MAIN STREET CARE

115 SUMMERS HOSPITAL ROAD, SUITE 300, HINTON, WV 25951 (304) 466-6090
Non profit - Corporation 34 Beds Independent Data: November 2025
Trust Grade
70/100
#30 of 122 in WV
Last Inspection: August 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Main Street Care in Hinton, West Virginia, has a Trust Grade of B, indicating it is a good option among nursing homes. It ranks #30 out of 122 facilities in the state, placing it in the top half, and is the top-ranked nursing home in Summers County. The facility is improving, with a decrease in reported issues from 9 in 2024 to just 1 in 2025. Staffing is a strong point, with a rating of 4 out of 5 stars and a turnover rate of 36%, which is better than the state average of 44%. However, the nursing home has concerning RN coverage, as it has less than 97% of facilities, which may affect the quality of care, especially since there were incidents where residents were left without proper medication monitoring and had medication left at their bedside without proper orders, creating potential safety risks.

Trust Score
B
70/100
In West Virginia
#30/122
Top 24%
Safety Record
Low Risk
No red flags
Inspections
Getting Better
9 → 1 violations
Staff Stability
○ Average
36% turnover. Near West Virginia's 48% average. Typical for the industry.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most West Virginia facilities.
Skilled Nurses
⚠ Watch
Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for West Virginia. Fewer RN minutes means fewer trained eyes watching for problems.
Violations
⚠ Watch
22 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★★☆
4.0
Inspection Score
Stable
2024: 9 issues
2025: 1 issues

The Good

  • 4-Star Staffing Rating · Above-average nurse staffing levels
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record
  • Staff turnover below average (36%)

    12 points below West Virginia average of 48%

Facility shows strength in staffing levels, fire safety.

The Bad

Staff Turnover: 36%

Near West Virginia avg (46%)

Typical for the industry

The Ugly 22 deficiencies on record

Jan 2025 1 deficiency
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based 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 opp...

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Based 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). On 01/14/25 at 11:10 AM, Nurse Aide (NA) #10 was asked, do you know which resident these belong to? NA #10 said, I'm not sure .I will throw them away. On 01/14/25 at 1:00 PM, the Director of Nursing (DON) confirmed the items should be labeled.
Aug 2024 9 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide a transfer form and notify the State Ombudsman of a t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Neuro (Neurological) checks initiated. (Name of facility physician) and POA notified via phone. Resident transferred to the emergency room for evaluation. The review, also, found no transfer form in the medical record and the State Ombudsman was not notified of the transfer. On 08/20/24 at 2:30 PM, the Assistant Director of Nursing (ADON) was notified of the transfer form not being found as well as the State Ombudsman notification. On 08/20/24 at 2:35 PM, the ADON stated, we send note summaries to the acute care facility and the State Ombudsman is not notified unless the resident is admitted . No further information was obtained during the survey process.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide a bed hold notice for Resident #30 after a fall. This...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. (Name of facility physician) and POA notified via phone. Resident transferred to the emergency room for evaluation. The review, also, found a bed hold notice had not been provided to the resident. The bed hold notice provided by the facility was dated for 07/23/23. On 08/20/24 at 2:30 PM, the Assistant Director of Nursing (ADON) was notified that a bed hold notice was not completed for this transfer to an acute care facility. On 08/20/24 at 2:35 PM, the ADON stated, we use the bed hold notice which is signed upon admission to the facility.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) regarding a fall ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. (Name of facility physician) and POA notified via phone. Resident transferred to the emergency room for evaluation. The review, also, found an inaccurate MDS dated [DATE]. Section J noted the resident had no falls. Although, the resident was noted to have a fall on 06/25/24. On 08/20/24 at 2:30 PM, the Assistant Director of Nursing (ADON) was notified of the inaccurate MDS. The ADON stated, I will get that corrected right away. No further information was obtained during the survey process.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

Based 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 ...

