurse had all quit/left the facility around 09/10/22 and the facility was currently recruiting for those positions at the time of the survey. Review of the facility policy titled Care Plan, dated 02/11/08 revealed acute care plans would be initiated upon admission if there were high risk areas for admitting residents. High risk areas were defined as falls, elopement risks, skin, nutrition/hydration, and behaviors. When care plans were not needed for high risk areas, each discipline on the interdisciplinary team had until twenty days after admission to complete a care plan and have it on the resident's medical chart. Based 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. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 09/27/22. The resident had diagnoses including end stage renal disease with hemodialysis, chronic pain, and rheumatoid arthritis. The resident had a physician's order for hemodialysis three times weekly and was on a renal diet. Record review revealed no evidence a comprehensive plan of care had been developed and initiated for Resident #30 since admission. Interview with the Administrator on 10/25/22 at 9:25 A.M. confirmed a comprehensive care plan had not been developed/completed for the resident. The Administrator revealed the Director of Nursing, Assistant Director of Nursing, and the Assessment (MDS) nurse had all quit working at the facility around mid September 2022. 2. Review of the medical record for Resident #43 revealed an admission date of 09/21/22. The resident had diagnoses including postherpetic trigeminal neuralgia, hypertension, lymphedema, acute kidney failure, and abdominal aneurysm. Record review revealed a comprehensive assessment was completed on 09/28/22. However, review of the corresponding plan of care for the resident revealed it only addressed range of motion and transfers. Interview with Licensed Practical Nurse #516 on 10/25/22 at 11:15 A.M. confirmed a comprehensive care plan had not yet been developed and should have been. She confirmed areas identified on the assessment with the need for care planning included bladder incontinence, fall risk, nutrition, high risk for skin breakdown, pain, side rails, and activities of daily living.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based 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. The assessment revealed Resident #32 required staff supervision with set up assistance only to complete activities of daily living (ADLs). Review of progress note, dated 10/01/22 at 3:20 A.M. revealed a nurse sitting at the nurse's station heard a loud thud. Resident #32 attempted to go to the bathroom, fell, and hit her head. Resident #32 was conscious when she was sent to a local hospital for evaluation. On 10/02/22 at 1:30 A.M., the hospital nurse called to report Resident #32 had a C1 fracture and was to wear a neck brace at all times. Review of the current physician orders, dated October 2022 revealed Resident #32 had an order to check placement of C collar to neck every shift, check function and placement of alarms every shift, mat to floor by bed, and bed/chair alarms for resident safety and fall prevention. Review of the plan of care (initiated 08/14/21) revealed Resident #32 was at risk for falls. Record review revealed the care plan had not been updated to include Resident #32's fall with fracture (on 10/01/22). The care plan also did not include any of the additional interventions implemented following the fall with fracture including a mat to floor, bed/chair alarms, or C collar. Interview on 10/20/22 at 3:35 P.M. with Registered Nurse (RN) #502 confirmed the plan of care for Resident #32 had not been updated following the resident's fall with fracture. Review of the facility policy titled Care Plan, dated 02/11/08 revealed care plans would be updated on a quarterly basis or when there was a significant change in condition. 2. Review of the medical record for Resident #28 revealed an admission date of 07/01/21 and a diagnosis of dementia. Review of the MDS 3.0 assessment, dated 08/02/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The assessment revealed the resident required extensive assistance from staff for bed mobility and transfers and had no pressure ulcers. The plan of care dated 08/03/21 revealed the resident had a potential for impaired skin integrity related to decreased mobility and diagnosis/disease processes. Review of facility skin sweeps, dated 09/06/22, 09/13/22, 09/20/22, and 09/27/22 revealed the resident had no pressure areas and bony prominences were without issues. Skin remained intact at present time. No skin breakdown any of type was identified. Record review revealed a physician's order was obtained on 09/24/22 for skin prep (forms a protective film to help reduce friction to the area) to heels at bedtime. There was no reason documented for the order. Review of a skin sweep assessment, dated 09/28/22 revealed the resident had a blister on the right heel measuring 4.2 centimeters (cm) by 4.0 cm. The area was noted to be 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. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage III or Stage IV pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur). Record review revealed there was no further description of the area. The assessment noted skin prep was ordered and applied per order. Observations on 10/19/22 at 2:05 P.M. revealed Resident #28 had a three centimeter (cm) long by 2.5 cm wide red/purple area on the right heel. The skin was intact. Interview with Licensed Practical Nurse #518 at the time of the observation verified the presence of the area. Review of the plan of care revealed no evidence it was reviewed and revised after the development of the pressure ulcer to the right heel. Interview with Registered Nurse #502 on 10/20/22 at 3:35 P.M. confirmed Resident #28's plan of care had not been reviewed and revised after the development of the pressure ulcer on the right heel on 09/24/22.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based 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. Findings include: 1. Review of the medical record for Resident #22 revealed an original admission date of 06/26/17 and a readmission date of 04/13/19. Resident #22 had diagnoses including Parkinson's Disease, atrial fibrillation, chronic obstructive pulmonary disease (COPD), dehydration, abnormal weight loss, anorexia nervosa-restricting type, major depressive disorder, and cerebral infarction (stroke). Review of the care plan, dated 07/08/17 revealed Resident #22 had actual and potential for impaired skin integrity. Interventions included skin checks weekly and as needed. Review of the quarterly MDS 3.0 assessment, dated 07/28/22 revealed Resident #22 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of three out of 15. The assessment revealed Resident #22 required total dependence from one to two staff for all activities of daily living (ADLs), except eating. The assessment also noted no pressure ulcer areas were reported at the time of the assessment. Review of a skin sweep assessment revealed Resident #22 developed 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) pressure ulcer to the coccyx on 09/28/22. There was an additional skin sweep assessment completed on 09/30/22. The assessment revealed the pressure ulcer was a Stage III wound to the coccyx the measured 0.5 centimeters (cm) long and 0.5 cm wide. There was no depth to the wound. The area was noted to be pink and zinc barrier cream was applied per orders. Record review revealed there were no skin assessments completed from 09/30/22 to current (10/20/22). Review of the current physician orders dated October 2022 revealed Resident #22 had an order for a weekly skin assessment on day shift every Friday. Review of progress notes from 09/01/22 to 10/19/22 revealed there were no notes related to the pressure ulcer being assessed or additional measurements. Record review revealed the Resident #22 had preventative skin interventions, including turning and repositioning, which was documented to be provided and the resident compliant with prior to the pressure ulcer development. On 10/20/22 10:40 A.M. observation of Resident #22's skin revealed the coccyx area had two small (less than dime size) areas. One was red and one was crusty with neither area noted to be open. The skin around and on the resident's buttocks was pink. Resident #22 was noted to have an air mattress in place with zinc oxide cream also noted to be intact to the area. Interview on 10/20/22 at 3:45 P.M. with Registered Nurse (RN) #502 confirmed there were not any skin sweeps or assessments/measurements completed to monitor Resident #32's pressure ulcer since 09/30/22. A nursing progress note, dated 10/20/22 at 4:45 P.M. revealed the resident was seen by the wound physician for wound care. The note indicated the coccyx wound site was healing and now smaller in size. The physician recommended to continue zinc ointment for 30 days, continue to off-load, turn and reposition side to side every two hours, except for meals, limit chair time to once daily for one to two hours to promote wound healing. Review of the undated facility policy titled Skin Protocol revealed pressure ulcers would be measured by the wound nurse or designee on a weekly basis. The information would then be placed on the weekly skin report and discussed during the weekly skin meeting. 2. Review of the medical record for Resident #28 revealed an admission date of 07/01/21 and a diagnosis of dementia. Review of pressure ulcer risk assessments revealed on 04/07/22, 07/07/22, and 08/11/22 the resident was identified as moderate risk for the development of pressure ulcers. The resident had a physician's order, dated 07/13/21 for weekly skin assessments every Tuesday. