Majestic Care of Flushing

Inspectors wroteThe Citation pertains to Intake Number 3074530. Based on interview and record review, the facility failed to ensure that staff were utilized appropriately to sufficiently meet the needs of facility residents through multiple resident interviews and interviews with the confidential group of residents and low weekend staffing was triggered through payroll-based journal, resulting in resident increased call light complaints, unmet care needs, and a lack of resident assessment and monitoring.

Inspectors wroteThis citation pertains to Intake Numbers 3074530 and 3037980. Based on observation, interview and records review, the facility failed to ensure that residents' call lights were accessible and answered in a timely manner for 10 residents (#3, #7, #10, #38, #44, #46, #50, #63, #78, #86), and a confidential group of residents, resulting in verbalizations of anger and frustration regarding not answering call lights in a timely manner. Resident 46 (R46): A review of R46's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] dementia, heart disease, diabetes and history of falling. A review of the Minimum Data Set assessment revealed the Resident had a Brief Interview of Mental Status score of 09/15 that indicated moderately impaired cognition and needed supervision or touching assistance with walking. [...]

Inspectors wroteThis Citation pertains to Intake Number 3074530. Based on interview and record review, the facility failed to ensure that orientation and annual competency skill assessments and annual performance evaluations were completed for 3 of 3 licensed staff and 5 of 5 unlicensed staff of 9 staff reviewed. Record review of the facility 'Education, Training, and Competency' policy, dated [DATE], revealed Training and competency evaluation programs ensure compliance with State and Federal regulations, support high-quality resident care, and ensure that all care team members possess and maintain the skills necessary to perform their roles safely and effectively . Competency evaluation is an integral component of the training program and is required for all care team members, including employees . Initial competency is evaluated during the orientation process. [...]

Inspectors wroteThis citation pertains to intake Number 3037980. Based on observation and interview the facility failed to serve food that was palatable and at an appropriate temperature and that residents were given choices of food preferences for 6 residents (R2, R3, R10, R22, R38, R78) of 10 residents reviewed for food and a confidential group of residents.

Inspectors wroteThis Citation pertains to Intake Number 2997914. Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place to provide a safe and monitored environment to prevent falls with injuries for 3 residents (Resident #1, Resident #4, Resident #5) of 3 resident reviewed for falls, resulting in Residents #1, #4 and #5 repeatedly falling, hitting their heads and sustaining injuries. Findings Include: FallsResident #1:A record review of the Face sheet and Minimum Data Set/MDS indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: History of Traumatic Brain Injury, history of falls, dementia, diabetes, depression, and heart failure. [...]

Inspectors wroteThis Citation pertains to Intake Number 2997914. Based on observation, interview and record review the facility failed to ensure that interventions were enacted to promote nutrition and prevent weight loss for one resident (Resident #1) of 1 resident reviewed for food or nutrition, resulting in Resident #1 experiencing significant weight loss without identification and access to favored foods. Findings Include: Resident #1:A record review of the Face sheet and Minimum Data Set/MDS indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: History of Traumatic Brain Injury, history of falls, dementia, diabetes, depression, and heart failure. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status (BIMS) score of 1/15 and the resident needed assistance with all care. [...]

Inspectors wroteThis Citation Pertains to Intake Number #2688386. Based on observation, interview and record review the facility failed to ensure that nail care was routinely provided for two residents (#1 and #3) of 3 residents reviewed for activities of daily living (ADL), resulting in Resident #1 and Resident #3 having long, soiled, fingernails. Resident #1: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: bipolar disorder, anxiety, restlessness and agitation, contractures of left hand, left ankle and foot, heart disease, neuropathy, asthma, and recent fracture right hand 3rd finger, and urinary tract infection. The MDS assessment, dated 10/17/2025, revealed the resident had a Brief Interview for Mental Status/BIMS score of 14/15 identifying intact cognitive abilities and needed assistance with all care. [...]

