Majestic Care of Hopemont

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure menus meet the nutritional needs of residents and menus were followed. This failed practice had the potential to affect more than a limited number of residents: Resident Identifiers:. #1, #4, #5, #11, #15 and #18. Facility Census: 47.e)Resident #4 On 02/16/2026 at approximately 12:00 PM a meal tray was delivered to Resident #4 room. It was placed down and when opened the tray was observed to contain the following: Tray contained Full chicken breast (not cut up and not diet appropriate) Polenta Summer squash was missing and was subbed w/ spinach (not diet appropriate) Roll (not diet appropriate) Malt vinegar - missing Margarine - missing Chocolate pudding was missing and subbed out w/ brownie (not diet appropriate) Coffee Soy milk The Residents diet is Minced and moist with nectar thick liquids. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to prepare food in a form to meet individual needs. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #1, #8, #4 and #24. Facility Census: 47.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 47.

Inspectors wroteBased on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to the resident's personal products and unsanitary practices. This failed practice was a random opportunity for discovery. Resident identifiers: 8, 34, 36, and 38 Facility Census: 47. [...]

Inspectors wroteBased on observation, staff interview and interview with Resident [NAME], the facility failed to ensure survey results were readily accessible in an area where individuals wishing to examine them did not have to ask to see them. Facility Census:

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents. This failed practice was observed to have affected a shared bathroom between room [ROOM NUMBER] and #215. Facility census: 47On 02/16/26 at 1:25PM, during a facility walk through it was observed that resident shared bathroom between room [ROOM NUMBER] and #215loose dark rusty pipes dirty buildup in the corners and around the base of the toiletcracked and loose drywall falling from the wall Dusty build up of hair and debris observed between the bathroom door and the [NAME] 02/18/26 at 12:40 PM, during a facility walk through and interview with the Assistant Director of Nursing (ADON) #79, she acknowledged the needed repairs in the resident rooms and hallways. [...]

Inspectors wroteBased on Record review and staff interview, the facility failed to provide quality care by not following or updating physicians orders as needed. This was discovered during the normal Long Term Survey Process and has the ability to affect more than a limited number of residents. Resident Identifiers: #4 and #5. Census 47.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible This failed practice was a random opportunity for discovery. Resident identifier: #8. Facility Census:47Findings included: a) During a facility tour on 02/17/26 at 2:40 PM, the following environmental accident hazards were observed: Solarium: A steady leak in the ceiling with a continuous drip was blocked off with a retractable post/belt barrier, The barrier did not encompass the entire restricted area leaving a 2(two) to 3(three) foot gap that anyone could freely walk through to the wet floor. Further observation found missing electrical conduit with jagged edges and exposed electrical wiring around the wall. 100 and 200 Hallways: [...]

Inspectors wroteThe facility failed to ensure the physician acknowledged Montly Medication Review's for residents. Resident identifiers: #2, #4, #31, and #36. Facility census: 47.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure residents were receiving therapeutic diets as ordered by the physician. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #1 and #8. Facility Census: 47.

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to ensure care was promoted in a manner that maintained or enhanced the resident's dignity and respect during the dining experience. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #18 and #24. Facility Census: 47.

Inspectors wroteBased on record review and staff interviews, the facility failed to monitor, evaluate and document restraints for residents. This was discovered during the Long Term Survey Process and had the ability to effect more than a limited number of residents. Resident Identifier: #6. Facility census: 47. Findings Include: a) Resident #6 On 02/16/2026 at approximatley 4:00 PM a record review was done on Resident #6. The record review revealed it stated that Resident #6 had a diagnosis of Huntington's Disease. This disease can limit a person's functional status and control of limbs. For Resident #6 safety they had orders to have a wheel chair restraint belt on while in a wheel chair at all times. Resident #6 also had orders for limb restraint for Inter-Muscular (IM) Injections, due to the disease process making it hard to stay still during these procedures. [...]

