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Deficiency Records for Main Street Care
A list of the most recent deficiencies for Main Street Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Main Street Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-08-21 | 2024-10-25 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-08-21 | 2024-10-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-08-21 | 2024-10-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-21 | 2024-10-25 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-08-21 | 2024-10-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-08-21 | 2024-10-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-08-21 | 2024-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-21 | 2024-10-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-21 | 2024-10-25 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-08-20 | 2024-10-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-20 | 2024-10-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-20 | 2024-10-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-08-20 | 2024-10-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-08-20 | 2024-10-07 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2024-08-20 | 2024-10-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-08-20 | 2024-10-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-20 | 2024-10-07 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-08-20 | 2024-10-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-09 | 2022-12-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-09 | 2022-12-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-09 | 2022-12-21 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-09 | 2022-12-21 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-08-11 | 2021-09-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-11 | 2021-09-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-11 | 2021-09-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-11 | 2021-09-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-08-11 | 2021-09-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-08-11 | 2021-09-10 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-08-11 | 2021-09-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-11 | 2021-09-10 | N |
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