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/02/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The assessment revealed the resident required extensive assistance from staff for bed mobility and transfers and had no pressure ulcers. A plan of care, dated 08/03/21 revealed the resident had a potential for impaired skin integrity related to decreased mobility and diagnosis/disease processes. Interventions included skin checks weekly and as needed. Review of skin sweeps on 09/06/22, 09/13/22, 09/20/22, and 09/27/22 revealed the resident had no pressure ulcers and and bony prominences were without issues. The resident's skin remained intact at present time. No skin breakdown of any type was identified. Record review revealed a physician's order was obtained on 09/24/22 for skin prep (forms a protective film to help reduce friction to the area) to heels at bedtime. There was no reason documented for the order. Review of a skin sweep assessment, dated 09/28/22 revealed the resident had a blister on the right heel measuring 4.2 centimeters (cm) long by 4.0 cm wide. The area was noted to be unstageable (unstageable pressure ulcer: 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. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage III or Stage IV pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur). Record review revealed there was no further description of the area. The assessment noted skin prep was ordered and applied per order. Record review revealed no further documentation of the pressure ulcer to the right heel after 09/28/22. There was no evidence of any monitoring of the area to include measurements, staging, characteristics, progress toward healing, signs of infection, or presence of pain. On 10/08/22 the resident was assessed at high risk for the development of pressure ulcers (after pressure ulcer developed). Weekly skin sweeps on 10/04/22, 10/11/22, and 10/19/22 did not identify any skin issues. On 10/19/22 at 2:05 P.M. observation revealed Resident #28 had a three cm long by 2.5 cm wide red/purple area on the right heel. The skin was intact. Interview with Licensed Practical Nurse #518 at the time of the observation confirmed the presence of the areas. Interview with Acting Director of Nursing #509 on 10/18/22 at 8:30 A.M. confirmed there were no measurements or descriptions of the pressure ulcer to Resident #28's right heel since 09/28/22. She stated she did not know how often the area was to be measured/assessed. Review of the undated facility policy titled Skin Protocol Policy revealed pressure ulcers would be measured by the wound nurse or designee on a weekly basis. Interview with Registered Nurse #502 on 10/20/22 at 3:35 P.M. revealed Resident #28's right heel pressure ulcer had developed on 09/24/22 when the physician's order for treatment was obtained but had no description or measurements until 09/28/22. She confirmed there were no further measurements or descriptions of the area after 09/28/22. She stated weekly measurements were to be done. She confirmed the weekly skin sweeps completed after the development of the pressure ulcer failed to accurately identify the ongoing skin issue. Resident #28 did have a preventative skin plan of care in place prior to development of the heel pressure ulcer with evidence of interventions including heel elevation being provided. The resident was assessed by the wound physician on 10/20/22 who documented the area had healed. The concern identified was related to the lack of evidence the facility was monitoring the ulcer following the development.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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Based 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. Findings include: 1. Review of the medical record for Resident #22 revealed an original admission date on 06/26/17 and a readmission date of 04/13/19. Resident #22 had diagnoses including Parkinson's disease, atrial fibrillation, chronic obstructive pulmonary disease (COPD), dehydration, abnormal weight loss, anorexia nervosa-restricting type, major depressive disorder, and cerebral infarction (stroke). Review of the plan of care, dated 07/08/17 revealed Resident #22 was at risk for altered nutrition. Interventions included administer medications as ordered and observe for effectiveness, continue to observe weights, labs, oral intakes, and other nutritional parameters with each nutritional review as indicated. Review of resident's weights dated from 07/01/22 to 10/2022 revealed Resident #22 weighed 156 pounds on 10/05/22 and 146 pounds on 10/20/22, a weight loss of five percent since 09/18/22, 7.5% since 07/24/22, and 10% since 04/28/22. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/28/22 revealed Resident #22 had impaired cognition with Brief Interview for Mental Status (BIMS) score of three out of 15. The assessment revealed Resident #22 required total dependence from one to two staff for all activities of daily living (ADLs), except eating. The resident required supervision with set up help only with eating. The resident's weight was 159 lbs with no noted weight loss. Review of the current physician orders for October 2022 revealed Resident #22 had the following orders in place: Remeron (anti-depressant) 7.5 milligrams (mg) one tablet daily for weight loss, Arginaid Extra Liquid (nutritional supplement) 240 milliliters (mL) daily to promote weight gain, and Boost VHC Liquid (nutritional supplement) 120 mL twice daily. Review of the nutrition progress note dated 10/04/22 revealed Resident #22 had a weight on 10/02/22 of 144 pounds (lbs). The weight was a decrease of 12 lbs in one week and the note indicated was questionable. The weight loss was significant for one week, 30 days, 90 days, and 180 day time frames. Resident #22 also had a new pressure area develop on 09/28/22. A re-weigh was requested. Registered Dietitian (RD) #592 recommended adding Stress Tab with Zinc and 30 milliliters (mL) liquid protein daily for 30 days. Also recommended an increase of Remeron medication back to 15 milligrams (mg) dose. The recommendations were forwarded to nursing. Review of the nutrition progress note, dated 10/24/22 revealed Resident #22 had a re-weight on 10/05/22 which showed a weight of 156 pounds. On 10/16/22, Resident #22 weighed 142 pounds and on 10/20/22 the resident weighed 146 pounds. The note revealed Resident #22's weights continued to fluctuate. Discussed with nursing to implement nutrition recommendations from 10/04/22. Interview on 10/24/22 at 4:04 P.M. with Registered Dietician (RD) #592 confirmed nutritional recommendations made following the nutritional review on 10/04/22 were not implemented for Resident #22 by the facility staff. The same recommendations were discussed again today (10/24/22) with the Director of Nursing (DON). Interview on 10/24/22 at 6:10 P.M. with the DON confirmed nutritional recommendations made by RD #592 were not implemented and Resident #22 showed additional weight loss upon review today, 10/24/22. Review of the undated facility policy titled Weight Loss Protocol revealed if a significant weight loss occurred place resident on appropriate nutrition interventions based on the results of the assessment. 2. Review of the medical record for Resident #28 revealed an admission date of 07/01/21 and a diagnosis of dementia. The resident's plan of care, dated 08/03/21 indicated the resident had potential for nutritional risk related to decreased mobility, diuretics, cognitive deficits, history of cancer, dysphagia, and weight changes. Interventions included obtaining weights as indicated. Review of the MDS 3.0 assessment, dated 08/02/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The assessment revealed the resident required extensive assistance from staff with bed mobility and transfers and supervision with eating and had no weight loss. Review of weight records revealed Resident #28 weighed 151 pounds on 09/10/22 and 142.2 pounds on 10/02/22. This represented an 8.8 pound, 5.8% significant weight loss in one month. Review of a nutrition progress note on 10/04/22 revealed the resident had varied meal intakes. Weight noted to be 142 pounds. The note indicated the resident's weight had decreased nine pounds/six percent in 30 days. It was noted the weight loss was significant in 30 days and was noted to be after a seven pound gain (weight was 143.8 pound on 8/22/22). It was noted weight inaccuracies were suspected. A re-weight was requested with weekly weights for closer monitoring. Record review revealed no evidence the resident had been weighed since 10/02/22 when the weight loss was identified. Review of the facility undated policy titled Weight Loss Protocol revealed the procedure could be used to help prevent a significant weight loss from occurring by identifying those residents at an increased risk for weight loss, providing close monitoring of nutritional status, and providing the appropriate interventions. If any weight loss had occurred follow the facility policy and procedure for obtaining accurate weights and re-weights as necessary and again notify the dietician and physician of any significant weight changes. Obtain weekly weights. Appropriate oral supplementation would be provided when deemed necessary. Interview with Registered Nurse #502 on 10/20/22 at 3:50 P.M. confirmed Resident #28 was identified with a significant weight loss 10/02/22. She confirmed a re-weight and weekly weights had not been completed as recommended by the dietician. She confirmed the facility did not follow their policy regarding re-weight and weekly weights.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