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Based 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. Findings included: a) Resident #13 On 08/19/24 at 3:43 PM during an interview with Resident #13, this surveyor observed five (5) small medication cups on Resident #13's bedside table with white creamy substance in it. On 08/19/24 at 12:59 PM the Assistant Director of Nursing (ADON) stated, It is Triamcinolone acetonide Cream 0.1% for Resident #13's face. During an interview on 08/20/24 at 10:06 AM the Director of Nursing (DON) stated that they do not have an order for Resident #13 to self administer the medication or have it by the bedside.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected multiple residents

. Based 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...

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. Based 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. Seroquel oral tablet 50 MG Give (1) one tablet by mouth (3) three times a day related to delirium due to known physiological conditions. Further record review of Resident #10's Medication Administration Record (MAR), and Treatment Administration Record (TAR) for the months of 06/24, 07/24, and 08/24 shows no side effect monitoring for psychotropic medications. During an interview on 08/20/24 at 11:17 AM, the Director of Nursing (DON) stated, We do monitor for behaviors, we look at them every day but we do not document that we monitor for side effects. b) Resident #10 A record review on 08/20/24 at 10:01 AM, revealed that Resident #10 is prescribed the following Psychotropic medications: Xanax Tablet 0.25 Milligrams (MG) Give (1) one tablet by mouth two times a day related to generalized anxiety disorder. Zoloft Tablet 100 MG Give (1) one tablet by mouth at bedtime related to other specified depressive disorder. Risperdal tablet 0.5 MG Give (1) one tablet by mouth two times a day related to vascular dementia with behavioral disturbance. Further record review of Resident #10's MAR, and TAR for the months of 06/24, 07/24, and 08/24 shows no side effect monitoring for psychotropic medications. During an interview on 08/20/24 at 11:17 AM, the DON stated, We do monitor for behaviors, we look at them every day but we do not document that we monitor for side effects. c) Resident #6 A record review on 08/20/24 at 11:00 AM, revealed that Resident #6 is prescribed the following Psychotropic medications: Seroquel oral tablet 50 MG Give (1) one tablet by mouth (3) three times a day related to delirium due to known physiological conditions. Further record review of Resident #6's MAR, and TAR for the months of 06/24, 07/24, and 08/24 shows no side effect monitoring for psychotropic medications. During an interview on 08/20/24 at 11:17 AM, the DON stated, We do monitor for behaviors, we look at them every day but we do not document that we monitor for side effects. d) On 08/21/24 at 11:21 AM a record review for unnecessary medications was completed for Resident #29. The review found the resident was prescribed Donepezil hydrochloride, DULoxetine HCl, Mirtazapine, and Mirtazapine. The review found there was no monitoring of side-effects for these psychotropic medications. On 08/20/2024 at 11:17 AM the Assistant Director of Nursing (ADON) was notified. The ADON stated, we monitor for behaviors and we look at them every day, but we do not document that we monitor side-effects. e) Resident #30 On 08/20/24 at 10:00 AM, a record review for unnecessary medications was completed for Resident #30. The review found the resident was prescribed Risperdal, an antipsychotic; Trazodone and Paxil, antidepressants. The review found there was no monitoring of side effects for these psychotropic medications. On 08/20/24 at 11:17 AM, the ADON was notified. The ADON stated, we monitor for behaviors and we look at them every day; but we do not document that we monitor for side effects.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

Based 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 r...