Inspectors wroteBased on staff interview and documentation review the Facility failed to complete [NAME] Virginia Pre-admission Screening with new diagnosis of Major Depressive Disorder. This is true for Resident #3. Facility Census 47. Findings Included:a) Resident #3 On 02/16/26, a review wascompleted of a document titled [NAME] Virginia Department of Health and Human Resources Pre-admission Screening (PAS) dated for 11/13/24. For Resident #3, on Question #30 the answer was marked a. None. Upon Review of Resident #3's diagnosis list, resident was diagnosed with Major Depressive Disorder, Recurrent, Moderate on 11/15/24. Interview with Administrator on 02/17/26 at 5:25 PM who acknowledged Resident #3 did not have a new PAS did not contain his new diagnosis of Major Depressive Disorder.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide a well -balanced diet taking into consideration preferences. The failed practice had the potential to affect a limited number of residents. Resident Identifier: #30. Facility Census: 47.

Inspectors wroteBased on observation, record review, staff interview and resident interview, the facilitate failed to ensure the resident received food that accommodated allergies, intolerances and preferences. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #30. Facility Census: 47.

Inspectors wroteBased on observation and staff interviews, the facility failed to follow prescribed dietary order for liquid consistency for the residents. Resident identifier: #4. Facility census: 47. Findings Include: a) Resident #4 On 02/16/26 at approximately 12:00 PM a meal tray was delivered to Resident #4 room. It was placed down and when opened the tray was observed to contain the following:Tray contained Full chicken breast (not cut up and not diet appropriate)Polenta Summer squash was missing and was subbed w/ spinach (not diet appropriate)Roll (not diet appropriate)Malt vinegar - missingMargarine - missingChocolate pudding was missing and subbed out w/ brownie CoffeeSoy milk The Residents diet was Minced and moist with nectar thick liquids. This was a requirement per Speech therapy #77, who confirmed Resident #4 was a high aspiration risk and pocketed their food. [...]

Inspectors wroteBased on observation and staff interview, the Facility failed to provide a resident with an assistive device during meals by not providing nosey cup. This was a random opportunity for discovery. Resident identifierz: #6. Facility Census: 47. Findings Included:a) Resident #6 On 02/17/26 at approximately 12:50 PM, Resident #6 was observed dining in the dining room with assistance from Nurse Aide #74. Observation of Resident #6's tray card revealed he was to have one nosey cup, not present on his tray. He did have cold tea, orange juice and and milk all served in regular clear plastic cups. An interview with Nurse Aide #74 was conducted 02/17/26 at 12:55 PM revealed they were not familiar with a nosey cup and these were the cups that resident normally used at meals. Review of Care Plan for Resident #6 stated the following: Focus: [...]

Inspectors wroteBased on record review and staff interview the Facility failed to provide accurate documentation by listing inaccurate diagnosis of Post Traumatic Stress Disorder for a resident. This was a random opportunity for discovery. Resident Identifier: #1. Facility census: 47.

Inspectors wroteBased on observation, and staff interview, the facility failed to provide food at a palatable and appetizing temperature as determined by the type of food to ensure resident satisfaction. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 51. Findingd included: a) A tray on A-Hall was tested by DM #100 and temperatures were as follows: Pureed Pork - 122 degrees Mashed Potatoes - 126 degrees Pureed Peas - 102 degrees Pureed Bread - 100 degrees b) Temperatures were confirmed by DM #100. DM #100 reported pork should have been at 130 degrees and the vegetable's temperature was low. DM #100 stated the bread could be served hot or cold. The facility's Policy and Procedure stated, Hot foods will be served at a temperature 120 degrees F or higher. These findings confirmed by Dietary Manager (DM) #100 on 11/19/24 at 12:25 PM.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to store and label food in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 51.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that an alleged violation involving resident-to-resident sexual abuse was reported within two (2) hours of the event/allegation being brought to the facility's attention, to appropriate state agencies as required. This was a random opportunity for discovery throughout the facility reportable incident (FRI) investigative process. Resident identifier: #48. Facility census: 51.

Inspectors wroteBased on facility record review and staff interview the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. This was true for two (2) of five (5) days identified during the long-term care survey process. This had the ability to affect all the residents. Facility census: 49.

Inspectors wroteBased on facility record review and staff interview the facility failed to conduct and document a complete facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility did not assess the physical environment, equipment, services, and other physical plant considerations that are necessary to care for the resident population. This was a random opportunity for discovery during the long-term care survey. Census: 49.