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Based 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. Findings include: 1. Review of the facility infection line listing report for August 2022 revealed one resident, Resident #1 was identified to have urinary tract infection. The listing report noted the resident was treated with antibiotics. However, the facility had no documentation the antibiotic use had been reviewed and met the criteria for appropriate antibiotic use (urine culture with >100,000 bacteria and symptomatic). Review of the medical record for Resident #1 revealed an admission date of 06/27/22. On 08/11/22 at 10:15 A.M. a nurse's note revealed the physician was in. The resident had increased confusion, dysuria, and foul smelling urine. New orders were obtained for a urinalysis and culture and sensitivity of the urine. Urine culture results on 08/14/22 indicated a urinary tract infection with >100,000 Klebsiella Pneumoniae. On 08/15/22 an antibiotic, Macrobid was started at 100 milligrams daily for seven days. On 08/18/22 the antibiotic was increased to twice daily for the next four days. The medication was given as ordered. Interview with Acting Director of Nursing (DON) #509 on 10/26/22 at 9:25 A.M. revealed she was not aware of how the facility documented antibiotic use met the criteria for appropriate use. A follow-up interview on 10/26/22 at 1:43 P.M. revealed the DON confirmed in the past three months antibiotic surveillance tracking forms had not been used per policy. She stated the facility had used the McGeer criteria for determining infections met surveillance criteria. However, she confirmed these had not been used in the past three months. Review of the facility policy dated 2001 and revised December 2016 titled Antibiotic Stewardship-Orders for Antibiotics revealed antibiotics would be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The policy revealed appropriate indications for use of antibiotics included criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility, based on culture and sensitivity, to antimicrobial. When a culture and sensitivity was ordered, it would be completed. Review of the facility policy dated 2001 and revised December 2016 titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes revealed the Infection Preventionist or designee would review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that were not consistent with the appropriate use of antibiotics. All resident antibiotic regimens would be documented on the facility approved antibiotic surveillance tracking form. The information gathered would include: Resident name, room number, date symptoms appeared, name of antibiotic, start date of antibiotic, pathogen identified, site of infection, date of culture, stop date, total days of therapy, outcome, adverse events. 2. Review of the facility infection line listing report for September 2022 revealed one resident, Resident #16 with a urinary tract infection was identified and one resident (#16) with antibiotic use for a urinalysis only. The line listing report noted the resident was treated with antibiotics. However, the facility had no documentation the antibiotic use had been reviewed and met the criteria for appropriate antibiotic use (urine culture with >100,000 bacteria and symptomatic). Review of the medical record for Resident #16 revealed an admission date of 07/22/22. Review of a nurse's note revealed on 09/06/22 at 10:35 A.M. the physician assistant was in. The resident had complaints of dysuria with foul smelling urine. A new order was received to obtain a urinalysis with culture and sensitivity of the urine. On 09/08/22 at 9:34 A.M. nurse's notes indicated the urinalysis results were reviewed with the physician and a new order was received for an antibiotic, Macrobid 100 milligrams twice daily for seven days. There was no evidence a culture and sensitivity was done to determine if a urinary tract infection was present. Review of the medication administration record revealed the antibiotics were given as ordered. Interview with Acting Director of Nursing (DON) #509 on 10/26/22 at 9:25 A.M. revealed she was not aware of how the facility documented antibiotic use met the criteria for appropriate use. A follow-up interview on 10/26/22 at 1:43 P.M. revealed the DON confirmed in the past three months antibiotic surveillance tracking forms had not been used per policy. She stated the facility had used the McGeer criteria for determining infections met surveillance criteria. However, she confirmed these had not been used in the past three months. During the interview with Acting Director of Nursing #509 on 10/26/22 at 1:43 P.M., the DON confirmed a urine culture and sensitivity was not completed for Resident #16. She stated she did not know why. She confirmed the antibiotics were prescribed based on the urinalysis, which showed elevated white blood cells. She confirmed this would not meet the criteria for appropriate antibiotic use without a culture and sensitivity. Review of the facility policy dated 2001 and revised December 2016 titled Antibiotic Stewardship-Orders for Antibiotics revealed antibiotics would be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The policy revealed appropriate indications for use of antibiotics included criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility, based on culture and sensitivity, to antimicrobial. When a culture and sensitivity was ordered, it would be completed. Review of the facility policy dated 2001 and revised December 2016 titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes revealed the Infection Preventionist or designee would review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that were not consistent with the appropriate use of antibiotics. All resident antibiotic regimens would be documented on the facility approved antibiotic surveillance tracking form. The information gathered would include: Resident name, room number, date symptoms appeared, name of antibiotic, start date of antibiotic, pathogen identified, site of infection, date of culture, stop date, total days of therapy, outcome, adverse events. There was no evidence antibiotic surveillance tracking forms had been utilized in the past three months or that antibiotic use was evaluated to determine it met the criteria for appropriate use.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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Based 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. Findings include: 1. On 10/17/22 the facility identified 12 residents, Resident #5, #6, #7, #8, #9, #11, #15, #18, #19, #29, #31, #32 who currently had COVID-19 and were in isolation and two residents, Resident #12 and #14 who were symptomatic (of COVID-19) and in quarantine but had tested negative. The resident's rooms were located near or next to the rooms of residents who were not currently positive for COVID-19. On 10/17/22 between 11:26 A.M. and 11:32 A.M. observations revealed Resident #18 and #32's room doors were halfway open with no curtains pulled. Resident #8's room door was open all the way with a curtain pulled across the doorway that had about a three foot gap. Resident #14's room door was open all the way with a curtain pulled across the doorway. On 10/17/22 at 11:38 A.M. Resident #7's door was noted open with no curtain pulled. The resident was visible in the room. On 10/17/22 at 11:43 A.M. Resident #6's room door was noted open with no curtain pulled. The resident was visible in the room. On 10/17/22 at 11:45 A.M. Resident #31's room door was open with no curtain pulled. The resident was visible in the room. The residents had signs on their doors indicating they were on isolation. On 10/18/22 between 10:17 A.M. and 10:22 A.M. observations revealed Resident #6, #31, #9, #15, and #7 had their room doors open without a curtain pulled near doorway. The residents had signs on their doors indicating they were in isolation. On 10/18/22 at 11:01 A.M. Resident #18's door was open. On 10/18/22 at 11:03 A.M. Resident #32's door was open. On 10/18/22 at 11:06 A.M. Resident #19's door was open. These residents were in isolation for COVID-19. Interview with Acting Director of Nursing (DON) #509 on 10/18/22 at 11:28 A.M. revealed all residents on isolation/quarantine for COVID-19 should have their room doors closed unless it was a safety issue for the resident. She stated she was not aware if there were any residents who could not have their door closed. She stated the Administrator was in charge of that. Interview with the Administrator on 10/18/22 at 1:32 P.M. revealed it was the DON's responsibility to determine if a resident couldn't have their door closed during COVID-19. The facility later provided a list of five residents who were in isolation or quarantine for COVID (Residents #7, #11, #14, #18, and #32) who were not safe to have their door closed. Signs were then added to their doors indicating not to close door. Review of the facility undated policy titled COVID-19 Policy/Procedure revealed under residents with known COVID-19 infection isolation and management always ensure resident stays in resident room with door closed if possible. 2. On 10/18/22 at 8:25 A.M. observation revealed the Administrator took a meal tray into the room of Resident #42 (not positive for COVID). Although there was an outbreak of COVID-19 in the facility, the Administrator was not wearing any eye protection in the resident room. Interview with the Administrator on 10/18/22 at 8:25 A.M. confirmed she should have worn eye protection into the resident room. Observation on 10/18/22 at 10:54 A.M. revealed Therapy Director #584 was in the therapy gym. She was standing in front of Resident #10 (not positive for COVID) who was receiving therapy and was not wearing any eye protection. Interview with Therapy Director #584 on 10/18/22 at 10:54 A.M. confirmed she was not wearing any eye protection and should have. She stated she forgot. Interview with the Administrator on 10/19/22 at 10:30 A.M. revealed staff were to wear eye protection while providing direct care to residents. She stated this was per the Centers for Disease Control (CDC) Guidance the facility was following, which she indicated she would provide for review. Review of the information provided from the Centers for Disease Control and Prevention titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 Pandemic, updated 09/23/22 revealed facilities located in counties where Community Transmission was high should consider having health care personnel use eye protections during all patient care encounters. (The facility was identified in a county with substantial community transmission rate and was in outbreak status within the facility at the time of the observations). Review of the facility undated policy titled Policy and Procedure for Use of and Disinfecting Face Shields and Goggles revealed face shields/goggles would be worn while providing direct patient care when our county transmission was red (high) and during a Covid outbreak. 3. Observation on 10/17/22 at 11:32 A.M. revealed State Tested Nursing Assistant (STNA)#546 applied personal protective equipment (PPE) to enter the room of Resident #14 who was in isolation precautions due to being symptomatic for COVID-19 (tested negative). STNA #546 was observed to put an N95 mask over top of the N95 mask she was already wearing (double mask). When she exited the room she removed only the top N95 mask and continued to wear the other N95 mask that she had worn into the room. Interview with STNA #546 at the time of the observation confirmed she wore two N95 masks into the room and only removed the top one when leaving the room. The sequence for putting on and taking off PPE was posted on Resident #14's door. It stated to apply a mask upon entering the room and remove the mask and discard upon leaving the room. Interview with Acting Director of Nursing #509 on 10/19/22 at 10:05 A.M. revealed staff were not to apply two N95 masks. She stated staff should wear one N95 mask into the room and change it upon leaving the room. 4. Observation on 10/18/22 at 3:40 P.M. revealed Licensed Practical Nurse #518 and Therapy Director #584 applied PPE to enter Resident #7's room (positive for COVID-19). Both staff applied a surgical mask over top of the N95 mask they were wearing before entering the room. When Therapy Director #584 left the room, she removed the surgical mask but did not change the N95 mask she had worn into the room. Interview with Therapy Director #584 at the time of the observation confirmed she had worn a surgical mask over the N95 mask and only removed the surgical mask and did not change the N95 mask. Interview with Acting Director of Nursing #509 on 10/19/22 at 11:07 A.M. revealed staff should not put a surgical mask over the N95 mask prior to going into an isolation room. She stated staff should wear an N95 mask and change it upon leaving the room. Review of the undated facility COVID-19 Policy/procedure revealed all staff were to wear appropriate PPE when caring for a resident with known COVID-19 infection. Prior to entering isolation room, apply clean N95 mask, gown, gloves, eye protection. Prior to exiting remove all PPE and obtain clean N95 mask outside isolation room door.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected most or all residents