Inspectors wroteThis Citation Pertains to Intake Number 2688386. Based on observation, interview and record review, the facility failed to ensure that wound interventions were provided as ordered for 1 Resident (# 1) of 3 residents reviewed for wound care. Resident #1:A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: bipolar disorder, anxiety, restlessness and agitation, contractures of left hand, left ankle and foot, heart disease, neuropathy, asthma, and a recent fracture right hand 3rd finger, and urinary tract infection. The MDS assessment, dated 10/17/2025, revealed the resident had a Brief Interview for Mental Status/BIMS score of 14/15 identifying intact cognitive abilities and needed assistance with all care. On 12/16/2025 at 3:50 PM, entered Resident #1's room with Nurse A. [...]

Inspectors wroteThis citation pertains to Intake Number 2574995. Based on observation, interview, and record review, the facility failed to provide the appropriate skin care interventions to prevent the development of pressure ulcers and promote healing consistent with professional standards for one resident (R103) of four sampled residents reviewed for pressure ulcers, resulting in a delay in treatment and healing, worsening of newly developed wounds, infection and further complications. Findings Include:Resident #103 (R103) A review of R103 Electronic Medical Record (EMR) was conducted on August 22, 2025, at 3:30 PM. According to the clinical record, R103 was [AGE] years old, admitted to the facility on [DATE], with the diagnosis of laceration of the scalp, Cerebral Palsy, Obstructive Hydrocephalus, and Epilepsy in addition to other diagnoses. [...]

Inspectors wroteThis citation pertains to Intake Number 2575492 Based on observation, interview and record review, the facility failed to ensure that a resident was appropriately assessed and provided pain relief for one resident (Resident #108), who had chronic pain out of four residents reviewed for pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Maintain a clean, sanitary kitchen and 2) Ensure that kitchen equipment (dishwasher), walk-in cooler fan covers and kitchen sink were in good working condition, resulting in the potential for cross contamination, residents, visitors and staff illnesses. Findings Include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. During the initial tour of the facility kitchen, done on 6/3/25 starting at 9:30 a.m., accompanied by [NAME] A #1 ([NAME]), the following was observed: [...]

Inspectors wroteDuring an observation done on 6/3/25 at 12:16 PM, no hand sanitizer was in the in container of Resident #40's room. Throughout the survey (from 6/3/25 to 6/5/25), at random times during first shift, food delivery with set-up, Dietary staff and Nursing Assistant's/CNA's were observed in the residents room touching the residents food tray, bedding and environment with no hand washing or hand sanitizer used prior to leaving the residents room. Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program including outcome and process surveillance resulting in 1) Inaccurate and incomplete outcome surveillance; 2) A lack of documentation of process surveillance; 3) A lack of surveillance to identify potential infections; 4) A lack of analysis of infection data; [...]

Inspectors wroteBased on interview, and record review the facility failed to implement and operationalize a comprehensive Antibiotic Stewardship Program including documentation and treatment for four residents (#7, #35, #81, and #82) of four residents reviewed for antimicrobial treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for one resident (Resident #58) and the facility's census of 91 residents and its staff resulting in an increased chance of harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity by, Residents #23, #40 and #76, -not having call lights accessible and extended call light response times, Resident #43- not assisting with toileting and Resident #42- not toileting prior to meals and residents' verbal complaints from the confidential Resident Council group meeting (held on 6/23/25 at 1:19 PM), regarding call light response times, resulting in, fear of abandonment, anger, skin irritation (from having urine and feces on skin for an extended time), and embarrassment. Findings Include: Review of Resident Council anonymous meeting notes done by State Social Worker dated 6/3/25 at 1:19 p.m., stated they (call lights) are not being answered in timely manner they (staff) say they answer it timely and don't meet their needs; taking an hour to answer to come or more; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident showers were given and Activities of Daily Living (ADL) were given for 8 resident's (Resident's #23, #30, #35, #40, #50, #65 and #85, and per interviews done during the anonymous Resident Council (done on 6/3/25), resulting in verbalizations of anger, disappointment, unfair treatment, and embarrassment. Findings Include: Resident #23: Review of the Face Sheet, care plans dated 3/23 through 5/25, and cognitive assessment dated [DATE], revealed Resident #23 was [AGE] years old, alert, cooperative, admitted to the facility on [DATE], had a guardian in place due and was dependent on staff for all Activities of Daily Living/ADL's. [...]

