Mainplace Post Acute

In the surveyor’s words

From the most serious findings on record at Mainplace Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 11, 2026

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure two of three final sampled residents (Residents 4 and 9) reviewed for accident hazards were free from accident hazards. * Resident 4 had a witnessed fall incident on 10/18/25, resulting in a left hip fracture and hospitalization. The facility failed to ensure appropriate safety measures were implemented during Resident 4's use of the sit-to-stand lift machine, including ensuring proper staff positioning and use of the sling's waist belt. Furthermore, the facility failed to conduct a thorough investigation to determine the cause of Resident 4's fall incident. […]

• Actual harm, isolatedF726Mar 11, 2026

  Based on interview and facility document review, the facility failed to ensure one out of one CNA (CNA 7) demonstrated the competencies and skill sets needed to provide safe nursing care. * The facility failed to ensure CNA 7 had the appropriate competence and skill set required to safely operate the sit-to-stand lift machine. In addition, CNA 7 was unable to differentiate between the types of belts used with the lift and was unable to identify the appropriate sling size for the sit-to-stand lift machine. […]

• Actual harm, isolatedF689Feb 16, 2023

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) remained free from accident hazards. Resident 1 had a history of elopement and left the facility multiple times without notifying the nursing staff. The facility's back door area was direct access to the street, did not have a camera or alarm system to set off if someone entered or exited the building. Resident 1 eloped from the facility and was hit by a car, resulting in death. Findings: Review of the facility's P&P titled Elopement - Policy and Assessment (undated) showed elopement is defined as slipping away secretly, running away, leaving without accompaniment or knowledge of the staff. […]

• No harm, potential for more than minimal, widespreadF880Mar 25, 2022

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * The facility failed to conduct the infection surveillance for the months of November and December 2021. This posed the risk of the facility not accurately investigating and preventing new infections from developing and an outbreak going unrecognized within the facility. * The facility failed to ensure COVID 19 screening which included screening for symptoms of COVID-19 of the visitors and resident's families were completed before allowing to enter the facility. […]

• No harm, potential for more than minimal, patternF698Mar 11, 2026

  Based on observation, interview, medical record review and facility P&P review, the facility failed to provide the necessary dialysis care and services for three of five final sampled residents (Residents 1, 63, and 135) reviewed for dialysis. * The facility failed to monitor Residents 1 and 63's fluid intake accurately as per the physician's order. In addition, the facility failed to monitor Resident 1 and 63's dialysis access site accurately. * The facility failed to ensure Resident 135's dialysis access site was consistently and accurately assessed as ordered by the physician. […]