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Based 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. Findings include: Review of the Quality Assurance and Performance Improvement (QAPI) Committee documentation revealed the facility identified Infection Preventionist, Registered Nurse #504 was not a member of the committee. Interview on 10/17/22 at 10:01 A.M. with the Administrator and Business Office Manager (BOM) #555 revealed the facility was currently in a COVID-19 outbreak. The facility had 13 residents and one staff who had confirmed positive tests for COVID-19. The facility had an additional two residents who had tested negative for COVID-19 but were displaying signs and symptoms of the virus. On 10/25/22 at 12:37 P.M. telephone interview with Infection Preventionist(IP)/Registered Nurse (RN) #504 revealed the facility was currently searching for another IP because she had started working as a floor nurse full time about three months ago. Prior to going back to working as a floor nurse, RN #504 stated she only worked one day a week on Fridays and picked up one shift on a weekend a month because she had small children to care for at home. RN #504 stated she was not working part-time hours. RN #504 confirmed she was still the acting IP for the facility at this time. RN #504 revealed the Director of Nursing (DON) prior to the current DON had started taking training courses to become the new IP, but had not completed the coursework before she quit working at the facility. RN #504 revealed the facility had two outbreaks of COVID-19 in the last year. RN #504 stated the Administrator was in charge of most of the oversight of the facility's Infection Control and Prevention programs and procedures. Interview on 10/25/22 at 4:10 P.M. with the Administrator confirmed RN #504 was the facility current IP. The Administrator confirmed RN #504 had not been overseeing the facility's infection control and prevention programs and procedures due to working as a floor nurse. The Administrator confirmed she had been overseeing the facility's infection control programs since the previous DON quit, but stated she (the Administrator) was not a certified IP. The Administrator confirmed part-time hours would equal 20 to 25 hours per week and RN #504 only worked on Fridays and one day on one weekend of a month prior to working full-time as a floor nurse. The Administrator also confirmed RN #504 was not a member of the Quality Assurance (QA) Committee and did not attend QA meetings regularly. Review of the facility policy titled Infection Preventionist, revised 07/2016 revealed the Infection Preventionist shall coordinate the development and monitoring of our facility's established infection prevention and control policies and practices. The Infection Preventionist shall report information related to compliance with our facility's established infection prevention and control policies and practices to the Administrator and Quality Assurance and Performance Improvement Committee (QAPI). The Infection Preventionist shall keep abreast of changes in infection prevention and control guidelines and regulations to ensure our facility's protocols remain current and aid in preventing and controlling the spread of infections.