Inspectors wroteThis Citation pertains, in part, to Intake Number MI00153038. Based on observation, interview and record review, the facility failed to ensure that adequate staffing to meet residents' needs for Activities of Daily Living (ADL) was performed and respond to and provide care to meet the needs, resulting in complaints about showers not being provided, and frustration of residents' unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow and/or revise care plans for Activities of Daily Living (ADL) for three (#35, #50, #85) residents, resulting in residents who verbalized concerns with missed bathing/showers, and with unkept appearances with body odor.

Inspectors wroteBased on observation, interview and record review, the facility failed to offer meaningful activities for one resident (Resident #37) of two residents reviewed for activities, resulting in complaints of nothing to do and being bored.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow care-planned interventions, provide supervision and provide assistance with toileting for one resident (Resident #43) of three residents reviewed for supervision, resulting in unassisted toileting and unassisted ambulation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure clean Continuous Positive Air Pressure(CPAP) equipment for one resident (Resident #30) of one resident reviewed for respiratory equipment, resulting in visibly soiled respiratory equipment.

Inspectors wroteResident #40: Review of the Face Sheet, care plans dated 8/23 to 3/25, and cognitive assessment dated [DATE], revealed Resident #40 was [AGE] years old, alert and able to make own decisions regarding health, bed bound and dependent on staff for all ADL's. resident #40's diagnosis included heart disease with heart failure, Atrial Fibrillation, morbid obesity, chronic respiratory failure with oxygen decency. Review of the resident's facility Fall, Skin, and ADL care plans dated 8/1/23, revealed she had a flat round call light, was incontinent, and preferred bed baths 2 times weekly. The resident had refusals of medications and care; staff were to re-approach and encourage resident to accept care and medications and honor decisions and preferences. During an interview done on 6/3/25 at 11:45 a.m., Resident #40 stated It's (food on meal tray) is cold, it's bad; [...]

Inspectors wroteThis Citation Pertains to Intake Numbers MI00152877 and MI00152910. Based on observation, interview and record review, the facility failed to ensure wounds were assessed, monitored, and that appropriate interventions were in place for 3 Residents (#1, #2, #3) of 3 residents reviewed for wounds, including Resident #1 who had a above the right knee amputation after a lack of assessment and monitoring, infection and a dehisced/opened right below the knee amputation surgical site. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: recent right below the knee amputation, diabetes, COPD, heart disease, atrial fibrillation, peripheral vascular disease, history of a stroke, depression and arthritis. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and monitor a percutaneous enteral tube (PEG) insertion site, provide enteral nutrition and obtain an admission weight timely for one resident (Resident #3) of three residents reviewed for enteral nutrition, resulting in a reddened area going unnoticed.

Inspectors wroteBased on interview and record review, the facility failed to provide medications timely for one resident (Resident #3) of three residents reviewed for pharmacy services, resulting in late and missed medications.

Inspectors wroteThis Citation pertains to Intake Number MI00147096. Based on interview and record review the facility failed to assess and monitor one resident (Resident #1) with pressure ulcers upon admission of 3 residents reviewed for pressure ulcers, resulting in the facility not documenting on pressure ulcers upon admission. Findings Include: Resident #1 (R1): Resident #1 is a 56-yo female who was admitted to the facility on [DATE] with diagnoses that include, necrotizing fasciitis, end stage renal disease, type 2 diabetes, peripheral vascular disease, dependence on renal dialysis and bilateral above the knee amputations. On 09/23/24, record review of a progress note dated 09/10/24 revealed that R1 had pressure ulcers upon discharging the hospital located on the coccyx and right ischium area and was to continue receiving wound care. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00147096. Based on interview and record review the facility failed to monitor one resident (Resident #1) requiring dialysis services of 3 residents reviewed, resulting in the resident being discharged to the emergency room with hallucinations and confusion.

