Majestic Care of Fairfield LLC

Inspectors wroteBased on observations, interviews, record reviews and facility policies and procedures, the facility failed to ensure staff followed infection control policies and procedures. This affected three Residents (#77, #85 and #61) of the three residents reviewed for infection control. The Facility census was 138.

Inspectors wroteBased on observation, staff interview, and record review the facility failed to ensure medications were stored and labeled properly. This affected seven (#14, #108, #153, #64, #103, #84 and #160) but had the potential to affect all residents. The facility census was 138.1) Record review for Resident #14 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: end stage renal disease, type 1 diabetes, and vascular dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had moderate cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 12. Review of physician orders dated 01/28/26 for Resident #14, revealed the resident was ordered to receive insulin lispro subcutaneous solution pen-injector. Orders dated 04/16/26 revealed an order for insulin glargine solution (Lantus). [...]

Inspectors wroteBased on observation, policy review and interviews, facility failed to Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This had the potential to affect 134 residents who received food from the kitchen. The facility census was 138.

Inspectors wroteBased on observation, record review and staff interview, facility failed to treat residents with dignity and respect. This affected two Residents (#39 and #106) of the three residents (#39, #106 and #110) reviewed for resident rights. Facility census was 138.

Inspectors wroteBased on medical record review, observation and staff interview, facility failed to establish a mood and behavior care plan for residents who demonstrated varying moods and behaviors This affected one (#110) of the three residents reviewed for behaviors in the Memory Care Unit (MCU) The facility census was 138Findings include: Review of Resident #110's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance, irritable bowel syndrome, spinal stenosis, and depression. Review of resident's Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #110 to be severely cognitively impaired, dependent for all activities of daily living and on hospice services. Review of the nurse's progress notes dated 05/01/26, revealed Resident #110 was sent out to the hospital and was admitted to the psychiatric unit. [...]

Inspectors wroteBased on Observation, medical record review, staff and resident interviews and review of the facility policy. The facility failed to ensure residents followed safe smoking practices which included smoking in their rooms. This affected one (#01) out of the three Residents (#01, #05, and #45) reviewed for smoking. The facility census was 138.

Inspectors wroteBased on medical record review, resident interview, staff interview, and facility policy review the facility failed to ensure residents followed safe smoking practices which included smoking in their rooms. This affected two Residents (#111 and #112) out of three Residents (#105, #111, and #112) reviewed for smoking. The facility identified the following seventeen Residents (#04, #06, #10, #14, #15, #24, #27, #33, #38, #43, #47, #53, #62, #63, #77, #85, #105) as smokers. The facility census was 145.

Inspectors wroteBased on observation and staff interview, the facility failed to have a Licensed Social Worker to provide services to the residents. This had the potential to affect all of the residents in the facility. The facility census was 135 residents.

Inspectors wroteBased on medical record review, review of facility posted signage, review of letter from Administrator, and staff interviews, the facility failed to administer the facility to ensure residents, families, and appropriate authorities were timely notified regarding a Legionella infection and potential water contamination in the facility. This had the potential to affect all residents. The facility census was 149.

Inspectors wroteBased on medical record review, review of letter from Administrator, review of email correspondence from the local health department, policy reviews, review of water temperature audits, review of Environmental Assessment of Water Systems report, review of the third -party consultant action plan, review of infection control logs, review of contract with a Water Management Consultant Company and staff interviews, the facility failed to implement a water management program to prevent Legionella in the water system and report a case of Legionella to the local authorities. This affected one (#10) of three residents reviewed for Legionella and had the potential to affect all 149 residents residing at the facility. The facility census was 149.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide a sanitary and comfortable environment for the residents, staff and public. This had the potential to affect the residents residing on the memory care unit, 200 and 300 halls. Census was 149.

Inspectors wroteBased on staff interview and review of resident fund account documents, the facility failed to ensure timely conveyance of resident funds following discharge. This affected one (#3) of three residents reviewed for funds post discharge. The facility census was 144.