Feb 2020 8 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, review of the facility's policy, and staff interview the facility failed to provide a transfer/discharge notice and failed to notify the Ombudsman when the resident was transferred to the hospital. This affected one resident (#24) of two residents investigated for hospitalization. Hospital census was 42. Findings include Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, cerebral infarction, and cardiomegaly. Review of the comprehensive assessment dated [DATE] revealed the resident had moderate cognitive impairment. Resident #24 required extensive assistance to total care of one to two staff members for activities of daily living. Review of the progress notes revealed on 12/19/19 Resident #24 was found to be in respiratory distress with an oxygen saturation level of 88 percent (%) while receiving oxygen at three liters per minute. The resident was experiencing seizure like activity, had moist lung sounds, and was briefly unconscious. The resident was emergently transported to the hospital. Resident #24 returned to the facility on [DATE]. Interview on 02/19/20 10:29 AM with Social Service #101 revealed the facility did not provide Resident #24 nor the resident's representative with a transfer/discharge notice nor notify the Ombudsman of Resident #24's transfer/discharge to the hospital on [DATE]. Review of the facility's undated policy titled Transfers and discharged revealed there were certain situations when less than a 30 day notice would be given, including if prompt medical care was required. The policy did not discuss notification of the Ombudsman.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of bed hold letters and staff interview, the facility failed to ensure residents were notified prior to transfer to the hospital of the bed hold policy. This affected one (Resident #44) of two closed records reviewed. Findings include: Review of Resident #44's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included osteoporosis, fractured vertebrae, myelodysplastic syndrome (result from something [NAME] in the spongy material inside your bones where blood cells are made (bone marrow). Resident #44 was discharged to the hospital on [DATE] from the facility and there was no evidence the facility notified the resident or guardian of the bed hold policy upon transfer from the facility. On 02/19/2020 at 2:27 P.M. interview with Social Service #101 verified she had not given bed hold letter to resident/POA.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete an accurate Pre-admission Screening and Resident Review (PASARR) application. This affected one (Resident #14) of one residents reviewed for PASARR. The census was 42. Findings Include: Record review revealed Resident #14 was admitted to the facility on [DATE]. Her diagnoses were schizoaffective disorder, localized edema, adult failure to thrive, hypoglycemia, history of falling, dementia, type II diabetes, hypertension, anxiety disorder, and major depressive disorder. Her Brief Interview for Mental Status (BIMS) score was not calculated due to her inability to answer the questions. The assessment was attempted on 12/02/19. Review of Resident #14 medical records revealed her PASARR application (dated 12/01/12) was completed by the hospital staff from where she was discharged and then admitted to her current long term care facility. In review of the PASARR application, section D Indications of Serious Mental Illness, it was documented that she had no diagnoses of serious mental illness. But according to her medical records, she was diagnosed with Schizoaffective Disorder and Anxiety Disorder on 12/01/17. Interview with Social Services #101 on 02/20/20 at 7:55 A.M. and 8:08 A.M. confirmed that Resident #14 had both diagnoses at the time of admission, and the person who completed the application at the hospital did not complete it accurately. She confirmed the facility did not identify the inaccuracy.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to adequately monitor resident behaviors while being prescribed and using psychotropic medications. This affected two (Resident #23 and Resident #35) of six residents reviewed for psychotropic medications. The census was 42. Findings Include: 1. Record review revealed Resident #23 was admitted to the facility on [DATE]. His diagnoses were congestive heart failure, type II diabetes, acute respiratory failure, moderate protein-calorie malnutrition, chronic kidney disease (stage III), hypothyroidism, history of falling, severe sepsis, anxiety disorder, major depressive disorder, edema, acute kidney failure, pneumonia, hypertension, mitral valve disorder, pleural effusion, laporscopic surgical procedure, and hyperlipidemia. His Brief Interview for Mental Status (BIMS) score was 14, which indicated he was cognitively intact. The assessment was completed on 02/15/20. Review of Resident #23's medical records revealed he was prescribed Citalopram 20 milligrams (mg) per day for depression. On his Treatment Administration Record (TAR), there was no indication that behaviors or any other measuring tool was being monitored or tracked to determine how often depressive symptoms occurred. According to his current plan of care, he was taking psychotropic medications related to depression. One of the interventions was to observe and document signs of depression in the medical record. In review of his medical records, there was no mechanism for staff to document instances of depression; including no electronic progress notes related to depressive behaviors or observation of potential depressive behaviors. Interview with Director of Nursing (DON) on 02/20/20 at 10:23 A.M. confirmed Resident #23 did not have a mechanism for staff to capture his depressive behaviors. She confirmed the log or mechanism to capture these behaviors should be on his TAR; she confirmed it was not there. 2. Record review revealed Resident #35 was admitted to the facility on [DATE]. Her diagnoses were pneumonia, hypokalemia, conjunctivitis, severe sepsis, polyneuropathy, type anxiety disorder, major depressive disorder, hemiplegia and hemiparesis, acute respiratory failure, heart failure, hypertension, anorexia, cerebral infarction, and dysphagia. Her BIMS score was three, which indicated she was severely cognitively impaired. The assessment was completed on 01/21/20. Review of Resident #35 medical records revealed she was prescribed Cymbalta 60 mg per day and Remeron 15 mg per day for major depressive disorder, and Xanax 0.5 mg three times daily for anxiety. On her TAR, the facility was tracking the number of anxious or restless behaviors Resident #35 had each day/month. There was no indication on the TAR which behavior was exhibited on a given day; only the number of behaviors that occurred. When there was a behavior captured on the TAR, there was no documentation in any other portion of her medical records that captured which specific behavior was exhibited. According to her current plan of care, he was taking psychotropic medications related to depression and anxiety. One of the interventions was to observe and document signs of depression and anxiety in the medical record. Interview with DON and Registered Nurse (RN) #103 on 02/20/20 at 10:10 A.M. confirmed that Resident #35's TAR did not specify whether the behavior of restlessness or anxiousness was being exhibited when it was documented. The DON stated the nursing staff should be documenting in the progress notes each time there is a behavior to give context and detail to the behavioral incident. The behaviors were not listed in the progress notes as they were documented in the TAR.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observation, staff interview, and facility policy review, the facility failed to serve and prepare food in a safe and sanitary manner. This affected two (Resident #14 and Resident #36) of 40 residents who received food from the kitchen (Resident #10 and Resident #243 do not take any food or drink by mouth). The census was 42. Findings Include: Observations on 02/18/20 from 11:31 A.M. to 11:35 A.M. revealed State Tested Nursing Aide (STNA) #118 and Speech Language Pathologist (SLP) #200 touching Resident #14 and Resident #36's rolls with their bare hands to put butter on them. They grabbed the rolls with their bare hands, used a butter knife to open the rolls, and then used the same knife to butter them. After completing that task, they placed the roll back onto each resident's plate. Interview with STNA #118 on 02/18/20 at 12:02 P.M. confirmed the process of buttering a resident's roll was to pick the roll up with her bare hand, open the roll with the knife, butter the roll, and place the roll back down on the plate. She confirmed that is what she did in the dining room for Resident #36 earlier that day for lunch. Attempted interview with SLP #200 on 02/18/20 at 12:05 P.M. and 12:30 P.M. were unsuccessful (unavailable) to confirm the observation. Review of facility General Food Preparation and Handling policy (dated 2008) revealed staff are to, never touch food directly with bare hands.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected multiple residents