Inspectors wroteThis Citation pertains to Intake Number MI00145161 Based on interview and record review the facility failed to maintain the safety of one resident (Resident #701) of one resident reviewed for mental health procedures, resulting in Resident #701 attempting twice to commit suicide via strangulation at the facility without appropriate facility interventions. The facility is being cited at Past-Non-Compliance with a Compliance Date of 06/15/2024. Findings Include: Redsident #701: On 8/13/2024 at approximately 3:30 PM, a review was conducted of Resident #701's record and it revealed he admitted to the facility on [DATE] with diagnoses that included Alcoholic Cirrhosis of Liver, Paranoid Personality Disorder and Alcohol induced persisting Dementia. Further review of Resident #701's record revealed the following: Care Plan: .resident attempting to wrap call light chord around neck .1:1 sitter . [...]

Inspectors wroteThis Citation pertains Intake Number MI00143956 Based on observation, interview and record review, the facility failed to provide supervision to prevent injuries for 2 residents (Resident #17, Resident #84) of 4 residents reviewed, resulting in Resident #17 sustaining a fracture of the 3rd and 4th metacarpal on the right hand, and no complete comprehensive post fall assessments for Resident #84, who sustained a fall with head injury, laceration, and required emergency medical treatment.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Maintain an accurate infection control program, 2. Follow antibiotic stewardship consistently, 3. Ensure infection control policies were up to date and reviewed annually, and 4. Ensure staff were educated on proper infection control procedures.

Inspectors wroteThis Citation relates to Intake Number MI00143452. Based on observation, interview, and record review, the facility failed to ensure resident rights pertaining to dignified care for six residents (R3, R13, R24, R39, R55, and R72) and six Confidential Group residents (C1, C2, C3, C4, C5, and C6). This deficient practice resulted in a lack of dignified dining for R55, untimely call light answering for R3, R13, R39, and R72, six confidential group residents, and a lack of dignity related to privacy for R24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide scheduled showers for four residents (R8, R17, R20, and R51) of four residents reviewed for activities of daily living (ADL).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate less than 5% when two medication errors were observed for one resident (Resident #292) from a total of 25 observations, resulting in a medication error rate of 8%. This deficient practice resulted in the potential for adverse medication effects and decreased medication efficacy related to a lack of implementation of standards of practice for medication administration and incorrect administration dosage.

Inspectors wroteOn 5/21/2024 at 4:33 PM, the North Hall medication cart was inspected in the presence of Nurse B. The following expired or undated medications were found on the cart: -Timolol Mal sol 0.5% OP eye drops- opened 4/10/24 with no use by date. -Brimonidine Sol 0.2 op eye drops -opened on 4/9/24 with use by date of 5/7/24. -Novolog Solution- with no open or use by date. -2 vials of Insulin Glargine YFGN Sol- with no open or use by date. Nurse B contacted pharmacy and they informed her the Timolol eye drops are good for 28 days after opening. Nurse B stated all expired medications should be discarded of and insulin should have open and use by date indicated on the labels. Review was completed of the facility policy entitled, Administering Medications, revised April 2019. The policy stated, .12. The expiration/beyond use date on the medication label is checked prior to administering. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) Maintain sanitary conditions in the kitchen, 2) Label and store foods in coolers properly, and 3) Ensure that a beard restraint was worn in the food preparation area, resulting in the potential for cross-contamination of food, spoilage and foodborne illness, to all residents that consume food and beverages from the kitchen in a census of 88 residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective vaccination program for four residents (R59, R72, R74, and R86) of five residents reviewed for vaccinations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly maintain resident equipment in safe operating condition including four residents' beds, one wheelchair, and one overhead light in residents' rooms. This deficient practice resulted in four residents' beds being unsafe, one resident's wheelchair not repaired, and one resident's overhead light fixture left broken, resulting in the risk of accidents, skin tears, and other adverse outcomes.

