Majestic Care of Bedford

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided the informed consent prior to an increase or a start of a psychotropic medications for 2 of 5 residents reviewed for unnecessary medications. (Resident 13 and 23)

Inspectors wroteBased on record review and interview, the facility failed to ensure the Discharge MDS (Minimum Data Set) assessment was completed within allotted timeframe for 1 of 1 residents reviewed for resident assessment. (Resident 108)

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. (Resident 23)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order was current for a resident receiving oxygen via a nasal cannula for 1 of 2 residents reviewed for respiratory care. (Resident 3)On the following dates and times, Resident 3 was observed in her room receiving oxygen from a humidifying oxygen delivery machine via a nasal cannula: 5/8/26 at 1:54 p.m.5/12/26 at 10:10 a.m. and 12:13 p.m.5/13/26 at 10:35 a.m. During an interview on 5/8/26 at 1:55 p.m., Resident 3 indicated after her last hospitalization she was told to use the oxygen for another 30 days. It was past 30 days, and she was still wearing the nasal cannula and receiving oxygen, because staff told her she needed it. The nasal cannula bothered her, and she did not want to wear it if it was not necessary. On 5/11/26 at 11:05 a.m., Resident 3's clinical record was reviewed. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from mental abuse by staff for 1 of 3 residents reviewed for abuse. CNA's covered a resident's face with a pillowcase during care. This deficient practice would result in a reasonable person experiencing distress, disorientation, fear, and mental anguish. (Resident B, CNA 2, CNA 3)

Inspectors wroteBased in interview and record review, the facility failed to ensure staff possessed the skill sets to provide care to a resident with behavior health needs for 1 of 3 residents reviewed for behavioral health. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from physical abuse when a severely cognitively impaired male resident grabbed another female resident by the hair, grabbed female resident's face causing a scratch, and slapped resident in the face and pushed on their eyes causing a corneal abrasion for 3 of 3 residents reviewed for abuse. (Resident B, Resident D, Resident E, Resident F)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received urinary incontinence care for a resident that was incontinent of urine for 1 of 3 residents reviewed for urinary incontinence. (Resident F)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for 1 of 2 kitchen observations. Food was not discarded by the discard date and food was stored under the condenser fan. This had the potential to affect 85 of 102 residents who were served food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and the resident representative for 2 of 3 residents reviewed for hospitalization. (Resident 41, Resident 74)

Inspectors wroteBased on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for a resident who transferred to the hospital was provided in writing to the resident or the resident representative for 1 of 3 residents reviewed for hospitalization. (Resident 41)

Inspectors wroteBased on interview and record review, the facility failed to document and implement new interventions to prevent falls for 1 of 5 residents reviewed for accidents. (Resident 31)

Inspectors wrote2. On 6/13/24 at 11:46 a.m., Resident 94's clinical record was reviewed. The diagnoses included, but were not limited to, heart failure and atrial fibrillation (a rapid and irregular heartbeat of the heart's upper chambers). A 3/16/24 progress note indicated the resident was sent to the hospital at 7:07 a.m., due to a critical digoxin lab (a test measures the amount of the heart medicine digoxin in the blood) result. The clinical record lacked documentation of written Notice of Transfer and Discharge forms having been provided to the resident and the resident representative. Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and the resident representative for 3 of 3 residents reviewed for hospitalization. (Resident 67, Resident 94, Resident 15)

Inspectors wrote2. On 6/13/24 at 11:46 a.m., Resident 94's clinical record was reviewed. The diagnoses included, but were not limited to, heart failure and atrial fibrillation (a rapid and irregular heartbeat of the heart's upper chambers). A 3/16/24 progress note, indicated the resident was sent to the hospital at 7:07 a.m., due to a critical digoxin lab (a test measures the amount of the heart medicine digoxin in the blood) result. The clinical record lacked documentation of written notification which specified the facility's bed-hold policy having been provided to the resident or the resident representative. Based on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for a resident who transferred to the hospital was provided in writing to the resident or the resident representative for 3 of 3 residents reviewed for hospitalization. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's Minimum Data Set assessment was electronically transmitted to the Center for Medicare and Medicaid Services system within 14 days of the final completion date for 1 of 1 residents reviewed for Resident . (Resident 12)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received an accurate Minimum Data Set (MDS) assessment, reflective of the resident's status at the time of the assessment for 2 of 22 residents reviewed for accuracy of assessments. (Resident 67, Resident 92)

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for a resident with behaviors for 1 of 1 residents observed for behaviors. (Resident 60)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment or services to prevent further decrease in range of motion for 3 of 5 residents reviewed for mobility. (Resident 29, Resident 63, Resident 79).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an open vial of insulin contained an open date for 1 of 1 resident reviewed for insulin during medication administration. (Resident 60)

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were provided for a resident with an order to obtain a blood draw every six months for 1 of 5 residents reviewed for unnecessary medications. (Resident 67)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to prevent accidents for 3 of 3 residents reviewed for accident hazards. Residents were in possession of electronic cigarettes and were not assessed for the safe use of electronic cigarettes. (Resident F, Resident C, Resident D)

Inspectors wroteBased on observation and interview, the facility failed to ensure a clean and sanitary environment for 3 of 5 shower rooms observed. A build up of soap scum and yellow discoloration in the shower stalls and personal care items were not stored in a sanitary manner. (Memory Care Shower Room, 300 Hall Shower Room, 500 Hall Shower Room)