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Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure mechanically altered diet textures were adequately completed. This had the potential to affect seven (Residents #5, #11, #16, #17, #19, #31, and #38) of seven residents who received puree diet textures. The census was 42. Findings Include: Observation on 02/19/20 from 9:30 A.M. to 9:45 A.M. revealed [NAME] #111 placed ten portions of fish into the blender. She turned the blender on and off approximately four times, scraping the sides of the blending container after each time it was turned off. After scraping the sides of the blending container with a rubber spatula, [NAME] #111 placed the spatula in a clean, empty metal container; the spatula was not completely clean of food particles. Finally, after approximately the fourth attempt at pureeing the fish, [NAME] #111 poured the contents of the blending container, into the metal container that housed the rubber spatula that had small chunks of fish when it was placed in the metal container after each blending attempt. Also, observation during the same timeframe on 02/19/20, revealed [NAME] #111 placed 10 portions of mixed fruit into the blending container from a plastic container. She blended the fruit until it was an appropriate texture. When the blending was completed, she started to place the pureed fruit back into the original plastic container in which the whole chunks of fruit were originally. Still in the plastic container were four pieces of fruit that were not in pureed texture. Surveyor stopped [NAME] #111 from continuing to put the pureed fruit in the original plastic container. Another clean, plastic container was retrieved and the pureed fruit was placed into it with no issues. Review of facility medical records revealed there were seven residents who received a pureed diet texture (Residents #5, #11, #16, #17, #19, #31, and #38). Interview with [NAME] #111 and Dietary Supervisor #108 on 02/19/20 at 9:50 A.M. confirmed that the rubber spatula was placed into the metal pan that the pureed fish into after completing the blending. They indicated they thought there were no food chunks on the spatula, but confirmed that the spatula was placed in the pan after each time the blender container was scraped. Also, they also confirmed the pureed fruit was going to be placed back into the original plastic container that had fruit chunks still in it. Review of facility Puree Food Preparation policy (undated) revealed all pureed foods must be smooth and served with the same consistency of the moist mashed potatoes or pudding.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on infection control log review, observation, staff interview, and facility policy review, the facility failed to ensure the ice scoop was not left in the ice machine while not in use. This had the potential to affect 40 of 42 residents who receive ice from the kitchen (Resident #10 and Resident #243 do not receive any food or drink by mouth). The census was 42. Findings Include: Observation on 02/18/20 at approximately 8:35 A.M. revealed the ice scoop lying on the ice in the ice machine, not in use. Dietary Supervisor #108 immediately took the ice scoop out (using a latex glove) and took it to the main kitchen to be washed. Interview with Dietary Supervisor #108 on 02/18/20 at 8:37 A.M. confirmed the ice scoop was inside the facility ice machine when it was not in use. She confirmed the ice scoop should be outside the ice machine, not lying on the ice, so there are no infection control issues. She confirmed she would wash the ice scoop and remove the top layer of ice so that there would be no infection control issues moving forward. Review of facility Handling Clean Equipment and Utensils policy (dated 2008) revealed, clean equipment and utensils will be handled to prevent contamination. Clean equipment and utensils will be stored in a clean, dry location in a way that protects them from contamination by splashes and dust.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected multiple residents