Inspectors wroteBased on medical record review, review of a facility Self-Reported Incident (SRI), review of a local police report, staff interview, review of the county on-line court docket and review of facility policy, the facility failed ensure residents were free from misappropriation. This affected one resident (#1) of five residents reviewed for misappropriation. The facility census was 144.

Inspectors wroteBased on medical record review, review of a facility Self-Reported Incident (SRI), review of the facility investigation, review of a local police report, staff interview, review of the county on-line court docket and review of facility policy, the facility failed to ensure an accurate and thorough investigation of misappropriation was completed. Furthermore, the facility failed to implement corrective actions to monitor and/or prevent further instances of resident misappropriation. This affected one resident (#1) of five residents reviewed for misappropriation. The facility census was 144.

Inspectors wroteBased on record review, staff and resident interview, review of facility's Self-Reported Incidents (SRIs) and review of facility policy, the facility failed to ensure care and services were provided by staff members. This affected one (#51) resident out of three residents reviewed for accidents hazards. The facility census was 155.

Inspectors wroteBased on review of Board of Executives of Long-Term Services and Support (BELTSS) documentation, review of the Enhanced Information Dissemination and Collection (EIDC), interview with a BELTSS Representative, and staff interview, the facility governing body failed to appoint an administrator, licensed in the State of Ohio who was responsible for the management of the facility. This had the potential to affect all 150 residents residing in the facility.

Inspectors wroteBased on observation, staff interview, resident interview, review of resident council meeting minutes, and policy review, the facility failed to ensure food was served warm and palatable. This had the potential to affect all but two (#27 and #93) residents who did not receive food from the facility's kitchen. The facility census was 150.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, review of facility policy, staff interview, and interview with contracted entity provider representative, the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This affected four (#03, #26, #23 and #36) of the four residents reviewed for medications administered by a contracted ancillary provider. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, and interview the facility failed to ensure medications were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This affected four (#03, #26, #23 and #36) of the four residents reviewed for medications administered by a contracted ancillary provider. [...]

Inspectors wrote837 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, review of facility policy, and interview the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This deficiency affected four of four Residents (#27, #89, #85, and #30) reviewed for medications administered by a contracted ancillary provider. This affected four (#03, #26, #23 and #36) of the four residents reviewed for medications administered by a contracted ancillary provider. [...]

Inspectors wroteBased on medical record review and staff interviews, the facility failed to provide a resident with appropriate behavioral health treatment and services. This affected one (#152) out of the three residents reviewed for behaviors. The facility census was 159.

Inspectors wroteBased on medical record review, staff interview, ophthalmologist interview, and policy review, the facility failed to administer eye medications (anti-glaucoma and antibiotic) as ordered resulting in significant medication errors. This affected one (#296) resident out of the three residents reviewed for medication administration. The facility census was 159.

Inspectors wroteBased on medical record reviews, observations, staff interviews, and policy reviews, the facility failed to ensure infection control policies and procedures were followed. This affected two (#218 and #268) out of the four residents reviewed for infection control procedures. The facility census was 159.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to food was stored in a manner to prevent the potential spread of foodborne illness, the facility failed to ensure kitchen equipment was maintained in a clean manner, the facility failed to ensure utensils placed on meal trays were not handled by the eating surface and the facility failed to ensure foods reached the appropriate cooking temperature prior to serving. This had the potential to affect 156 out of 156 residents in the facility who received food from the kitchen, the facility identified two residents (#06 and #108) who did not receive food from the kitchen. The facility census was 158.

Inspectors wroteBased on medical record review, observations, staff interviews, facility policy review and review of information from the Centers for Disease Control and Prevention (CDC), the facility failed to implement infection control practices to potentially prevent the spread of infectious diseases such as Coronavirus Disease 2019 (COVID-19) and/or Carbapenem-Resistant Acinetobacter Baumannii (CRAB). Additionally, the facility failed to develop and follow an infection disease program to aide in the potential spread of urinary tract infections (UTI) based on the facility identified concern from January 2023 through August 2023. This had the potential to affect all 158 residents who resided in the facility. The facility census was 158.