Inspectors wroteBased on interview and record review the facility failed to prevent the misappropriation of narcotic pain medication for one resident (Resident #58) reviewed for storage, acquisition, destruction, and reconciliation of narcotics. This deficient practice resulted in misappropriation of a resident's pain medication and gross inaccuracies with narcotic documentation on the controlled substance log and medication administrator record.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown source to the State Agency (SA) for one resident (Resident #17) of one resident reviewed for incident reporting. This deficient practice resulted in the potential for undetected abuse or neglect.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation for an injury of unknown origin for one resident (Resident #17) of one resident reviewed for incident reporting. This deficient practice resulted in the potential for undetected abuse and/or neglect and the potential for unmet care needs:

Inspectors wroteThis Citation pertains to Intake Number MI00143579 Based on interview and record review the facility failed to administer and document medications per professional standards of practice for two residents (Resident #58 and Resident #293) reviewed for accuracy of medication administration, resulting in misappropriation of Resident #58's narcotics and erroneous medication documentation and administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services according to facility policy and standards of clinical practice for two residents (Resident #290 and Resident #292) of two residents reviewed for a Peripheral Inserted Central Catheter (PICC) line, resulting in non-occlusive dressings with no admission measurements, timely site dressing changes, discrepancies in documentation and the potential for infection. Findings Include: Resident #290: During initial tour on 5/20/2024, Resident #290 was observed resting in bed and was in good spirits. This writer observed residents PICC line dressing that was not occlusive, dated 5/8 and had no initials. Resident #290 reported her IV (intravenous) antibiotic was already administered this morning. [...]

Inspectors wroteBased on observation, interview, and record review the facility to obtain informed consents for the usage of psychotropic medications for two residents (Resident #60 and Resident #84) of five residents reviewed for unnecessary medications, resulting in Resident #60 being administered an antipsychotic medication for 8-weeks and Resident #84 being administered two antipsychotics, an antidepressant, and Alzheimer's medications for one month without proper consent and with the potential for an unnecessary drug regimen and adverse side effects.

Inspectors wroteThis Citation pertains to Intake Number MI00143579. Based on observation, interview, and record review the facility failed to provide pressure ulcer care per health care provider order and prevent the deterioration of Resident #74's unstageable coccyx wound and Resident #290 and #292's wound dressings not being completed per standards of clinical practice, resulting in Resident #74's wound care treatment not being completed as ordered, wound worsening, infection, and sepsis and Resident #290's and #292's foot wounds not being dated and labeled per nursing standards of practice. Findings Include: Resident #74: During initial tour on 5/20/2024, Resident #74 was observed resting in bed and did not appear to be in any distress. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00135839. Based on interview and record review, the facility failed to complete yearly PASSAR's and/or Level II evaluations for three residents (Resident #602, Resident #603 and Resident #604), resulting in the lack of yearly follow-up and PASSAR/Level II documentation with the likelihood of unmet mental health needs.

Inspectors wroteThis citation pertains to intake MI00138477. Based on interview and record review, the facility failed to prevent an injury during activities of daily living (ADL) care for one (Resident #7) of three reviewed for accidents, resulting in Resident #7 sustaining a fractured hip during a shower.

Inspectors wroteThis citation pertains to Intake MI00135041 and MI00138477. Based on interview and record review, the facility failed to notify the responsible party and physician of a change in condition for two (Resident #4 and Resident #7) of four reviewed.

Inspectors wroteThis citation pertains to Intake MI00135041. Based on interview and record review, the facility failed to obtain timely laboratory services for one (Resident #4) of one reviewed, resulting in the potential for delayed treatment.

Inspectors wroteThis Citation pertains to Intake Number MI00140688. Based on observation, interview, and record review the facility 1) Failed to document administration of homemade enteral formula, 2) Failed to enter physician's orders upon admission for the administration of seizure medication, and 3) Failed to assess, educate, and document the spouse's ability to administer enteral formula and complete wound care treatment in accordance with current nursing standards of practice for one resident (Resident #701), resulting in, several omissions in enteral nutrition charting, a two-day delay in entering and administration of seizure medication that led to hospitalization and the development of facility processes to address administration of medications and wound care by family members.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for pressure ulcer (wounds caused by pressure) care for five residents (Resident #10, Resident #21, Resident 37, Resident #245, and Resident #250) of seven residents, resulting in a lack of implementation of resident-centered and/or planned interventions, timely assessment, inaccurate documentation/staging of wounds/pressure ulcers, care per professional standards of practice, Resident #245 developing a Deep Tissue Injury (DTI-unstageable pressure injury with unknown depth due to damage to underlying tissues) and Stage II (partial thickness loss of tissue presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure ulcers, unnecessary pain, and the likelihood for decline in overall health status. Resident #245: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent and monitor weight loss for one resident (Resident #70), resulting in the likelihood for continued weight loss and prolonged illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize processes and procedures to ensure monitoring, accountability, and pharmacological oversight of controlled medications in the Med-bridge and North Hall of the facility per professional standards of practice. This deficient practice resulting in lack of appropriate storage, securement, reconciliation, administration, and disposal and/or return of controlled medications including lack of accurate comprehensive documentation and reconciliation of Methadone (prescription opioid medication frequently used to treat individuals with opioid dependence) brought into the facility, and the likelihood for inappropriate medication use and administration, accidental exposure, and diversion which has the potential to effect all 92 residents residing in the facility.

