Majestic Care of Beckley

Inspectors wroteBased upon record review and staff interview, the facility failed to implement and carry out the comprehensive care plan. This was found to be true for three (3) of twenty residents reviewed during the long term care survey process. Resident identifiers: #2, #16, #34, Facility census: 48a) Resident #2 Record review of physician orders revealed an order for Basaglar 100 unit/mL KwikPen insulin, to inject 10 units subcutaneously once daily for diabetes mellitus baseline coverage, with instructions to hold the medication if the resident's blood glucose reading was below 80 mg/dL (milligrams per deciliter) Review of the resident's comprehensive care plan failed to reveal interventions or parameters addressing the physician's order to hold insulin when blood glucose levels were below 80 mg/dL. [...]

Inspectors wroteBased on observation and interview, the facility failed to promote dignity while dining by ensuring residents at the same table were served lunch at the same time. This was a random opportunity for discovery during the long-term care survey process. Resident identifier: #27 Census: 48The following observations were made in the C wing dining room: On 03/02/26, four (4) residents were seated at the long table. Two residents received their meals at 12:25 PM, while Resident #27 was served at 12:38 PM. These times were confirmed during an interview with Nurse #19 at 12:38 PM. On 03/03/26, two (2) residents were seated at a table when state surveyors arrived at 12:15 PM. One resident was served at 12:32 PM, and Resident #27 was served at 12:40 PM. This information was confirmed in an interview with the DON at 12:40 PM.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses. This was true for two (2) out of eight (8) residents reviewed for the category of PASRR (Pre-admission Screening and Record Review, during the Long-Term Care Survey Process. Resident identifiers: #12 and #36. Facility Census: 48a) Resident #12 A review on 03/03/26 revealed that this resident's admission diagnoses (dated 06/19/13) included Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, Generalized Anxiety Disorder, Schizophrenia, and Epilepsy. Although the resident has current medication orders for these conditions, a review of the PASRR dated 10/10/24 shows that Schizophrenia and Epilepsy (seizures) were omitted from Section III (Current Diagnosis) and Section V (Major Mental Illness). [...]

Inspectors wroteBased upon observation, record review and staff interviews, the facility failed to follow physician orders to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This related to insulin administration and diet orders. This was found to be true for two (2) of two (2) residents reviewed during the long term care process. Resident identifiers: #2, and #15. Facility census: 48 a) Resident #15 A review of the resident's Dietary Order revealed the following: Regular diet, Regular texture, Thin consistency no salt packet, food in bowls, double protein portions all meals. 2 Peanut butter and jelly sandwiches to lunch and dinner trays. Diet Active 12/02/2025 An observation was made of the resident during lunch meal service on 03/03/26. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to increase/prevent decrease in range of motion/mobility for one (1) of three (3) residents. Resident identifier: 16. Facility census: 48.

Inspectors wroteBased on observation and interview, the facility failed to ensure Resident #34 received assistive device to prevent accidents by not having dycem in resident's recliner. This was true of one (1) of two (2) residents sampled. Resident identifier: #34. Facility census: 48. a) Resident #34 An observation at 2:23 PM on 03/03/26 confirmed Resident #34 did not have dycem in his recliner as was written in resident's care plan to help prevent falls. This was confirmed in resident's room by Nurse #39 at 2:23 PM on the same day.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #4 was provided a slow-sip cup to decrease risk for swallowing and choking problems. This was a random opportunity for discovery during the long-term care survey process. Resident identifier: #4. Census: 48a) Resident #4 At 12:30PM on 03/02/26 in the dining room on C wing, Resident #4 had a slow-sip cup listed on the meal ticket. However, Resident #4 was only given two (2) cartons of milk with straws and no cups. An interview with Nurse #19, who was in the dining room at the time, confirmed resident should have a slow-sip cup. Speech Language Pathologist (SLP) #116 came in to assist resident with his meal, and the surveyor asked if she was working on resident not using a slow-sip cup. She stated she was not and that the resident should have it. The care plan read as follows: [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure each resident was free from physical restraints. Resident #48 was physically restrained by the facility, causing psychosocial harm. This was true for one (1) of one (1) residents reviewed for physical restraints during the long term care survey process. Resident identifier: #48. Facility census: 51.

