Main Street Care

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF727Jan 8, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF731Jan 8, 2026

  Based 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: #28 Findings include: a) Registered Nurse Waiver 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. […]

• No harm, potential for more than minimal, widespreadF947Jan 8, 2026

  Based 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.Findings include: a) Certified Nurse Aide Training On 01/07/26 at 1:10 PM review of Certified Nurse Aide (CNA) training documentation for the following staff members were missing required training documentation on Abuse/Neglect. Staff Members:Nure Aide: #4, #9, #11, #15, #33 On 01/07/26 at 1:32 PM during an interview with the Administrator and Director of Nursing they stated there is no training for abuse/neglect. They felt this was covered under the Ethics in Healthcare in Medline University. […]

• No harm, potential for more than minimal, widespreadF727Aug 21, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF644Jan 8, 2026

  Based 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. Findings included:a) Resident #24 Review of Resident #24's medical record showed a Preadmission Screening and Resident Review (PASRR) was completed on 03/22/22. No diagnoses of mental illnesses were documented on the PASRR. On 10/01/24, while a resident at the facility, Resident #24 received a diagnosis of major depressive disorder, recurrent, moderate. […]