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Based on review of the infection control log, staff interview and review of the facility policy and procedure, the failed to ensure antibiotic stewardship was implemented. This affected three of 42 residents (Residents #4, #8, and #40) and had the potential to affect all 42 residents in the facility. Findings include: 1. Review of the infection control log revealed Resident #4 was started on Macrobid 100 mg twice a day for seven days 05/09/19. The culture was negative for a Urinary Tract Infection (UTI). There was a note on the infection control log that referenced confusion. 2. Review of the infection control log revealed Resident #40 was started on Macrobid 100 mg twice a day for seven days for a urinary tract infection (UTI) on 08/06/19. No culture or sensitivity was completed. On 08/28/19 Resident #40 was again started on Macrobid 100 mg twice a day for seven days for a UTI. No culture and sensitivity was completed. 3. Review of the infection control log revealed Resident #40 was ordered Keflex 500 mg three times a day for a UTI on 11/22/19; no culture and sensitivity was completed. On 01/28/20 Resident #40 was ordered Cipro 250 mg twice a day for a UTI. No culture and sensitivity was completed. 4. Review of the infection control log revealed Resident #8 was ordered Cipro 250 mg twice a day for a UTI on 01/22/20. No culture and sensitivity was completed. On 02/19/2020 at 3:17 P.M. interview with Registered Nurse (RN) #103 verified Residents #4, #8, and #40 were ordered antibiotics without culture and sensitivity testing. RN #103 revealed it is up to the physician if he treats the symptoms and orders an antibiotic and staff try to work with the medical director. Review of the policy and procedure Antibiotic Stewardship (dated 2016) revealed antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship program.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No fines on record. Clean compliance history, better than most Ohio facilities.
• 27% annual turnover. Excellent stability, 21 points below Ohio's 48% average. Staff who stay learn residents' needs.

