Main Street Care

Inspectors wroteBased on record review and staff interview, the facility failed to employee a Registered Nurse for eight (8) hours per day, seven (7) days a week as required. Facility:Faciity. Facility Census: 28Findings include: a) Registered Nurse Staffing On 01/07/26 at 11:00 AM observation of the Daily Staffing Report for the time period of 12/23/25 through 01/05/26 (14 days) finds there was not a Registered Nurse (RN) on duty for eight (8) consecutive hours daily as required. The facility employees four (4) Registered Nurses. They are the Director of Nursing (DON) (#28), The Assistance Director of Nursing (ADON) (#35) and two (2) part time Registered Nurses, #18 and #19. According to a review of the Employee Period Total Report, RN #19 did not work at all during the above time period. RN #18 worked 7.3 hours over the fourteen (14) days in the time period. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure a new, current Registered Nurse waiver was completed. Resident Identifier: Facility:Facility. Facility Census:

Inspectors wroteBased on record review and staff interview the facility failed to ensure the continuing competence of nurse aides to include no less than 12 hours per year which include dementia management training and resident abuse/neglect prevention training. Facility Census: 28.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a new Preadmission Screening and Resident Review (PASRR) was completed when residents received a diagnosis of a newly evident psychiatric disorder. This deficient practice had the potential to affect three (3) of three (3) residents reviewed for the care area of PASRR. Resident identifiers: #24, #3, and #5. Facility census: 28.

Inspectors wroteBased on observation and staff interviews the facility failed to ensure resident hand hygiene was performed before meals in order to maintain an effective infection control program to prevent spread of disease and infections. Facility Census: #28 Findings Include: a) hand hygiene in rooms On 01/05/26 at 12:05 PM observation of the lunch meal tray pass found thygiene was not provided to residents on the [NAME] Hall specifically room [ROOM NUMBER] and #338. On 01/05/26 at 12:10 PM an interview with Certified Nurse Aide (CNA) #4 when asked if the residents were provided hand hygiene prior to the meal she stated, I usually give them a wipe or I give them a wet washcloth. When the surveyor stated they did not see them provide hand hygiene care, she stated, I didn't do it. On 01/05/26 at 12:25 PM observation In the dining room found hand hygiene was not performed. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed and accurate when residents were admitted with a diagnosis of an evident psychiatric disorder. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of PASRR. Resident identifier: #5. Facility census: 28.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to maintain medication in accordance with accepted standards of practice. Multi-dose insulins had been in use longer than was recommended by the manufacturer. This was a random opportunity for discovery. Resident Identifiers: #6 and #3. Facility census: 28.

Inspectors wroteBased on observation, and staff interview, the facility failed to maintain an appropriate infection control program for storage of personal hygiene products in a shared bathroom. This was a random opportunity for discovery. Facility Census: 30. Findings Included: a) Personal hygiene products On 01/14/25 at 11:05 AM, an observation was made of personal hygiene items sitting on the safety bar and on the floor of the shower. The personal items were two (2) cans of shaving cream, one (1) bottle of shampoo/conditioner/body wash, one (1) container of eczema soothing lotion, and one (1) stick. The personal hygiene items were not labeled. On 01/14/25 at 11:07 AM, Resident #12 was asked, Are these your personal items? Resident #12 stated, I think they are (Name of Resident #18). [...]

Inspectors wroteBased on record review and staff interview, the facility failed to have a Registered Nurse (RN) in the facility for at least eight (8) hours on weekends. This failed practice had the potential to affect all residents residing in the facility. Facility census: 31. a) RN weekend staffing During a record review on 08/21/24 it was revealed that the facility did not have an RN working on weekends in the facility. A review of the schedule revealed there was no RN working on 07/06/24, 07/07/24, 07/13/24, 07/14/24, 07/20/24, 07/21/24, 07/27/24, 07/28/24. In addition, there was no RN coverage on 08/03/24, 08/04/24 and 08/11/24. On 08/21/24 at 1:36 PM the Director of Nursing (DON) stated she and the Assistant Director of Nursing (ADON) were on call and can be at the facility with in seven (7) to fifteen minutes, however they did not work in the facility on weekends. [...]

Inspectors wroteBased on observations and staff interview, the facility failed to protect residents from possible hazards, by leaving five (5) medicine cups of Triamcinolone acetonide cream 0.1% at the bedside. This was a random opportunity for discovery and had the potential to affect a limited number of residents residing in the facility. Resident identifier: #13. Facility census: 31.

