Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Main Street Terrace Care Center during CMS and state inspections, most recent first.
A resident admitted with a Stage III sacral pressure ulcer did not receive appropriate treatment, leading to the ulcer worsening to an unstageable condition. The facility failed to obtain a proper treatment order, instead applying house barrier cream, which is not suitable for treating such ulcers. Interviews confirmed that necessary steps were not taken to address the ulcer, resulting in actual harm to the resident.
The facility failed to develop comprehensive care plans for four residents, omitting critical aspects such as wandering behaviors, TED hose use, supplemental oxygen, and diabetes management. Interviews with staff confirmed these deficiencies, which were not aligned with the facility's policy for person-centered care plans.
The facility failed to properly clean glucometers and ensure infection control during wound care. A nurse used an alcohol swab instead of a disinfectant wipe on a glucometer, contrary to policy. Additionally, another nurse used the same gauze on two separate wounds, leading to cross-contamination. The DON confirmed these practices did not adhere to infection control standards.
The facility failed to notify physicians of significant weight changes for a resident with congestive heart failure and abnormal urinalysis results for another resident. Despite care plans requiring monitoring and reporting, the facility did not document physician notifications. The DON and an RN confirmed these oversights.
A resident with multiple health conditions, including dementia, required assistance with denture care, which was not consistently provided as per physician's orders. Despite the care plan and MDS assessment indicating the need for assistance, the ADL Task Log showed incomplete documentation of denture cleaning. Interviews confirmed the deficiency, with the DON acknowledging the lack of documentation for the required care.
The facility failed to perform regular blood pressure checks for a resident with hypertension and did not apply TED hose as ordered for another resident. Blood pressure checks were missed for several months, and TED hose were not worn despite being marked as applied in records. Staff confirmed these deficiencies during interviews.
The facility failed to assess elopement risk and supervise residents, affecting two individuals. A resident with dementia was not assessed for elopement risk despite exit-seeking behavior, and another resident with a fall risk was left unattended in the shower, resulting in a fall. The facility's policies on elopement and fall risk were not followed, as confirmed by the DON.
A registered nurse failed to prime an insulin pen before administering 20 units of Lantus insulin to a resident with diabetes mellitus, chronic obstructive pulmonary disease, and Parkinson's disease. The nurse acknowledged not following the manufacturer's instructions during the administration process.
Failure to Implement Comprehensive Pressure Ulcer Care
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer program for a resident, leading to the deterioration of a pressure ulcer. The resident was admitted with a Stage III sacral pressure ulcer, but the facility did not obtain an appropriate treatment order upon admission. Instead, the resident was only ordered to have house barrier cream applied, which is not suitable for treating a Stage III pressure ulcer. This lack of appropriate treatment led to the ulcer worsening to an unstageable condition with slough and necrotic tissue. The resident's medical record indicated a high risk for skin breakdown, and the admission assessment confirmed the presence of a Stage III pressure ulcer. Despite this, there was no order for wound cleansing or dressing application to promote healing. Interviews with facility staff, including the Director of Nursing and the Assistant Director of Nursing, confirmed that the necessary steps to obtain a proper treatment order were not taken. The wound physician later assessed the ulcer as unstageable and prescribed a more aggressive treatment regimen. The facility's policy on skin protocol was not followed, as it stated that house barrier cream should be used as a preventative measure, not as a treatment for existing pressure ulcers. The National Pressure Ulcer Advisory Panel guidelines emphasize the importance of wound dressings and maintaining a moist environment for healing, which was not initially implemented for the resident. This oversight resulted in actual harm to the resident, as the pressure ulcer deteriorated significantly due to inadequate care and treatment.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to complete comprehensive resident care plans for four residents, leading to deficiencies in addressing their specific needs. Resident #18, with diagnoses including hemiplegia, major depressive disorder, and Parkinson's disease, did not have a care plan for wandering or exit-seeking behaviors despite having a Wanderguard order and documented incidents of exit-seeking. The Director of Nursing confirmed the absence of a care plan addressing these behaviors. Resident #15, diagnosed with dementia and other conditions, lacked a care plan for TED hose use and activities, despite physician orders and the resident's expressed interest in various activities. Interviews with the Director of Nursing and other staff confirmed these omissions. Resident #20, with conditions such as congestive heart failure and chronic respiratory failure, did not have a care plan for supplemental oxygen use, despite physician orders for oxygen therapy. A registered nurse confirmed the absence of this care plan. Additionally, Resident #9, diagnosed with diabetes mellitus and other conditions, did not have a care plan addressing their diabetes diagnosis or daily insulin use, as confirmed by a licensed practical nurse. The facility's policy requires comprehensive person-centered care plans, but these were not developed for the residents in question.
Infection Control Deficiencies in Glucometer Cleaning and Wound Care
Penalty
Summary
The facility failed to properly clean and disinfect glucometers after use, affecting one of the diabetic residents. During an observation, a registered nurse used an alcohol swab instead of an approved disinfectant wipe to clean a multi-use glucometer after checking a resident's blood sugar. This action was contrary to the facility's policy, which requires the use of a germicidal disinfectant wipe for cleaning and disinfecting glucometers. The nurse confirmed the improper cleaning method during an interview. Additionally, the facility did not ensure proper infection control practices during wound care for another resident. During an observation, a registered nurse used the same saline-soaked gauze on two separate wounds, treating them as one, which led to cross-contamination. The Director of Nursing confirmed that the nurse did not follow proper infection control practices, as each wound should have been treated separately to prevent the spread of infection.