Inspectors wroteBased on record review and staff interview the facility failed to ensure residents did not receive a second purified protein derivative test (PPD) when it was not warranted. This is true for five (5) of eight (8) residents reviewed for immunizations during the survey. Resident Identifiers: #1, #4, #10, #26 and #31 Facility Census: #51 This will be cited as past non compliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not reoccur. All components of the plan of correction were completed prior to this survey beginning. Findings Include: a) Resident #1 On 08/13/24 record review shows Resident #1 received a purified protein derivative test (PPD) 04/09/24. The PPD skin test is a method used to diagnose silent (latent) tuberculosis (TB) infection. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the food was stored in accordance with professional standards for food service safety. This was identified during the long term care survey and had the potential to affect more than a limited number of residents. Identifiers: Walk-in refrigerator, Refrigerator #1, Walk-in freezer. Facility census: 51. Findings Included: a) Walk-in refrigerator During a tour of the kitchen on 08/12/24 at 10:37 AM the walk-in refrigerator the following food storage issues were identified: * [NAME] peppers that had began to rot and the outside was watery and softened with white mold. * Watermelon that had began to rot and the outside was watery and softened. * Tomato's that had began to rot and the outside was watery and softened with white mold. * Busted egg in open carton. [...]

Inspectors wroteBased on observation and staff interview the facility failed to maintain an effective infection control program to prevent spread of disease and infections by not properly identifying Enhanced Barrier Precaution (EBP) isolation rooms. This was a random opportunity of discovery. Resident Identifiers: #26, #45 and #307. Facility Census: #51 Findings Included: a) Resident #26 On 08/13/24 at 11:15 AM observation found Enhanced Barrier Precaution (EBP) isolation personal protective equipment (PPE) (provided in caddies on the door) on resident room doors that had no identifying isolation sign. The Infection Prevention Nurse #34 provided a list of residents that are in EBP. The list provided identified eighteen (18) residents that should be in EBP. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure each resident was treated with dignity and respect. Resident #48 visibly soiled for an extended period of time in the little dining room on the third floor. This was a random opportunity for discovery. Resident identifier: #48. Facility census: 51.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the residents were provided a safe, clean, comfortable and homelike environment. A wall was in poor repair in a residents room. This was a random opportunity for discovery during the long term care survey process. Identifier: Room C 316. Facility census: 51.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure each resident was free from abuse and neglect by leaving Resident #48 visibly soiled for an extended period of time. This was a random opportunity for discovery. Resident identifier: 48. Facility census: 51.

Inspectors wroteBased on record review and staff interview, the facility failed to properly investigate an allegation of injury of unknown origin. This was a discovered during an investigation of a facility reported incident. Resident identifier: #55. Facility census: 51.

Inspectors wroteBased on record review and staff interview the facility failed to ensure the admission Preadmission Screening and Resident Review (PASSR) contained all pertinent diagnoses. This was true for one (1) of seven (7) PASSRs' reviewed during the long term care survey process. Resident Identifier: #42 Facility Census: #51 Findings Include: a) Resident #42 On 08/13/24 at 8:23 AM record review shows Resident #42 has the following medical diagnosis: Schizophrenia 12/10/19 Dementia 12/10/19 Intellectual disabilities 08/28/23 The PASSR provided by the Director of Social Work #63, which was dated 10/22/19 did not contain a dementia diagnosis. The following diagnoses were on the PASSR: [...]

Inspectors wroteBased on resident interview, staff interview and observation, the facility failed to update and implement a person-centered comprehensive care plan to meet the resident preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. Resident identifiers: Resident #26 and Resident #48. Facility Census: 51.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident did not have an Activities of Daily Living (ADL) decline unless unavoidable, due to Resident #48 being physically restrained in a geri chair with a lap tray. This was true for one (1) of one (1) residents reviewed for ADL decline during the survey process. Resident identifier: 48. Facility census: 51.

