A list of the most recent deficiencies for Main Street Terrace Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2022-10-20 | 2023-01-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-20 | 2023-01-31 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-10-20 | 2023-01-31 | N |
| 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. | Health | 2022-10-31 | 2022-12-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-31 | 2022-12-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-10-31 | 2022-12-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-31 | 2022-12-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-10-31 | 2022-12-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-31 | 2022-12-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-31 | 2022-12-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-31 | 2022-12-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-31 | 2022-12-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-31 | 2022-12-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-10-31 | 2022-12-14 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-10-31 | 2022-12-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-20 | 2022-12-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-20 | 2020-04-09 | N |
| 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. | Health | 2020-02-20 | 2020-04-09 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-02-20 | 2020-04-09 | N |
| 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. | Health | 2020-02-20 | 2020-04-09 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2020-02-20 | 2020-04-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-20 | 2020-04-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-20 | 2020-04-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-02-20 | 2020-04-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-21 | 2020-04-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-21 | 2020-04-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-21 | 2020-04-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-28 | 2019-01-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-12-28 | 2019-01-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-12-28 | 2019-01-31 | N |