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Based 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. Seroquel oral tablet 50 MG Give (1) one tablet by mouth (3) three times a day related to delirium due to known physiological conditions. Further record review of Resident #10's Medication Administration Record (MAR), and Treatment Administration Record (TAR) for the months of 06/24, 07/24, and 08/24 shows no side effect monitoring for psychotropic medications. During an interview on 08/20/24 at 11:17 AM, the Director of Nursing (DON) stated, We do monitor for behaviors, we look at them every day but we do not document that we monitor for side effects. b) Resident #10 A record review on 08/20/24 at 10:01 AM, revealed that Resident #10 is prescribed the following Psychotropic medications: Xanax Tablet 0.25 Milligrams (MG) Give (1) one tablet by mouth two times a day related to generalized anxiety disorder. Zoloft Tablet 100 MG Give (1) one tablet by mouth at bedtime related to other specified depressive disorder. Risperdal tablet 0.5 MG Give (1) one tablet by mouth two times a day related to vascular dementia with behavioral disturbance. Further record review of Resident #10's MAR, and TAR for the months of 06/24, 07/24, and 08/24 shows no side effect monitoring for psychotropic medications. During an interview on 08/20/24 at 11:17 AM, the DON stated, We do monitor for behaviors, we look at them every day but we do not document that we monitor for side effects. c) Resident #6 A record review on 08/20/24 at 11:00 AM, revealed that Resident #6 is prescribed the following Psychotropic medications: Seroquel oral tablet 50 MG Give (1) one tablet by mouth (3) three times a day related to delirium due to known physiological conditions. Further record review of Resident #6's MAR, and TAR for the months of 06/24, 07/24, and 08/24 shows no side effect monitoring for psychotropic medications. During an interview on 08/20/24 at 11:17 AM, the DON stated, We do monitor for behaviors, we look at them every day but we do not document that we monitor for side effects. d) On 08/21/24 at 11:21 AM a record review for unnecessary medications was completed for Resident #29. The review found the resident was prescribed Donepezil hydrochloride, DULoxetine HCl, Mirtazapine, and Mirtazapine. The review found there was no monitoring of side-effects for these psychotropic medications. On 08/20/2024 at 11:17 AM the Assistant Director of Nursing (ADON) was notified. The ADON stated, we monitor for behaviors and we look at them every day, but we do not document that we monitor side-effects. e) Resident #30 On 08/20/24 at 10:00 AM, a record review for unnecessary medications was completed for Resident #30. The review found the resident was prescribed Risperdal, an antipsychotic; Trazodone and Paxil, antidepressants. The review found there was no monitoring of side effects for these psychotropic medications. On 08/20/24 at 11:17 AM, the ADON was notified. The ADON stated, we monitor for behaviors and we look at them every day; but we do not document that we monitor for side effects.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based 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...

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Based 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.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based 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 Cen...

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Based 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.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

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 affe...

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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. 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. At approximately 2:00 PM on 08/21/24 the facility's Administrator stated they have an agreement with the hospital and if the on-call is not available then the emergency room RN will come up to the unit.
Nov 2022 4 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure Resident #16's Minimum Data Set (MDS) reviewed durin...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based 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. Findings included: a) Resident #16 A medical record review for Resident #16, revealed the resident had a facility acquired pressure ulcer on left posterior thigh noted on 07/15/22. A review of Resident #16's initial pressure ulcer assessment dated [DATE], revealed the resident had a stage IV (4) pressure ulcer on the left posterior thigh. The annual MDS with an Assessment Reference Date (ARD) of 09/16/22, under Section M-skin conditions, indicated the resident had a stage IV (4) pressure ulcer on the left posterior thigh which was present on admission. (re-admission date was 04/26/22). An interview was conducted with the Director of Nursing (DON) on 11/08/22 at 11:06 AM. During the interview Resident #16's medical records were reviewed, and she verified the resident had a facility acquired Stage IV (4) pressure ulcer on the left posterior thigh. She verified the MDS with ARD of 09/16/22 was inaccurate concerning the pressure ulcer on left thigh present on admission. The resident was re-admitted on [DATE] and the pressure ulcer developed on 07/15/22. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

. Based 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 ...

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. Based 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. Findings included: An observation of medication pass on 11/03/10 at 8:40 AM for Resident #12 showed Licensed Practical Nurse (LPN) #34 to crush Eliquis 2.5 mg tablet, Metoprolol Succinate 25 mg tablet, Multivitamin tablet, Plavix 75 mg tablet, Senocot 8.6-50 mg 2 tablets, and Trimethoprim 100 mg tablet and then dump all the crushed medications into apple juice. LPN #34 then opened the hydrochlorothiazide 12.5 mg capsule and sprinkled it in the juice mixture, along with 15 ml of liquid potassium (20 meq dose). LPN #34 stated, I hope it is ok to crush and mix all these together, that's the only way I can get her [Resident #12] to take them is in liquid. She [Resident #12] drinks them better through a straw than she takes them in food. A record review of Resident #12's care plan did not indicate the Resident's need to take medications crushed mixed in liquid. No specific focus for medication administration was indicated on the care plan. During an interview on 11/08/22 at 2:14 PM LPN #34 stated I have been dissolving them in juice for a while now, you have to give them [medications] to her through a straw. She won't take them on a spoon. Her daughter was giving them [medications] to her with a syringe in the hospital but we can't do that that here. Even before her last hospitalization in September 2022 she wasn't able to take her meds from a spoon mixed with food. During an interview on 11/08/22 at 2:19 PM the Director of Nursing (DON) stated, I know she was having trouble taking her mediations from a spoon, they [hospital staff] were doing it like that [putting medications in liquids] at the hospital as well. During an interview on 11/08/22 at 2:21 PM the Assistant Director of Nursing (who is responsible for care plans) stated they did not put anything specific on the care plan for Resident #12's medications being given in fluids because she thought the diet order would cover it. The diet order indicated a Regular diet, Pureed texture, Regular/Thin consistency, with no mention of the need for mediations to be given in liquids. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

