Majestic Care of Columbus LLC

Inspectors wroteBased on record review, review of a facility self-reported incident (SRI) and staff and resident interviews, the facility staff failed to ensure a resident was treated with respect/dignity. The affected one (#23) out one resident reviewed for resident rights. The facility census was 69.

Inspectors wroteBased on record review, staff interview, and review of a facility policy, the facility failed to ensure a resident's advanced directives matched in the paper and electronic health record. This affected one (#7) out of 26 residents in the initial sample. The facility census was 69.

Inspectors wroteBased on medical record review, review of a facility self-reported incident (SRI), staff and resident interview and facility policy review, the facility failed to ensure allegations of abuse were timely reported to the State Agency. This affected one (#23) of one resident reviewed for abuse. The facility census was 69.

Inspectors wroteBased on medical record review, review of a facility self-reported incident (SRI), review of a facility investigation, staff interview and facility policy review, the facility failed to ensure a thorough investigation was completed following a potential abuse incident. This affected one (#23) of four residents reviewed for abuse. The facility census was 69.

Inspectors wroteBased on record review, review of resident funds, and interview, the facility failed to notify each resident, who received Medicaid benefits, when the amount in the resident's account reached $200 less than the Social Security Income resource limit for one person. This affected two residents (#6 and #48) out of four residents reviewed for personal funds.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure appropriate care and services were provided, including dignity and proper technique, during routine suprapubic catheter care. This affected one (Resident #29) out of one resident reviewed for catheter care. The facility identified six residents with indwelling catheters. The facility census was 75.

Inspectors wroteBased on observations, medical record review, staff interview, and facility policy review, the facility failed to ensure pressure reducing devices were in place as ordered. This affected one (Resident #61) of three residents reviewed for pressure ulcers. The census was 75. Findings Include: Review of the medical record revealed Resident #61 was admitted to the facility on [DATE]. His diagnoses were cerebral atherosclerosis, bipolar disorder, benign prostatic hyperplasia, dementia, moderate protein calorie malnutrition, hypertension, delusional disorder, anxiety disorder, insomnia, depression, violent behavior, psychosis, visual hallucinations, and Parkinsonism. The record revealed the resident did not have any active wounds. Review of Resident #61's Minimum Data Set (MDS) assessment, dated 03/05/25, revealed he was cognitively intact. [...]

Inspectors wrote2. Review of Resident #59's medical record revealed an admission date of 01/17/25 with diagnoses including bipolar disorder, emphysema, fusion of cervical spine, spinal stenosis, other chronic pain, lumbago with sciatica, and type two diabetes mellitus, Review of Resident #59's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition and the resident received scheduled and as needed pain medications. Review of Resident #59's physician order dated 05/19/25 revealed an order for Percocet Oral tablet 325 milligrams (mg) one tablet by mouth every six hours as needed for pain. Review of Resident #59's plan of care revised 06/10/25 revealed the resident had pain related to sciatica pain radiating to legs and a chronic pain diagnosis. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control practices were implemented during routine suprapubic catheter care. This affected one (Resident #29) out of one resident reviewed for catheter care. The facility identified six residents with indwelling catheters. The facility census was 75.

Inspectors wroteBased on medical record review, hospital record review, review of the facility's incident/accident investigation, staff interview, and policy review the facility failed to develop and implement a comprehensive, individualized and effective fall management program to prevent a fall with injury for Resident #1. Actual harm occurred on 12/01/24 at approximately 12:55 P.M. when Resident #1, who had a diagnosis of dementia, fall risk with history of falls, increased lethargy and confusion sustained an avoidable unwitnessed fall out of bed resulting in head trauma/head hematoma which required hospital treatment. Prior to this fall, the resident sustained an unwitnessed fall out of bed on 12/01/24 at 1:30 A.M. with no evidence the facility implemented timely, adequate and effective interventions/measures to prevent the additional fall with injury on the same date. [...]

Inspectors wroteBased on observations, staff interviews, and record review the facility failed to ensure safe and sanitary storage of food and drink items in the kitchen to prevent contamination and/or spoilage. This had the potential to affect all 74 of 74 residents residing in the facility.

Inspectors wroteBased on observations, staff interviews, residents interviews, and record review, facility failed to ensure residents' personal funds were available in a timely manner. This affected one resident (#7) and had the potential to affect 68 additional residents (#1, #2, #3, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #26, #27, #28, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #46, #47, #48, #49, #50, #51, #52, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #69, #70, #72, #73, #74, #76, #77, #130, #180, and #182) identified to have personal fund accounts with the facility. The facility census was 74.

