Cycle 1
Health 2024-10-28 · Fire 2024-10-28
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Lancaster, OH
Main Street Terrace Care Center
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1318 E Main Street, Lancaster, OH
(740) 653-8767
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-07-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.64
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.74
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.40
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
32%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,184
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.72
Composite VBP score used to determine payment impact.
Payment multiplier
0.9879
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2
Baseline 23.43% · Performance 21.83% · Measure score 2 · Achievement 0 · Improvement 2
Healthcare-associated infections
2.26
Baseline 8.69% · Performance 7.66% · Measure score 2.26 · Achievement 0.57 · Improvement 2.26
Total nurse turnover
7.80
Baseline 32.56% · Performance 31.82% · Measure score 7.80 · Achievement 7.80 · Improvement 0.46
Adjusted total nurse staffing
1.43
Baseline 3.70 hours · Performance 3.48 hours · Measure score 1.43 · Achievement 1.43 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.28% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 12.99% · Lower 95% interval 7.9% |
| Discharge to community | 47.2% |
50.57%
3.4 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 41.43% · Lower 95% interval 35.94% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 97.37% |
95.27%
2.1 pts better
|
Numerator 37 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 21.21% |
53.69%
32.5 pts worse
|
Numerator 7 · Denominator 33 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 11 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 38 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.66% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 9.62% · Lower 95% interval 4.1% |
| Staff COVID-19 vaccination coverage | 1.35% |
8.2%
6.8 pts worse
|
Numerator 1 · Denominator 74 |
| Staff flu vaccination coverage | 32.43% |
42%
9.6 pts worse
|
Numerator 24 · Denominator 74 |
| Discharge function score | 39.39% |
56.45%
17.1 pts worse
|
Numerator 13 · Denominator 33 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.8
1.3 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
92.4%
3.4 pts better
|
93.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.3% · Q3 90.5% · Q4 97.4% · 4Q avg 95.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.4% |
94.5%
5.1 pts worse
|
95.5%
6.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.3%
0.9 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.3% · Q3 2.4% · Q4 2.6% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.6% |
26.1%
20.5 pts better
|
11.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 4.9% · Q3 4.9% · Q4 2.7% · 4Q avg 5.6% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
6.2%
2.4 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 11.4% · Q4 0.0% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.1% |
25.4%
4.3 pts better
|
19.6%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 18.2% · Q3 17.1% · Q4 21.9% · 4Q avg 21.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.7% |
11.5%
2.8 pts better
|
16.7%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 11.1% · Q3 6.9% · Q4 6.9% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.2% |
7.7%
1.5 pts better
|
16.3%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 14.1% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.5% |
6.2%
0.7 pts better
|
14.9%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.2% · Q3 14.7% · Q4 0.0% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.2%
0.4 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.6% |
21.7%
2.9 pts worse
|
19.8%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 20.8% · Q3 31.5% · Q4 30.5% · 4Q avg 24.6% |
| Percentage of long-stay residents with pressure ulcers | 0.9% |
3.7%
2.8 pts better
|
5.1%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.5% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.6% |
78.1%
11.5 pts better
|
81.7%
7.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 88.9% · Q3 82.4% · Q4 89.6% · 4Q avg 89.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
12.5%
6.5 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.6% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.1% |
75.6%
6.5 pts better
|
79.7%
2.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 10.2% |
25.1%
14.9 pts better
|
23.9%
13.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 8.3% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-31 · Fire 2022-10-31
12 health deficiencies
Top issue: Resident Rights (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2020-02-20 · Fire 2020-02-20
8 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-10-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-10-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-10-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-06
F · Potential for more than minimal harm
2022-10-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-31
E · Potential for more than minimal harm
2022-10-31
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-01-31
E · Potential for more than minimal harm
2022-10-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-10-31
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-01-31
F · Potential for more than minimal harm
2020-02-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2020-04-09
F · Potential for more than minimal harm
2020-02-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-04-09
E · Potential for more than minimal harm
2020-02-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-04-09
Inspection history
Recent health citations
G · Actual harm
2024-10-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-10-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-10-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-28
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-06
F · Potential for more than minimal harm
2022-10-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-14
F · Potential for more than minimal harm
2022-10-31
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-10-31
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-10-31
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-10-31
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-10-31
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-10-31
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-10-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-10-31
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-10-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-10-31
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-10-31
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-12-14
E · Potential for more than minimal harm
2020-02-20
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2020-04-09
E · Potential for more than minimal harm
2020-02-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-09
E · Potential for more than minimal harm
2020-02-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2020-04-09
D · Potential for more than minimal harm
2020-02-20
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2020-04-09
D · Potential for more than minimal harm
2020-02-20
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2020-04-09
D · Potential for more than minimal harm
2020-02-20
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2020-04-09
D · Potential for more than minimal harm
2020-02-20
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2020-04-09
D · Potential for more than minimal harm
2020-02-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-04-09
Penalties and ownership
What sits behind the stars
$0
2024-10-28
Payment Denial
Payment Denial · denial start 2024-11-20 · 16 days
16 day denial
Ownership
Carecore At Main Street
5% Or Greater Direct Ownership Interest · Organization
Hertanu, Chaim
5% Or Greater Indirect Ownership Interest · Individual
Carecore Health LLC
Operational/Managerial Control · Organization
Lloyd, John
Operational/Managerial Control · Individual
Main Street Nursing Propco, LLC
Operational/Managerial Control · Organization
Wentz, Tracy
Operational/Managerial Control · Individual
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#2
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0-star overall rating with 0-star inspections
#3
Lanfair Center For Rehab & Nsg Care Inc
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3-star overall rating with 2-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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