. Based 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 ...

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. Based 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. Findings included: a) Resident #8 A review of Resident #8's physician orders found and order for Lantus insulin- inject 12 units subcutaneously (sq) in the morning and 10 units sq at bedtime for diabetes mellitus. (Effective date 09/29/22). Resident #8's Medication Administration Record (MAR) reviewed for October and November 2022 found the licensed nurses had obtained Accuchecks twice daily prior to the administration of the Lantus insulin. The Director of Nursing (DON) reviewed the physician orders and MAR during our interview on 11/08/22 at 2:00 PM, she verified there was no order for Accuchecks prior to the administration of the Lantus insulin. b) Resident #16 Review of Resident #16's physician orders found an order for Monthly weights. Effective 11/09/22. Review of Resident #16's electronic weights found no weights for September and October 2022. An interview with the DON on 11/08/22 at 2:20 PM, she verified Resident #16's had no weights for September and October 2022. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

. Based 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 rand...

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. Based 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. Findings included: Observation of medication pass on 11/03/10 at 8:40 AM for Resident #12 showed Licensed Practical Nurse (LPN) #34 to crush Eliquis 2.5mg tablet, Metoprolol Succinate 25mg tablet, Multivitamin tablet, Plavix 75 mg tablet, Senocot 8.6-50 mg 2 tablets, and Trimethoprim 100mg tablet and then dump all the crushed medications into apple juice. LPN #34 then opened the hydrochlorothiazide 12.5mg capsule and sprinkled it in the juice mixture, along with 15ml of liquid potassium (20 meq dose). LPN #34 stated, I hope it is ok to crush and mix all these together, that's the only way I can get to her [Resident #12] to take them is in liquid. She [Resident #12] drinks them better than she takes them in food. Review of Patient #12's medical record showed an order for Metoprolol Succinate Extended Release (ER) 24 Hour 25 MG Tablet. Give 1 tablet by mouth one time a day related to hypertensive heart disease with heart failure. Hold if pulse below 60 beats per minute. Hold if Systolic blood pressure is less than 100 or diastolic blood pressure is less than 60. Order date 10/14/22. Review of Patient #12's medical record showed may crush medication (unless on the Do Not Crush list) or open capsules and mix with food or fluids as needed. Order date 06/21/21. Record review of the facility's do not crush list titled, Meds That Should Not Be Crushed, dated January 2020, showed Metoprolol Succinate as a medication that should not be crushed due to the drugs modified release properties. During an interview on 11/08/22 at 10:15 AM, the facility pharmacist stated that the Metoprolol Succinate Extended Release (ER) 24 Hour 25 MG Tablet was an extended-release dose and should not have been crushed. The Pharmacist was not aware nursing staff was giving the medication this way or that Resident #12 had a special need for medication to be administered in liquids. Record review of Resident #12's care plan did not indicate the Resident's need to take medications crushed mixed in liquid. During an interview on 11/08/22 at 2:14 PM LPN #34 stated I have been dissolving them in juice for a while now, you have to give them [medications] to her through a straw. She won't take them on a spoon. Her daughter was giving them [medications] to her with a syringe in the hospital but we can't do that that here. Even before her last hospitalization in September 2022 she wasn't able to take her meds from a spoon mixed with food. During an interview on 11/08/22 at 2:19 PM Director of Nursing (DON) stated, I know she was having trouble taking her mediations from a spoon, they [hospital staff] were doing it like that at the hospital as well. During an interview on 11/08/22 at 2:21 PM the Assistant Director of Nursing (who is responsible for care plans) stated they did not put anything specific on the care plan for the medications being given in fluids because she thought the diet order would cover it. The diet order indicated a Regular diet, Pureed texture, Regular/Thin consistency, with no mention of the need for mediations to be given in liquids. .
Aug 2021 8 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

