Main Street Terrace Care Center

In the surveyor’s words

From the most serious findings on record at Main Street Terrace Care Center, in the surveyor’s own words.

• Actual harm, isolatedF686Oct 28, 2024

  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… […]

• No harm, potential for more than minimal, widespreadF812Dec 31, 2025

  Based on observation, interview, and review of service report and email, the facility failed to maintain a clean stove hood in the kitchen. This had the potential to affect all 45 residents residing in the facility. The facility census was 45.Findings include:Observation of the kitchen on 12/30/25 at 10:20 A.M. revealed the kitchen hood above the stove to be dusty. Observation of the inspection and cleaning sticker on the kitchen hood revealed it was last cleaned 08/27/25 and due again after 90 days. Interview with the Dietary Manager on 12/30/25 at 10:22 A.M. confirmed the kitchen hood above the stove was dusty and should have been cleaned and confirmed the kitchen hood was supposed to be cleaned every 90 days. […]

• No harm, potential for more than minimal, widespreadF880Oct 31, 2022

  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. […]

• No harm, potential for more than minimal, widespreadF882Oct 31, 2022

  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. […]

• No harm, potential for more than minimal, patternF656Oct 28, 2024

  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 admitted [DATE] 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. […]