Main Street Care Center

Inspectors wroteBased on resident representative and staff interviews, record review, review of the National Pressure Injury Advisory Panel 2025 guidelines and review of facility policy, the facility failed to evaluate and identify risk factors and define and implement interventions to prevent avoidable pressure injuries. Additionally, the facility failed to initiate treatment timely to the newly identified avoidable pressure injury. Actual Harm occurred on 07/19/25 when Resident #125 developed an avoidable deep tissue injury (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue.) to her right knee from an immobilizer that was not physician ordered or identified by the facility to be in place. This affected one (Resident #125) of three residents reviewed for wounds. The facility census was 113.

Inspectors wroteBased on resident representative and staff interviews, record review, policy review, and review of the National Institute for Health's National Library of Medicine (NIH) publications, the facility failed to ensure a resident who was at a high risk for falls was assessed for the cause of falls and ensure interventions were implemented to prevent additional falls. Actual Harm occurred on 04/10/25 when Resident #125 was found on the floor in her room and sustained a closed compression fracture of lumbar 3 (L3) vertebra. The facility stated the fall was related to orthostatic hypotension (sudden drop in blood pressure occurring when standing up from a sitting or lying position defined as a systolic drop of greater than or equal to 20 millimeters of mercury (mm Hg) or diastolic greater than or equal to 10 mm Hg within three minutes); [...]

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure residents meals were palatable and at a appetizing temperature. This had the potential to affect all 113 residents receiving meals from the kitchen. The facility identified there were no residents who were nothing by mouth. The facility census was 113.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure refrigerated medications were kept in a safe and sanitary manner in accordance with accepted professional practices to maintain the efficacy of medication and ensure expired medications were not kept past the recommended expiration date. This affected Residents #5, #9, #12, #18, #19, #32, #38, #50, #51, and #96 and had the potential to affected residents who receive medications from the 200-hall storage area. The facility census was 113.

Inspectors wroteBased on record review, staff interviews, observations, and review of the facility policy, the facility failed to ensure residents received the food according to the menu, recipe, and therapeutic spreadsheet. This affected Residents #9, #14, #19, #22, #47, #53, #63 and #115. The facility identified two residents were on a pureed diet. The facility census was 113.

Inspectors wroteBased on observations, staff interviews and review of facility policy, the facility failed to ensure staff followed proper hand hygiene and personal hygiene in the kitchen when serving food. This had the potential to affect 57 residents who resided on the 100, 200 and 500 halls and were receiving meals from the 200 hall serving station. The facility indicated no residents received nothing by mouth. The facility census was 113.

Inspectors wroteBased on observation, medical record review, resident and staff interviews, and interview with optometry staff, the facility failed to ensure a resident received eye glasses in a timely manner. This affected one (Resident #81) of two residents reviewed for ancillary services. The facility census was 113.

Inspectors wroteBased on medical record review, staff interview, hospice staff interview, review of the facility hospice agreement, and review of facility policy, the facility failed to ensure hospice was part of the care conference and a hospice provided care plan was part of the medical record for Resident #28. This affected one (Resident #28) of one reviewed for hospice. The facility identified 17 residents who were on hospice. The facility census was 113.

Inspectors wroteBased on medical record review, interview, and facility policy review, the facility failed to report an incident of possible neglect involving Resident #195 to the State Agency as required. This affected one (Resident #195) of three residents reviewed for elopement. The facility census was 101.

Inspectors wroteBased on medical record review, interviews, facility incident report review, the facility failed to maintain an accurate medical record. This affected one (Resident #195) of three residents reviewed for accuracy of medical records. The facility census was 101.

Inspectors wroteBased on medical record review, interviews, facility incident report review, and facility policy review, the facility failed to provide adequate supervision to prevent the elopement of one resident (Resident #195) out of three residents reviewed for elopements. The facility census was 101.

Inspectors wroteBased on closed record review, staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #202) of three residents reviewed for medication administration. The facility census was 101.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #56 received care and services to prevent prolonged pressure to her bilateral buttocks resulting in pressure injury. Actual Harm occurred on 06/24/24 at 10:00 A.M. when Resident #56, who was at risk for developing pressure ulcers and required assistance on staff for incontinence care, was left on a bed pan for a unknown length of time resulting in a deep tissue pressure injury (a serious type of pressure injury that occurred when prolonged pressure and shear forces damage the tissues beneath the skin) to her bilateral buttocks. This affected one resident (Resident #56) out of three residents reviewed for pressure injuries. The facility census was 110.