Inspectors wroteBased on resident observation, record review and staff interview, the facility failed to ensure the resident and or representative was informed in advance by the physician, other practitioner or health professional of the risks and benefits of proposed care, of treatment alternatives or treatment options and to choose the alternative option preferred. This was true for 1 (one) of 18 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #36. Facility census: 49.

Inspectors wroteBased on resident council meeting interviews, observation and staff interview the facility failed to ensure residents were able to submit grievances anonymously. This had the potential to affect more than an isolated number of residents. Facility census: 49.

Inspectors wroteBased on record review, resident observation and staff interview the facility failed to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs. This was true for 3 (three) of 18 residents reviewed during the Long Term Care Survey Process. Resident identifiers: Resident #36, Resident #25 and Resident #45. Facility census: 49. Findings Include: Resident #36 On 05/28/24 at 12:30 AM, a review of Resident #36 ' s medical record was conducted. A fall care plan was noted with interventions stating, Encourage resident to wear hipsters at all times for safety. and Encourage resident to wear soft helmet while ambulating for safety. On 05/28/24 at 01:07 PM an observation of Resident #36 was conducted. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice which would allow the residents to achieve their highest practicable physical, mental, and psychosocial well-being. This was true for two (2) out of four (4) residents reviewed for restorative nursing services. Resident identifiers: #5 and #37. Facility census: 49.

Inspectors wroteBased on record review, staff interview and resident observation the facility failed to provide supervision, implementation, monitoring and modifying of interventions to prevent avoidable accidents. This was true for 2 (two) of 7 (seven) residents reviewed during the Long-Term Care Survey Process. Resident identifiers: Resident #36 and Resident #25. Facility census: 49.

Inspectors wroteBased on facility record review and staff interview the facility failed to provide the accurate data on the nurse staffing information form. The daily census was not accurate for 4 of 5 daily of the nurse staffing information forms reviewed during the long-term care process. This issue had the ability to affect more than a limited number of residents. Census: 49.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure behavior monitoring and medication side effect monitoring was documented for a resident receiving psychotropic meds. This deficient practice affected one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #12. Facility census: 49. Resident identifier: a) Resident #12 Review of the facility's policy titled Behavioral Assessment, Intervention, and Monitoring with no implementation date specified, stated the following: - If a resident was being treated for altered behavior and mood, the Interdisciplinary Team (IDT) would document any improvements or worsening in the resident's behavior, mood, and function. - The IDT would monitor for side-effects related to psychoactive medications. [...]

Inspectors wroteBased on observation and staff interview the facility failed to provide hand washing to residents on B hall before their lunch meal. Resident #33 had a pool noodle type piped foam taped around the head and foot board of the bed. This foam could not be effectively cleaned. These practices were random opportunities for discovery during the Long-Term Care Survey Process. Facility Census: 49.

Inspectors wroteBased on staff interviews and observation the facility failed to provide a dignified dining service. This failed practice was found true for (1) one random resident observed during the lunch dining in the Long-Term Care Survey Process. Resident identifier #44. Facility Census 49. Findings Include: a) Resident #44 During an observation on 05/29/24 at 12:15 PM, Resident #44 was sitting at a table with (3) three other residents. The other (3) three residents got their lunch tray at 12:15PM. (9) nine other residents at different tables were served before Resident #44 received her lunch tray at 12:25 PM. Further observation showed that (1) one of the residents seated at the table with Resident #44 was finished eating when Resident # 44 got her lunch tray. [...]

Inspectors wroteBased on staff interview and facility documentation, the facility failed to provide reasonable accommodation in regard to activities of daily living (ADLs). This was true for one (1) of eighteen (18) residents reviewed under the ADL pathway. Resident identifier: #43. Facility Census:

Inspectors wroteBased on observation, staff interview, and resident interview the facility failed to provide a homelike environment by not allowing Resident # 29 access to his personal belongings by his own freewill. Resident #33's room had personal health information taped on the bed and had cosmetic imperfections that could pose a safety hazzard in the bathroom. This failed practice was found true for two (2) of two (2) residents reviewed for environment during the Long-Term Care Survey Process. Resident identifiers: #29, #33. Facility Census: 49. Findings Include: a) Resident # 29 During the initial interview on 05/28/24 at 1:46 PM, Resident # 29 stated, I want stuff out of my closet, and I can't get to it because there is a lock on it. When surveyor asked if he had a key to it Resident #29 stated, No, the nurse or NA has it and I have to have them come and unlock. It takes them a long time. [...]

