Main Street Care Center

In the surveyor’s words

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

• Actual harm, isolatedF686Apr 24, 2026

  Based 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. […]

• Actual harm, isolatedF689Apr 24, 2026

  Based 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. […]

• Actual harm, isolatedF686Sep 3, 2024

  Based 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. […]

• Actual harm, isolatedF689Feb 28, 2024

  Based 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. […]

• Actual harm, isolatedF689Mar 20, 2023

  Based on medical record review, hospital record review, staff interviews, review of a fall incident report, and policy review, the facility failed to ensure proper positioning in the bed occurred during care for a resident who required total assistance for bathing. This resulted in Actual Harm when Resident #114 was positioned too close to the edge of the bed while receiving bathing from a State tested Nursing Assistant (STNA) and rolled off the bed when the STNA turned away, resulting in a hospitalization for treatment of a comminuted intra-articular right proximal humerus fracture, mildly displaced anterior right 3rd through 10th rib fracture, a nondisplaced posterior right 11th rib fracture, impacted fractures of the left distal femoral metaphysis and proximal tibia metaphysis of… […]