Concerns

• 28 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.

Bottom line: Mixed indicators with Trust Score of 68/100. Visit in person and ask pointed questions.

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About This Facility

What is Main Street Terrace's CMS Rating?

CMS assigns MAIN STREET TERRACE CARE CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Ohio, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Main Street Terrace Staffed?

CMS rates MAIN STREET TERRACE CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 27%, compared to the Ohio average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Main Street Terrace?

State health inspectors documented 28 deficiencies at MAIN STREET TERRACE CARE CENTER during 2020 to 2024. These included: 1 that caused actual resident harm and 27 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Main Street Terrace?

MAIN STREET TERRACE CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 50 certified beds and approximately 48 residents (about 96% occupancy), it is a smaller facility located in LANCASTER, Ohio.

How Does Main Street Terrace Compare to Other Ohio Nursing Homes?

Compared to the 100 nursing homes in Ohio, MAIN STREET TERRACE CARE CENTER's overall rating (4 stars) is above the state average of 3.2, staff turnover (27%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Main Street Terrace?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Main Street Terrace Safe?

Based on CMS inspection data, MAIN STREET TERRACE CARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Ohio. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Main Street Terrace Stick Around?

Staff at MAIN STREET TERRACE CARE CENTER tend to stick around. With a turnover rate of 27%, the facility is 19 percentage points below the Ohio average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.

Was Main Street Terrace Ever Fined?

MAIN STREET TERRACE CARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Main Street Terrace on Any Federal Watch List?

MAIN STREET TERRACE CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 50
Avg. Residents: 48
Occupancy: 96.4%
Ownership: For profit - Corporation
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
4-Star Rating: +30
Low Turnover: +3
1 Actual Harm citation: -5
28 Deficiencies: -10
Final Score: 68/100

Nearby Alternatives

PICKERINGTON CARE AND REHABILI... 4-star BUCKEYE CARE AND REHABILITATIO... 3-star LANFAIR CENTER FOR REHAB & NSG... 3-star

View all in LANCASTER →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 366016