Inspectors wroteBased on medical record review, resident and staff interviews, and policy review, the facility failed to ensure care conferences were held with residents. This affected four (#03, #97, #108, and #145) of six residents reviewed for care conferences. The facility census was 158.

Inspectors wroteBased on record review, observations, staff interview, and policy review, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being at risk for elopements did not elope from the facility and failed to ensure the an exterior gate on the secured unit was functioning appropriately. This affected one (#14) out of three residents reviewed for elopements and had the potential to affect 30 (#104, #39, #36, #48, #101, #27, #143, #14, #308, #58, #116, #149, #141, #62, #24, #70, #114, #94, #99, #60, #63, #28, #137, #151, #154, #133, #118, #153, #91, and #83) residents residing on the secured unit who were at risk for elopement. Additionally, the facility failed to ensure fall interventions were in place and to ensure safe transfers. This affected three (#99, #16, and #149) of eight residents reviewed for accidents. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately document on the Minimum Data Set (MDS) related to a residents bladder function. This affected one (#34) out of 31 residents reviewed for MDS. The facility census was 158.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure residents were provided with necessary care to maintain good personal hygiene. This affected three (#97, #16 and #149) of three reviewed for care of dependent residents. This census was 158.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to provide medication per physician ordered. This affected one (#149) out of three residents reviewed for medication administration. Facility census was 158. Findings Included: Review of medical record for Resident #142 revealed an admission date of 12/13/22. Diagnoses included open wound of abdominal wall left lower quadrant without penetration into peritoneal cavity (non-orthopedic surgery) 06/12/23, local infections of skin and subcutaneous tissue, pressure ulcer of right heel stage four, pressure ulcer of left ankle stage four, pressure ulcer of part of back stage four, pressure ulcer of left heel stage four, pressure ulcer of unspecified site stage three, pressure ulcer right hip unstageable, and carrier of suspected carrier of methicillin resistant staphylococcus aureus on 02/24/23. [...]

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure the Ombudsmen was notified for hospital transfers and discharges. This affected five (#25, #78, #108, #131, and #157) out of six residents reviewed for discharges. The facility census was 158.

Inspectors wroteBased on observation, staff interviews, and review of planned menus, the facility failed to follow the planned menus which had been reviewed and approved by the Registered Dietitian (RD) in regards to portion sizes. This affected 28 (#50, 55, 99, 155, 4, 157, 35, 31, 67, 182, 19, 46, 71, 68, 169, 90, 102, 48, 126, 30, 91, 158, 49, 167, 143, 52, 51, 153) of 28 residents in the 5B/600 unit. The facility census was 196.

Inspectors wroteBased on medical record review, staff interview and review of the Resident Assessment Instrument Manual the facility failed to comprehensively assess a residents cognitive in her native language. This affected one of one reviewed for cognitive function. The facility census is 196.

Inspectors wroteBased on medical record review, staff interview and review of the Minimum Data Set (MDS) the facility failed to complete a comprehensive significant change assessment. This affected one (#109) of one resident reviewed for significant change assessments. The facility census is 196.

Inspectors wroteBased on medical record review and staff interview, the facility failed to code a MDS assessment accurately. This affected one (#109) of four residents reviewed for accurate assessments. The facility census is 196.

Inspectors wroteBased on observations, medical record review, and staff interview, the facility failed to ensure fingernails were trimmed and clean. This affected one resident (#161) of one resident reviewed for assitance with activities of daily care. The facility census was 196.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident did not receive an unnecessary medications, when the physician ordered parameters for administration were not followed. This affected one (#37) of one residents reviewed for dialysis medication. The facility census was 196.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure infection control measures were followed during a treatment to a wound. This affected one (#49) of seven residents reviewed for infection control. The facility census was 196.