Inspectors wroteResident #10: On 4/26/23 at 11:30 AM, Resident #10 was observed in their room in bed with their eyes closed. The Resident was positioned on their back with their heels directly on the mattress. The Resident did not provide meaningful responses when asked questions. The Resident had an unkept appearance and their hair was uncombed and oily in appearance. A urinary catheter drainage bag was present on the right side of the Resident's bed (away from the doorway) with the drainage bag positioned directly on the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility 1) Failed to ensure adequate staffing for residents' needs for Activities of Daily Living (ADL) care for 4 of 8 Residents in the confidential Resident Council meeting, and for five residents (Resident #14, Resident #18, Resident #33, Resident #37, and Resident #46) 2) Failed to ensure adequate staffing to respond to call lights for residents' needs for 7 of 8 residents in the confidential Resident Council meeting and for three residents (Resident #14, Resident #29, and Resident #45) and 3) Failed to ensure that ensure staff competencies check-off forms were accurate and completed, resulting in the confidential Resident Council meeting voicing concerns of not receiving showers and/or baths consistently and call lights being turned off without staff returning to perform the requested care and staff competencies to be [...]

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure that food preparation and kitchen equipment were maintained in a sanitary manner and in good working condition, and 2) Failed to ensure that the kitchen refrigerators and freezers maintained a daily temperature log, resulting in an increased potential for food borne illness with possible hospitalization and with the potential to affect the census of 54 residents who consume nutrition from the facility kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to institute and operationalize policies and procedures to ensure comprehensive administrative oversight of facility programs and knowledge of residents' conditions and care needs for all 92 residents residing in the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive Infection Control program that included: 1) Failure to properly store Immunization/vaccines, 2) Failure to log employee illness and analysis for three months, 3) Failure to clean a glucometer after using on a resident and before using on another resident, 4) Failure to have enhanced barrier precautions and cross contamination during wound dressing change for Resident #37, and 5) Failure to ensure PEG tube dressings for Resident #37 and Resident #79, resulting in the likelihood for ineffective Immunization/vaccines therapy, lack of analysis of employee illness, and the likelihood of cross contamination of organisms from improper glucometer cleaning and for open wounds, with likeliness of prolonged illness and hospitalizations.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' dignity by 1) Not ensuring staff assisted 2 residents with the noon meal (Resident's #30 and Resident #45), 2) Not offering drinks and/or food while 6 residents were waiting to be served the noon meal in the main dining room, 3) Not serving the correct monthly menu, 4) Not answering call lights in a timely manner for 4 residents (Resident #14, Resident #25, Resident #29 and Resident #30), and 5) Complaints regarding food preferences not being honored for 4 of 8 residents in the the confidential Resident Council meeting of a total of 20 residents reviewed for dignity, resulting in the likelihood for weight loss, anger, shame, embarrassment, and isolation with decreased socialization. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility failed to update Preadmission Screening and Resident Review (PASARR), mental health screening, for 10 residents of a census of 92 residents reviewed for PASARR screenings, resulting in the potential for unmet mental health and psychiatric care needs. Findings Include: Review of the facility list of facility residents who do not have timely PASARR's, dated 4/27/23, and given to this surveyor on 4/28/23 at 11:20 a.m., from the Director of Nursing revealed a total of 10 residents out of a total census of 96 residents whose PASARR was not done at all or late to be done. During an interview done on 4/28/23 at 8:15 a.m., Social Worker H stated About November or December (of 2022) when I got here (started at the facility), I had no access to get into OBRA (Budget Reconciliation Act) to do the PASARR's. I contacted OBRA web site when I got here. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop or implement comprehensive care plans for four residents (Resident #37, Resident #45, Resident #46, and Resident #79) of 20 residents reviewed for care plan implementation, resulting in care plans not being comprehensive with interventions of Activities of Daily Living, accommodations for the blind, and monitoring of weight loss