. Based on medical record review and staff interview, the facility failed to ensure a resident's Physician's Order for Scope of Treatment (POST) form conveying end of life wishes was complete. This wa...

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. Based on medical record review and staff interview, the facility failed to ensure a resident's Physician's Order for Scope of Treatment (POST) form conveying end of life wishes was complete. This was true for one (1) of 11 residents reviewed during the long-term care survey process. Resident identifier: #8. Facility census: 29. Findings included: a) Resident #8 Review of Resident #8's medical records revealed a Physician's Order for Scope of Treatment (POST) form. The responsible party completed the POST form and checked the box indicating intravenous (IV) fluids were desired. The POST form required a specific time period to be completed regarding how long IV fluids would be provided. The time period was not specified on the POST form. On 08/10/21 at 10:09 AM, the Director of Nursing (DON) verified the POST form did not contain any direction for the time frame for which IV fluids would be administered. No further information was provided through the completion of the survey. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

. b) Resident #20 Review of Resident #20's medical records showed a diagnosis of generalized anxiety disorder, for which the resident was prescribed the medication Ativan (lorazepam). Resident #20's ...

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. b) Resident #20 Review of Resident #20's medical records showed a diagnosis of generalized anxiety disorder, for which the resident was prescribed the medication Ativan (lorazepam). Resident #20's quarterly Minimum Data Set (MDS) Assessment with Assessment Reference Date (ARD) 07/02/21 did not document a diagnosis of generalized anxiety disorder. On 08/11/21 at 10:30 AM, the Assistant Director of Nursing (ADON) confirmed Resident #20's MDS with ARD 07/02/21 was incorrect and should have documented a diagnosis of generalized anxiety disorder. No further information was provided through the completion of the survey. Based on medical record reviews and staff interviews the facility failed to accurately complete Minimum Data Sets (MDS) for active diagnoses. This was true for two (2) of eleven (11) residents reviewed for unnecessary medications during the Long Term Care Survey Process (LTCSP). Resident identifiers: #12 and #20. Facility census: 29 Findings included: a) Resident #12 A medical record review on 08/11/21 revealed Resident #12 was taking Allopurinol Tablet 300 milligrams (mg) in the morning for Gout. A review of the Medication Administration Record (MAR) for the month of July 2021, verified Resident #12 had received the medication as ordered. Further review of the current Physician's Orders for August 2021 had an order for Colchicine capsule 0.6 mg every 24 hours as needed for Gout. The annual MDS with an Assessment Reference Date (ARD) of 06/11/21, revealed the Active Diagnoses section did not accurately reflect the diagnosis of gout. An interview with the Assistant Director of Nursing on 08/11/21 at 10:35 AM, verified the Active Diagnoses section of the MDS did not reflect the diagnosis of gout for Resident #12. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

. Based on medical record review and staff interview, the facility failed to contact the physician for a change in condition following a head injury. This was true for one (1) of two (2) residents rev...

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. Based on medical record review and staff interview, the facility failed to contact the physician for a change in condition following a head injury. This was true for one (1) of two (2) residents reviewed for the care area of Accidents during the Long Term Care Survey Process (LTCSP). Resident identifier: #22 Facility census: 29 Findings included: a) Resident #22 A medical record review on 08/10/21 for Resident #22 revealed an Incident/Accident Report for a fall on 01/04/2, where the resident was found on the floor outside the bathroom. The assessment revealed a large hematoma to the back of head on the right side, vital signs were taken and the physician was notified, and an order was obtained to start neurological cheeks. A review of the progress note on 01/08/21 at 2:35 PM (as written) reported: Resident had complaint of a headache, medicated with Tylenol at 8:30 AM and Ultram at 12:15 PM. There was no indication the physician or resident representative had been contacted regarding change in condition. An interview with the Director of Nursing (DON) on 08/10/21 at 11:45 AM, verified the physician or resident representative should have been contacted for the change in condition on 01/08/21 when Resident #22 had complaint of a headache. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

. Based on record review and staff interview, the facility failed to establish pharmaceutical procedures to promptly identify the loss or potential diversion of controlled medications. This had the po...