Inspectors wroteBased on record review and staff interview, in response to allegations of abuse, the facility failed to have evidence that all alleged violations are thoroughly investigated. This was true for 1 (one) of 7 (seven) residents reviewed in the Long Term Care Survey Process. Resident identifier: Resident #25. Facility census: 49.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate Preadmission Screening and Resident Review (PASRR) and failed to complete a new PASRR when a PASRR expired. This deficient practice had the potential to affect two (2) of two (2) residents reviewed for the care area of PASRR. Resident identifiers: #27 and #41. Facility census: 49.

Inspectors wroteBased on staff interview and facility documentation, the facility failed to provide accurate and complete medical records in regard to activities of daily living (ADLs). This was true for one (1) of eighteen (18) residents reviewed under the ADL pathway. Resident identifier: #43. Facility Census:

Inspectors wroteBased on reportable allegation review, staff interview and policy review the facility failed to ensure they implemented their abuse/neglect policy as it relates to thoroughly investigating allegations of abuse. Resident identifier: #34, #28. Facility census: 48.

Inspectors wroteBased on reportable allegation review, staff interview and policy review the facility failed to ensure they thoroughly investigated allegations of abuse. Resident identifier: #34, #28. These were random opportunities for discovery. Facility census: 48.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure one (1) of three (3) residents were free from significant medication errors. Resident #54 received two (2) medications that were intended for his roommate. Resident #54 received a sulfonylureas (Glipizide) and an anticonvulsant (Dilantin). The resident did not have diagnoses that supported the need for these two (2) classes of medications. Resident identifier: #54. Facility census: 48.

Inspectors wroteBased on medication error report review, policy review, medical record review and staff interview the facility failed to ensure their quality assurance committee analyses a significant medication errors to determine a root cause analysis and prevent the possible recurrence. Resident #54 received two (2) medications that were intended for his roommate. Resident #54 was one (1) of three (3) residents who were reviewed for significant medication errors. Resident #54 received a sulfonylureas (Glipizide) and an anticonvulsant (Dilantin). Resident identifier: #54. Facility census: 48.

Inspectors wroteBased on observation, staff interviews, medical record review, temperature log review, and facility reportable incident (FRI) review, and hospital record review the facility neglected to ensure one (1) of six (6) residents was not subjected to hot water temperatures of 134 degrees Fahrenheit (F). This failure resulted in physical harm to Resident #19. Resident #19 sustained second degree burns to left hand, bilateral lower extremities and feet, bilateral buttocks and scrotum. This created an immediate jeopardy situation that began on 01/04/24 at 7:12 PM when the resident was placed in the tub and ended on 01/07/24 at 6:54 PM when all hot water was shut off in the facility. All residents had the potential to be affected by the hot water temperatures. Resident identifier: #19. Facility census: 44.

Inspectors wroteBased on observation, staff interviews, medical record review, temperature log review, facility reportable incident (FRI) review, and hospital record review, the facility failed to ensure one (1) of six (6) residents had an environment which was as free of accident hazards as was possible. Nurse Aide (NA) #99 failed to monitor the water temperature when filling the tub. In addition NA #99 failed to supervise this resident during the bathing process. After Resident #19 was placed in the tub, water at 134 degrees (F) was used to fill the tub. Resident #19 sustained second degree burns to the left hand, bilateral lower extremities and feet, bilateral buttocks and scrotum. This created an immediate jeopardy situation that began on 01/04/24 at 7:12 PM when the resident was placed in the water and it ended on 01/07/24 at 6:54 PM when the hot water in the facility was turned off. [...]