Inspectors wroteBased on observation and staff interview, the facility failed to provide Actiity of Daily Living (ADL) care for dependent residents, by leaving Resident #48 soiled for an extended period of time. This was a random opportunity for discovery. Resident identifier: 48. Facility census: 51.

Inspectors wroteBased on observation and staff interview the facility failed to provide a dignified dining experience for Resident #28 when administering medications while the resident was eating in the dining room in the presence of two table mates. This was a random opportunity for discovery. Resident identifier: #28. Facility census:

Inspectors wroteBased on record review, facility documentation review, staff interview and resident interview, the facility neglected to use a lift to transfer a Resident resulting in a fractured foot. The facility also neglected to provide pain medication for a resident with a fractured foot. This was true for one (1) of three (3) Residents reviewed for abuse. Resident identifier: #18. Facility census: 51.

Inspectors wroteBased on record review, resident interview and staff interview the facility failed to report an allegation of emotional abuse within the appropriate timeframe. The failed practice was true for one (1) of three (3) Residents reviewed for abuse. Resident identifier: #18. Facility census: 51.

Inspectors wroteBased on record review, resident interview and staff interview the facility failed to investigate an allegation of emotional abuse. The failed practice was true for one (1) of three (3) Residents reviewed for abuse. Resident identifier: #18. Facility census: 51.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for one (1) of 20 residents in the long-term care survey sample. Resident identifier: #47. Facility census: 51.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the development of the comprehensive care plan for one (1) of one (1) residents reviewed for the care area of elopement. Resident identifier: #29. Facility census: 51.

Inspectors wroteBased on medical record review and staff interview the facility failed to revise a comprehensive care plan to include use of hipsters as a safety intervention for the problem area of falls for Resident #23. This was discovered for one (1) of three (3) residents reviewed for the care area of accidents. Resident identifier: #23 Facility census:

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This was discovered for one (1) of three (3) residents reviewed for the care area of limited range of motion. The order to apply hipsters to Resident #23 when out of bed was not being followed. Resident identifier: #23 Facility census:

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to ensure the resident enviroment of which the facility had control was free from accident hazards. This was a random opportunity for discovery and had the potential to effect more than a limited number of residents. Resident #38. Facility Census: 51. Findings Included: a) Resident #38 On 09/19/22 at 11:56 AM, an observation was made while interviewing Resident #38. A medication cup containing pills was sitting on the over bed table by the resident's bed. There was no indication of what the pills were as well as how long the medication cup had been sitting there. On 09/19/22 at 12:00 PM, Resident #38 stated, they just left them there .I haven't taken them yet. On 09/19/22 at 12:22 PM, Licensed Practical Nurse #108 confirmed the medication should not have been left at bedside. [...]

Inspectors wroteBased on observation and staff interview the facility failed to maintain appropriate storage procedures for a bilevel positive airway pressure device (BiPap) mask for Resident #43. This was a random opportunity for discovery and the potential to affect only a limited number of residents. Resident identifier: #43. Facility census: 51.

Inspectors wroteBased on record review, staff interview and resident interview the facility failed to provide pain management to a resident when the resident complained of pain. The failed practice was true for one (1) of three (3) residents reviewed for pain. Resident identifier: #18. Facility census: 51.

Inspectors wroteBased on observations and staff interviews the facility failed to serve foods at appetizing temperatures. Test trays temperatures revealed unacceptable temperatures for all the foods being tested. This had the potential to a limited number of residents receiving nourishment from the kitchen. Facility census:

Inspectors wroteBased on observation, record review, and staff interview the facility failed to provide appropriate assistive device to resident #21 (small maroon spoon) to maintain his ability to independently eat. This is failed practice was a random opportunity for discovery. Resident identifier: #21. Facility census: 51.

Inspectors wroteThe facility failed to store, prepare. distribute and serve food in accordance with professional standards for food service. During the kitchen tour it was discovered food was not dated after opening, and a dirty shelving unit. This had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census:

Inspectors wroteBased on record review and staff interview the facility failed to ensure a resident's medication administration record accurately reflected the nursing progress note that indicated administration of medication. The failed practice was true for one (1) of 20 sampled residents. Resident identifier: #18. Facility census: 51.