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. Based on record review and staff interview, the facility failed to establish pharmaceutical procedures to promptly identify the loss or potential diversion of controlled medications. This had the potential to affect all residents receiving controlled substances. Facility census: 29. Findings included: a) Medication Storage and Labeling On 08/10/21 at 09:05 AM, the facility's controlled substance notebook and procedures were reviewed with Licensed Practical Nurse (LPN) #11. Controlled substances were in blister packs kept in a locked drawer in the medication cart. Blister packs, also called cards, had each tablet encased in a sealed, numbered compartment. Each resident had a separate blister pack for each controlled substance. Each blister pack had a corresponding tally sheet. The tally sheets were hole punched and kept in a notebook at the medication cart. When the medication was needed, the tablet was removed from the blister compartment by the nurse. The medication removal was recorded on the tally sheet in the notebook, along with the number of tablets remaining in the blister pack. A controlled substance count was performed every shift to recognize any discrepancies that may indicate documentation errors or possible drug diversion. LPN #11 stated that each shift change, the oncoming nurse and outgoing nurse counted the medications remaining on each card and ensured the number matched the amount documented on the tally sheets. LPN #11 stated the number of cards were not counted. LPN #11 was asked how it could be determined cards were missing if someone were to remove the card and the accompanying tally sheet. LPN #11 stated she did not know. During an interview on 08/10/21 at 9:16 AM, the Director of Nursing (DON) was informed of the situation described above. She agreed that if the tally sheet and card were removed, a period of time could pass before anyone realized the card was gone. The DON agreed that counting the number of cards each shift in addition to the number of tablets remaining would reveal if a card and tally sheet had been removed. She stated that the procedure for the controlled substance count would be changed to include counting the number of cards every shift. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

. Based on medical record review and staff interview, the facility failed to ensure policies regarding medication regimen reviews and consultant pharmacist reports indicated the time frame for physici...

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. Based on medical record review and staff interview, the facility failed to ensure policies regarding medication regimen reviews and consultant pharmacist reports indicated the time frame for physicians to respond to recommendations made by the pharmacist. This was a random opportunity for discovery. Facility census: 29. Findings included: a) Policy review Review of the facility's policies titled Medication Regimen Reviews with effective date 10/15/2011 and Consultant Pharmacist Reports with effective date 10/01/2015 revealed the policies did not indicate the time frame for physicians to respond to recommendations made by the pharmacist. During an interview on 08/11/21 at 09:02 AM, the Director of Nursing (DON) confirmed the facility did not have a policy indicating the time frame for physicians to respond to recommendations made by the pharmacist. She stated the policies would be revised to include this. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

. Based on medical record review and staff interview, the facility failed to ensure a yearly Gradual Dose Reduction (GDR) for a psychotropic medication was attempted or was documented as clinically co...