Failure to Notify Physician of Significant Changes
Penalty
Summary
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 for another resident. Resident #38, who was admitted with diagnoses including acute respiratory failure with hypoxia, morbid obesity, and congestive heart failure, experienced weight fluctuations from April to September 2024. Despite the care plan's directive to monitor and report weight changes due to the resident's diuretic use and congestive heart failure, the facility did not document any physician notification regarding these fluctuations. The Director of Nursing confirmed that the weight changes were not reported to the attending physician. Resident #46, admitted with diagnoses including metabolic encephalopathy, type two diabetes, obstructive uropathy, and benign prostatic hypertrophy, had an abnormal urinalysis result indicating a level greater than 100,000 mixed pathogens, suggesting a contaminated sample. The care plan required monitoring lab results and reporting them to the physician, but the facility failed to notify the physician of the abnormal urinalysis result. A Registered Nurse confirmed the lack of notification to the resident's physician regarding the abnormal test result.
Failure to Assist with Oral Hygiene
Penalty
Summary
The facility failed to assist all dependent residents with oral hygiene, specifically affecting one resident who required assistance with denture care. The resident, who had diagnoses including dementia, major depressive disorder, type two diabetes, atherosclerotic heart disease, hypertension, and hypothyroidism, was admitted with a care plan indicating the need for assistance with personal hygiene and oral care. The Minimum Data Set (MDS) assessment noted the resident had mild cognitive impairment and required supervision or touching assistance with oral care. Despite a physician's order for denture care to be completed four times daily, the ADL Task Log showed that out of 88 opportunities, the resident's dentures were only documented as being cleaned 43 times. Interviews with the resident's representative and staff confirmed the deficiency. The resident's representative reported concerns to facility management about the cleanliness of the resident's dentures during visits. A State tested Nurse Aide (STNA) confirmed that if denture care was not signed off in the ADL Task Log, it was not performed. The Director of Nursing (DON) verified that the ADL Task Log was the sole documentation for ADL care and acknowledged the lack of documentation for the required denture cleaning frequency as ordered.
Failure to Monitor Blood Pressure and Apply TED Hose
Penalty
Summary
The facility failed to perform regular blood pressure checks for Resident #38, who was admitted with diagnoses including acute respiratory failure with hypoxia, hypertension, morbid obesity, and congestive heart failure. The physician's orders required monthly blood pressure checks, but records show that these checks were not completed in June, July, and August of 2024, with no blood pressure measurements recorded from May 10, 2024, to September 10, 2024. The Director of Nursing confirmed that the facility did not adhere to the required schedule for monitoring the resident's blood pressure. Additionally, the facility did not apply thromboembolic deterrent (TED) hose as ordered for Resident #29, who had diagnoses including Parkinson's disease, major depressive disorder, schizophrenia, and hypertension. The physician's orders specified that TED hose should be worn in the morning and removed at bedtime. Observations revealed that the resident was not wearing the TED hose on multiple occasions, and staff interviews confirmed that the resident had refused to wear them for an extended period. Despite this, the Medication Administration Record was inaccurately marked to indicate that the TED hose were in place.
Failure to Assess Elopement Risk and Supervise Residents
Penalty
Summary
The facility failed to assess residents for elopement risk and ensure proper supervision to prevent falls, affecting two residents. Resident #15, diagnosed with dementia and other conditions, was admitted without an elopement risk assessment. Despite showing exit-seeking behavior, the care plan did not address this risk until after the behavior was observed. The facility policy required elopement risk assessments upon admission, quarterly, and with significant changes, but this was not completed for Resident #15, as confirmed by the Director of Nursing (DON). Resident #20, with a history of falls and cognitive deficits, was identified as at risk for falls. Despite this, the resident was left unattended in the shower room by a State tested Nursing Assistant (STNA), leading to an unwitnessed fall. The resident attempted to self-transfer from the commode, resulting in a fall without injury. The facility's policy on managing falls required specific interventions to prevent falls, but the resident was left alone, contrary to the policy, as confirmed by the DON.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to ensure that staff primed insulin needles prior to insulin administration, resulting in a significant medication error. This deficiency was identified during an observation of insulin administration for Resident #9, who has diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, and Parkinson's disease. The resident, who was admitted on an unspecified date, was receiving daily insulin injections as per physician's orders. On the observed date, a registered nurse administered 20 units of Lantus insulin via a pen injector without priming the pen, contrary to the manufacturer's instructions. The nurse confirmed during an interview that she did not prime the insulin pen prior to administration, acknowledging that she should have followed the manufacturer's guidelines.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Buckeye Care And Rehabilitation | 0.9 mi | — | 21 | 0 |
| The Springs At Wyandot Trail | 1.7 mi | — | 1 | 0 |
| Lanfair Center For Rehab & Nsg Care Inc | 1.9 mi | — | 0 | 0 |
| Luxe Rehabilitation And Care Center | 4.2 mi | — | 3 | 0 |
| Arbors At Carroll | 5.8 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.