Inspectors wroteBased on record review and interview, the facility failed to ensure arbitration agreements were thoroughly explained in a language the resident/representative could understand and also failed to ensure all required components and information was included in the context of the agreement. This affected three residents (#25, #27 and #55) and had the potential to affect 23 additional residents (#19, #30, #32, #46, #55, #60, #61, #66, #70, #74, #75, #76, #77, #78, #79, #130, #180, #181, #182, #183, #184, #185, and #186) who were admitted to the facility since 08/05/24. The facility census was 74.

Inspectors wroteBased on observation, record review, policy review and interview, the facility failed to provide Resident #13 necessary supervision as per the resident's plan of care to ensure the resident maintained good nutrition and decreased risk of choking during meals. This affected one resident (#13) of three residents reviewed for nutrition. The facility census was 74.

Inspectors wroteBased on record review and staff interview, the facility failed timely identify and treat urinary tract infections (UTIs) for Resident #72 and Resident #59. This affected two residents (#72 and #59) of two residents reviewed for UTIs. The facility census was 74.

Inspectors wroteBased on medical record review, staff interview and facility policy review, the facility failed to ensure the physician provided a rationale for the decline of a pharmacy recommended gradual dose reduction (GDR) for Resident #31 and Resident #59. This affected two residents (#31 and #59) of five residents reviewed for unnecessary medications. The facility census was 74. Findings Include: 1. Review of the medical record for Resident #31 revealed an initial admission date of 07/19/24 with the diagnoses including but not limited to Alzheimer's disease, diabetes mellitus, bipolar disorder, hypertension, anxiety disorder, hyperlipidemia, overactive bladder, sleep disorder, dementia with mood disturbance, adjustment disorder with mixed anxiety and depressed mood, and chronic pain syndrome. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure medications were properly stored to include labeling that identified the date multi-use vials were first accessed/used, and medications did not exceed the expiration date on stock medication supplies. This affected two residents (#46 and #130) of two residents admitted to the third floor after 11/14/24. The facility census was 74.

Inspectors wroteBased on medical record review, staff interview and facility policy review, the facility failed to provide adequate justification for the use of antibiotics for Resident #73 and Resident ##72. This affected two residents (#73 and #72) of five residents review for unnecessary medications. The facility census was 74. Findings Include: 1. Review of the closed medical record for Resident #73 revealed an initial admission date of 05/13/24 with the latest readmission of 06/27/24. [...]

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure an adequate water supply was maintained in case of emergency. The facility emergency water supply policy did not include provisions for how emergency water would be stored including potable and non-potable water, method for distributing water and details for how the facility shall estimate the needed volume of water. This had potential to affect all facility residents. Facility census was 74.

Inspectors wroteBased on closed record review, review of e-mail communication, facility policy review and interview the facility failed to ensure an orderly discharge for Resident #79, when the facility did not timely inform the resident of a planned discharge and packed the resident's belongings without her knowledge or involvement. This affected one resident (#79) of three residents reviewed for discharge. The facility census was 75.

Inspectors wroteBased on observations, record review and resident and staff interview, facility failed to ensure resident rooms were kept in a clean and sanitary manner for two (Residents #29 and #55) and the facility failed to ensure it maintained resident rooms in safe, homelike and well maintained condition for nine (Residents #5, #17, #20, #22, #29, #30, #41, #65, and #69) of 11 reviewed for environment. The total facility census was 75.

Inspectors wroteBased on observations, resident and staff interviews, review of the facility census, review of a facility list and policy review, the facility failed to ensure air temperatures were maintained at a comfortable and safe range in the first-floor common area and first-floor dining room. Additionally, the facility failed to ensure the third-floor shower room and shower chair were maintained in a clean manner. This affected six residents (#19, #44, #45, #64, #69, and #76) who were utilizing the first-floor common area and dining area and had the potential to affect 34 residents (#46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78 and #79) who used the third-floor shower room out of 79 residents who resided in the facility. The facility census was 79.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure resident medications were held appropriately and were not administered. This affected one (Resident #10) out of three residents reviewed for medication administration. The facility census was 79.

Inspectors wroteBased on medical record review, review of Controlled Drug Administration Records, staff interview, and facility policy review, the facility failed to ensure the administration of controlled substances was accurately documented in the medical record. This affected two (Residents #36 and #80) out of six residents reviewed for unnecessary medications. The facility census was 81.