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. Based on medical record review and staff interview, the facility failed to ensure a yearly Gradual Dose Reduction (GDR) for a psychotropic medication was attempted or was documented as clinically contraindicated. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #25. Facility census: 29. Findings included: a) Resident #25 Review of Resident #25's medical records showed she was prescribed Ativan (lorazepam) 0.25 mg every morning for anxiety disorder. The pharmacist's Note to Attending Physician/Prescriber dated 04/17/20 stated, The patient is receiving anxiolytic Ativan 0.25 mg daily. It is recommended to attempt a Gradual Dose Reduction (GDR) of these mediations at regular intervals. If appropriate, please consider a trial of reducing or discontinuing this medication. The physician declined to attempt a GDR due to the resident's chronic anxiety. The medical records contained no further GDR attempt or documentation of GDR contraindication for Resident #25's Ativan. The pharmacist's Note to Attending Physician/Prescriber dated 04/19/21 only requested consideration of a GDR for the resident's Zoloft (sertraline), an antidepressant. This note was signed by the physician on 04/20/21. During an interview on 08/11/21 at 8:43 AM, the Director of Nursing confirmed no GDR had been addressed for Resident #25's Ativan since 04/21/20. The DON did provide a physician's progress noted dated 04/26/21 which stated, Continue p.r.n. [as needed] pain medication, anxiolytic and laxatives. No evidence of a further GDR attempt or documentation of GDR contraindication for Resident #25's Ativan was provided through the completion of the survey. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0773 (Tag F0773)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview and policy review the Medical Director (or designee) failed to respond to a no...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview and policy review the Medical Director (or designee) failed to respond to a non-immediate laboratory test result in a timely manner. This was discovered for one (1) of five (5) residents reviewed for unnecessary medications during the Long Term Care Survey Process (LTCSP). Resident identifier: #4 Facility census: 29 Findings included: a) Resident #4 A medical record review on 08/10/21 revealed a Comprehensive Metabolic Panel (CMP) was collected on 04/20/21 and the Medical Director (or designee) did not review the laboratory test results until 04/28/21. The CMP indicated Resident 4's potassium level was low and orders for Potassium 10 milli-equivalents ([NAME]) to be given daily and repeat testing in 30 days. A review of the policy for Lab, Radiology and Diagnostic Test Results, had Time Frames for Physician Responses: The physician should respond within one (1) hour regarding test results requiring immediate notification, and by the end of the next office day for non-emergency test results. An interview with the Director of Nursing (DON) on 08/10/21 at 1:35 PM, verified the Medical Director (or designee) did not respond to the laboratory test results in a timely manner and this was not their standard of practice. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

. Based on medical record review and staff interview the facility failed to ensure a complete and accurate medical record regarding a resident's determination of capacity. This was discovered for one ...

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. Based on medical record review and staff interview the facility failed to ensure a complete and accurate medical record regarding a resident's determination of capacity. This was discovered for one (1) of eleven (11) sample residents reviewed during the Long Term Care Survey Process (LTCSP). Resident #22 had an incomplete Physician's Determination of Capacity. Resident identifier: #22 Facility census: 29 Findings included: a) Resident #22 A medical record review on 08/11/21, revealed a Physician's Determination of Capacity, for which the physician indicated Resident #22: Demonstrates Incapacity to make medical decisions. The physician failed to date the determination. This failed practice did not inform the resident representative of an effective date for decision making regarding life-prolonging interventions or mental health treatments. An interview with the Director of Nursing (DON) on 08/11/21 at 1:50 AM, verified Resident #22's Physician's Determination of Capacity was not signed at the time of completion. .
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most West Virginia facilities.
  • • 36% turnover. Below West Virginia's 48% average. Good staff retention means consistent care.
Concerns
  • • 22 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.

About This Facility

What is Main Street Care's CMS Rating?

CMS assigns MAIN STREET CARE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within West Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Main Street Care Staffed?

CMS rates MAIN STREET CARE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 36%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Main Street Care?

State health inspectors documented 22 deficiencies at MAIN STREET CARE during 2021 to 2025. These included: 22 with potential for harm.

Who Owns and Operates Main Street Care?

MAIN STREET CARE is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 34 certified beds and approximately 29 residents (about 85% occupancy), it is a smaller facility located in HINTON, West Virginia.

How Does Main Street Care Compare to Other West Virginia Nursing Homes?

Compared to the 100 nursing homes in West Virginia, MAIN STREET CARE's overall rating (4 stars) is above the state average of 2.7, staff turnover (36%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.

What Should Families Ask When Visiting Main Street Care?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Main Street Care Safe?

Based on CMS inspection data, MAIN STREET CARE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Main Street Care Stick Around?

MAIN STREET CARE has a staff turnover rate of 36%, which is about average for West Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Main Street Care Ever Fined?

MAIN STREET CARE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Main Street Care on Any Federal Watch List?

MAIN STREET CARE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.