Inspectors wroteBased on observation, interview, record review and review of the manufacturers instructions and facility policy the facility failed to ensure appropriate incontinence care was provided for Resident's #43, #48 and #56. This affected three residents (#43, #48, and #56) and had the potential to affect resident residing in the facility who were incontinent. The facility census was 110.

Inspectors wroteBased on interview, record review and review of facility policy the facility failed to ensure care planned interventions were implemented to treat Resident #75's substance abuse. This affected one resident (Resident #75) out of three residents reviewed for substance abuse. The facility census was 110.

Inspectors wroteBased on interview, record review and review of facility policy the facility failed to ensure appropriate placement and interventions were in place to ensure Resident #111's choice and safety were maximized. This affected one resident (Resident #111) out of three residents reviewed for behavioral health services. The facility census was 110.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident call lights were answered in a timely manner. This affected one (Resident #59) of one resident reviewed for call lights. The facility census was 106.

Inspectors wroteBased on observation, record review, interview, facility policy and procedure review, self-reported incident (SRI) and investigation review, the facility failed to ensure bilateral bed bolsters (long firm narrow cushion used to prop, position and/ or support) were in place per the physician's orders and care plan prior to completing bed mobility and incontinence care resulting in Resident #63's fall with significant injuries. Actual Harm occurred on 01/31/24 at approximately 11:00 A.M. [...]

Inspectors wroteBased on medical record review, observation, resident interview, and staff interviews, the facility failed to ensure Resident #5's sacral pressure ulcer wound care was completed per the physician's order. This affected one (Resident #5) of three residents reviewed for pressure ulcers. The facility census was 99.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to properly store food and maintain the kitchen and the 200 hall servery in a clean and sanitary manner. This had the potential to affect all residents except one resident (#58) who received nothing by mouth. The facility census was 98.

Inspectors wroteBased on review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight Memo (QSO-20-29-NH), record review, and staff interview, the facility failed to inform residents, their representatives and families of those residing in the facility by 5:00 P.M. the next calendar day following the occurrence of a confirmed infection of COVID-19 as required. This had the potential to affect all 98 residents residing in the facility.

Inspectors wrote4. Medical record review for Resident #48 revealed an admission date of 10/29/21. Diagnoses included Alzheimer's disease and dementia with behavioral disturbance. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had impaired cognition. Resident #48 received antipsychotic medications for seven days of seven-day review period. Review of the physician's orders dated 02/01/22 revealed an order for Ativan 0.5 milligrams (mg) every four hours as needed for anxiety with no stop date noted. Interview with Director of Nursing (DON) on 03/29/22 at 4:30 P.M. verified there was no stop date for Resident #48's as needed Ativan order. The DON stated she didn't know that they needed a stop date. [...]

Inspectors wroteBased on observation, record review, and resident and staff interview, the facility failed to maintain a homelike and safe environment for the residents. This affected two (Resident #61 and #64) of 36 residents during the initial pool of the survey process. The facility census was 98.

Inspectors wroteBased on observation, record review, family interview, and staff interview, the facility failed to implement physician orders for Resident #94) and failed to assess for a device in use for Resident #48). This affected two (Resident #48 and #94) of 28 residents reviewed for devices. The facility identified six residents with wanderguards. The facility census was 98.

Inspectors wroteBased on review of the facility's policy, record review, resident interview, and staff interview the facility failed to assess and monitor the dialysis access site for one (#40) of one resident reviewed for dialysis. The facility identified two current residents receiving dialysis services. The facility census was 98.

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility failed to maintain a complete and accurate medical records. This affected three (#18 #94, and #150) of 28 residents reviewed for medical record accuracy. The facility census was 98.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure posted nursing staff was up to date as required. This had the potential to affect all 98 residents residing in the facility.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to maintain its dumpster area in a clean and sanitary condition. This had the potential to affect all 98 residents residing in the facility.