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5% when three medication errors were observed for three residents (Resident #248, Resident #249, and Resident #250) from a total of 25 observations, resulting in a medication error rate of 12%. This deficient practice resulted in the likelihood for adverse medication effects including hypoglycemia (decreased blood sugar), hypotension (low blood pressure), bleeding, and decreased medication efficacy related to incorrect administration dosage.

Inspectors wroteBased on observation, interview and record review, the facility failed to operationalize policies and procedures to ensure medication storage, labeling, and disposal per professional standards of practice for four of five medication carts and two of two medication rooms resulting in medications without resident identifiers, opened and undated medications, expired medications and medical supplies, and the potential for all Residents receiving medications from those medication carts, to receive medications with altered efficiency.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement supportive interventions for blind residents regarding the environment, safety, Activities of Daily Living (ADL) and food service for 1 resident (Resident #25) of 20 Residents reviewed for accommodation of needs, resulting in the potential for unmet care needs, food safety concerns and weight loss, falls with injury, isolation with feelings of frustration, and anger.

Inspectors wroteBased on interview and record review, the facility failed to ensure that guardianship documentation was present in the medical record for one resident (Resident #10) of one resident reviewed, resulting in a lack of review and confirmation of legal guardianship prior to implementing the decision maker, and the potential for inaccurate guardianship and care decisions.

Inspectors wroteBased on observation, interview and record review, the failed to issue a beneficiary notice (ABN/Nomnic) for one resident (Resident #28) and notify eligible residents in writing of the items and services which are or are not covered under Medicaid or by the facility's per diem rate, including the cost of those items and services, resulting in Resident #28 having no documentation of beneficiary notices (ABN of NOMNIC) found with in her electronic record or in a paper format within the facility resulting in the likelihood for financial hardship.

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure that Resident #1's advanced directive care plan was updated when the resident received hospice services, 2) Failed to ensure that Resident #46's antipsychotic medication care plan was updated with a new order on 05/03/2023, and 3) Failed to ensure that Resident #79 weight loss/re-weights were care planned, resulting in a failure to review and update care plans timely for three residents (Resident #1, Resident #46, and Resident #79), resulting in a failure to that ensure interventions were in place necessary for care and services to maintain the highest level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure an appropriate documentation, assessment, and diagnosis for psychotropic medication use for one resident (Resident #84) of one resident reviewed, resulting in Seroquel (antipsychotic medication frequently used to treat Bipolar, caution use in individuals with dementia) being administered without a consent, a comprehensive assessment, and a documented diagnosis for use.

Inspectors wroteBased on interview and record review, the facility failed to implement and operationalize guidelines and procedures for the enactment of a Durable Power of Attorney (DPOA) for one resident (Resident #90) of one resident reviewed, resulting in the enactment of a DPOA without determination of legal incompetency and the potential for inappropriate enactment of a DPOA and unwanted care decisions.

Inspectors wroteBased on observation, interview and record review, the facility failed to place tube feed dressings for two residents (Resident #37 and Resident #79) per standards of practice and facility policy, resulting in the likelihood for cross contamination to PEG tube sites and prolonged illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize a comprehensive nursing orientation program to ensure staff competency prior to working independently with residents, resulting in nursing staff providing care to residents without demonstrated and documented competency, medication administration errors, and the likelihood of additional errors, inaccurate and incomplete resident assessments, and the potential in alteration in overall health status for all 92 facility residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that informed consents were obtained for psychotropic medications prescribed for four residents (Resident #1, Resident #46, Resident #79, and Resident #84), resulting in Residents #1, #46, #79, and #84 being administered antipsychotic medication without appropriate consent and risk-versus-benefit analysis of the medications explained to the resident and/or the responsible party with the increased likelihood for serious side effects and adverse effects.