Inspectors wroteBased on record review and staff interview, the facility failed to provide side effect monitoring for Psychotropic medications. This failed practice was found true for (5) five of (5) five residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifiers #8, #10, #29, #6, and #30. Facility Census: 31. Findings Included: a) Resident #8 A record review on 08/20/24 at 10:01 AM, revealed that Resident #8 is prescribed the following Psychotropic medications: Alprazolam oral tablet 0.5 Milligrams (MG) Give (1) one tablet by mouth two times a day related to anxiety disorder. Depakote oral tablet delayed release 250 MG Give (1) one tablet by mouth one time a day related to anxiety disorder. Effexor XR oral capsule extended release 24 hour 75 MG Give (1) one capsule by mouth one time a day related to anxiety disorder. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide side effect monitoring for Psychotropic medications. This failed practice was found true for (5) five of (5) five residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifiers #8, #10, #29, #6, and #30. Facility Census: 31. Findings Included: a) Resident #8 A record review on 08/20/24 at 10:01 AM, revealed that Resident #8 is prescribed the following Psychotropic medications: Alprazolam oral tablet 0.5 Milligrams (MG) Give (1) one tablet by mouth two times a day related to anxiety disorder. Depakote oral tablet delayed release 250 MG Give (1) one tablet by mouth one time a day related to anxiety disorder. Effexor XR oral capsule extended release 24 hour 75 MG Give (1) one capsule by mouth one time a day related to anxiety disorder. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain cleanliness of the air conditioning vents blowing into the kitchen. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 31. Findings Included: a) Kitchen The initial tour of the facility kitchen on 08/19/24 at 12:16 PM, revealed (7) seven vents in the window blowing over the (3) three compartment sink and into the open area of the kitchen where food is prepared and served that were covered in dust and a black substance. During an interview on 08/19/24 at 12:21 PM, the Food and Nutrition Contact (FNC) #14 stated, The maintenance department takes them down for us and we clean them. Yes, I agree. It is time to get that done The FNC confirmed that the vents were dirty and covered in a black substance.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain an appropriate infection control program for storage of clean linen. This was a random opportunity for discovery. Facility Census: 32. Findings Included: a) Linen Cart On 08/20/24 at 10:42 AM, a tour of the unit was completed. During the tour, a linen cart with clean linen was observed uncovered on the top and sides. On 08/20/24 at 10:46 AM, the Assistant Director of Nursing (ADON) was notified and observed the clean linen cart which was uncovered. The ADON stated, I'll take care of this.

Inspectors wroteBased on record review and staff interview, the facility failed to provide a transfer form and notify the State Ombudsman of a transfer to an acute care facility for Resident #30. This was true for one (1) of three (3) residents reviewed under the care area of hospitalizations. Resident identifier: #30. Facility Census: 32. Findings Included: a) Resident #30 On 08/20/24 at 9:55 AM, a record review was completed for Resident #30. The review found the resident was transferred to an acute care hospital on [DATE] for an unwitnessed fall. The resident was noted with a large knot and bruising to the back of the head. The following progress note dated 06/25/24 at 2:03 PM stated, Resident found lying in the floor beside of her bed. Resident stated she, fell on her head. Full body assessment completed. Hematoma with bruise observed to back of resident's head. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide a bed hold notice for Resident #30 after a fall. This was true for one (1) of three (3) residents reviewed under the care area of hospitalizations. Resident Identifier: #30. Facility Census: 32. Findings Included: a) Resident #30 On 08/20/24 at 9:55 AM, a record review was completed for Resident #30. The review found the resident was transferred to an acute care hospital on [DATE] for an unwitnessed fall. The resident was noted with a large knot and bruising to the back of the resident's head. The following progress note dated 06/25/24 at 2:03 PM states, Resident found lying in the floor beside of her bed. Resident stated she fell on her head. Full body assessment completed. Hematoma with bruise observed to back of resident's head. Neuro (Neurological) checks initiated. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) regarding a fall for Resident #30. This was true for one (1) of two (2) residents reviewed under the care area of falls. Resident Identifiers: #30. Facility Census: 32. Findings Included: a) Resident #30 On 08/20/24 at 9:55 AM, a record review was completed for Resident #30. The review found the resident was transferred to an acute care hospital on [DATE] for an unwitnessed fall. The resident was noted with a large knot and bruising to the back of the head. The following progress note dated 06/25/24 at 2:03 PM states, Resident found lying in the floor beside of her bed. Resident stated she fell on her head. Full body assessment completed. Hematoma with bruise observed to back of resident's head. Neuro (Neurological) checks initiated. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #16's Minimum Data Set (MDS) reviewed during the Long-Term Care Survey Process (LTCSP) were accurately coded in the area of pressure ulcers. Resident identifier: #16. Facility census: 28.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to develop a care plan that specified Resident #12's medication administration needs. This failed practice was true for one (1) of 13 sample residents reviewed. Resident identifier: #12. Facility census: 28.

Inspectors wroteBased on medical record review and staff interview, the facility failed to follow physician's orders. Resident #8 had Accuchecks twice daily without an order and Resident #16 the facility failed to follow the physician's order for monthly weights. Resident identifiers: #8 and #16. Facility census: 28.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure medications were administered without any significant errors for Resident #12. This failed practice was a random opportunity for discovery and the potential to only affect a limited number of residents. Resident identifier: #12. Facility census: 28.