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
Staffing
Hours and turnover
RN hours / resident day
0.64
Registered nurse staffing
LPN hours / resident day
0.88
Licensed practical nurse staffing
Aide hours / resident day
2.22
Nurse aide staffing
Weekend hours
3.40
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
32%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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