Inspectors wroteBased on a review of the orientation records, and staff interviews, the facility failed to ensure licensed staff and nurse aides were able to demonstrate competency skills and techniques necessary to care for resident needs. Registered Nurse #100 (RN) failed to render aid timely to Resident #19 who sustained third degree burns. A nurse aide (NA) failed to ensure one (1) of six (6) resident's safety during a bath. The nurse aide exposed the resident to water at 134 degrees Fahrenheit (F). This caused third degree burns to the resident. Resident identifier: #19. Staff identifiers: Registered Nurse (RN) #100, Nurse Aide #99. This failed practice created an immediate jeopardy situation that began on 01/04/24 when the resident was place in the bath and ended on 01/22/24 when all staff completed competencies on safe bathing. [...]

Inspectors wroteBased on observation, record review, and staff interview the licensee failed to maintain hot water mechanical equipment in safe operating condition. According to CMS guidelines exposure at water temperature of 133 degrees Fahrenheit can lead to third degree burns in 15 seconds. Resident #19 was bathed in 134 degrees Fahrenheit water. Resident #19 sustained second degree burns to his feet, legs, thigh, and hand. The staff responsible for monitoring water temperatures and maintaining equipment knew the hot water had measured more than 110 degrees Fahrenheit (F) since January 2023. This caused an immediate jeopardy situation that began on 01/03/23 and ended on 01/07/24. This practice had the potential to affect all facility residents. Resident identifier: #19. Facility census 44.

Inspectors wroteBased on observation, record review, and staff interview the licensee failed to maintain hot water mechanical equipment in safe operating condition. According to CMS guidelines exposure at water temperature of 133 degrees Fahrenheit (F) can lead to third degree burns in 15 seconds. Resident #19 was bathed in 134 degrees (F) water. Resident #19 sustained second degree burns to the left hand, bilateral lower extremeties, bilateral buttocks, and scrotum. The staff responsible for monitoring water temperatures and maintaining equipment knew the hot water had measured more than 110 degrees (F) since January 2023. This caused an immediate jeopardy situation that began on 01/03/23 and ended on 01/07/24. This practice had the potential to affect all facility residents. Resident identifier: #19. Facility census 44.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure the activities program is directed by a qualified professional. This had a potential to affect more than a limited number of residents residing in the facility. Facility census: 44. Findings Included: a) Qualified Activity Professional During an observation on 08/22/22 at 12:05 PM the Activity Department was void of a certificate for a qualified activity professional. During an interview on 08/23/22 at 9:10 AM, the Social Worker #82 stated, We don't have an activity director we have not had one in months, I have told them we needed one, I am doing the best I can but I am not certified and really don't know what I am doing. During an interview on 08/23/22 at 10:39 AM, the Administrator stated, The Activity Director has been gone since August 2021. [...]

Inspectors wroteBased on employee record reviews and staff interview, the facility failed to complete the annual performance evaluations for nurse aides. This was true for five (5) of five (5) agency nurse aides reviewed during the sufficient and competent nurse staffing. Employee #23, #32, #46, #57, and #61 had not received their annual nurse aide performance reviews. Facility census:

Inspectors wroteBased on observation and staff interviews, the facility failed to store food in sanitary conditions by not labeling foods appropriately and not discarding when foods expired in the kitchen. The facility also failed to correctly document temperatures for all the dietary equipment requiring temperature logs. This deficient practice had the potential to affect more than a limited number of residents that receive nutrients from the kitchen. Facility Census:44 Findings Included: A facility policy titled Food Storage Labeling with a revision date of 04/2018 stated (Typed as written) .Procedures 4. An accurate thermometer will be kept in each refrigerator and freezer. A written record or daily temperatures will be recorded. 5. All foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment in the area of psychiatric/mood disorders for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #23. Facility census: 44.

Inspectors wroteBased on record review staff interview, the facility failed to ensure pressure ulcer care was provided in accordance with professional standards of practice. Resident #4's pressure ulcer treatment to the coccyx was not on the treatment administration record. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for the care area of pressure ulcers. Resident identifier: #4. Facility census: 44.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure temperature checks were completed daily for one (1) of the two (2) refrigerators used for medication storage. This failed practice had the potential to affect a limited number of residents. Facility census:44.