Majestic Care of Lakin

Inspectors wroteBased on observation, staff interview the facility failed to maintain an infection control program to provide a sanitary environment and help prevent the transmission of communicable diseases and infections. Two (2) residents had personal care equipment that had exposed padding which created a surface that could not be cleaned effectively. One (1) resident with a Contact Isolation sign outside her door was seated in a chair outside of her room. Resident identifier #1, #60, and #39. Facility census: 60. a) Resident #60 On initial tour on 06/29/26 at 2:00 pm Resident #60 was observed outside her room. On 06/30/26 at 11:00 am Resident #60 was observed seated outside of her room with signage still listed as Contact Precautions. Resident #60 requested oxygen. The surveyor observed NA (nurse aide) #75 enter room A -10 and bring an oxygen concentrator into hall way. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure they offered staff education regarding the benefits and risks associated with the COVID-19 vaccine and offered staff the vaccine or information on obtaining the vaccine. Facility census: 60.

Inspectors wroteBased on record review and staff interview, the facility failed to notify Resident's Medical Power Of Attorney (MPOA) when the resident's treatement was changed. A wanderguard was applied. This was true for one (1) of one (1) residents sampled for notification of changes during the Long-Term Care survey process. Census: 60 Resident identifier: #59Findings included: a) Resident #60 A policy titled, Change in Condition/Physician Notification stated, The nurse will notify the physician/[Nurse Practitioner] NP/[Physician Assistant] PA and the Resident/Patient representative including but not limited to when: there is a need to alter medications or treatment or there is a significant change in the Resident's/Patient's physical, mental, or psychosocial status. An order dated 06/29/26 at 7:00 PM stated: Wanderguard: check placement right arm/wrist every shift. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. This was true for Resident #1's wheel chair. This was a random opportunity for discovery. Resident identiifer: #1. Facility census: 59. Findings Included: a) Resident #1 A tour of the facility was completed on 07/01/26 at 12:31 PM with the facility administrator found Resident #1's wheelchair had a build up of debris from dirt food underneath the seat cushion and Resident # 9's Geri-chair with broken pieces of plastic on and around the arm rests. The facility administrator confirmed the Geri-Chair with breaks in the arm rest plastic and the wheel chair seat under the cushion was full of dirt and food debris and told the residents she would get them repaired and cleaned up.

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to correctly code the Minimum Data Set (MDS) for functional abilities for Resident #44. This was true for one (1) of one (1) residents sampled for Activities of Daily Living (ADLs) during the Long-Term Care Survey process. Census: 59. Resident identifier: #44.

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to ensure Resident #60 received timely treatment to maintain vision. This was true for one (1) of one (1) residents sampled for vision during the Long-Term Care Survey process. Resident identifier: #60. Facility census: 60. a) Resident #60 During initial interview on 06/29/26 at 12:55 PM, Resident #60 stated she had an eye appointment several months ago and she needed cataract surgery. However, she stated she had not heard anything about it since then. A review of the records show Resident #60 had an eye appointment with 360 Eye Care on 02/05/26 that included an order to refer to ophthalmologist for cataract surgery. In an interview with Director of Nursing (DON), on 07/01/26 at approximately 3:30 PM, she stated she did not have any upcoming appointments for cataract surgery. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #6 was administered oxygen as ordered. This was a random opportunity for discovery during the Long-Term Care Survey process. Facility census: 60. Resident identifier: #6.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records. This deficient practice had affected two (2) of 26 residents in the long-term care survey sample. Resident Identifiers: #22 and #60. Facility census: 59.

Inspectors wroteBased on observation, record review, and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Nurse Aide (NA) #107 was observed transferring Resident #1 by himself on two (2) occasions. Resident #1 was identified as a resident who required the assistance of two (2) staff when transferring. NA #107 had the resident Kardex available to him which identified the correct way to transfer Resident #1, but he failed to look at the Kardex and transfer the resident in a correct manner. The State Agency (SA) identified this failure placed Resident #1 in an immediate jeopardy (IJ) situation. The facility was notified of the IJ on 03/04/25 at 11:23 PM. The final plan of correction (POC) was accepted by the SA on 03/05/25 at 4:21 PM. [...]

Inspectors wroteBased on observation, record review and staff interviews the facility failed to ensure Residents #1, #2, and#14, had the proper consistency thickened liquids. This was a random opportunity of discovery and had the potential to cause harm such as choking, aspiration or death. Resident identifier: #1, #2, and #14. Facility Census: 61. The State Agency (SA) determined this to be an Immediate Jeopardy situation.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents of the facility were free from abuse and neglect. For Residents #2 and #56, the facility failed to ensure they were free from sexual abuse, committed by Resident #214. For Residents #33, #50, #38, #43, #216, #51, #215, #46, #6, #35, and #17, the facility failed to ensure these residents were free of neglect related to medication administration. For Resident #33, the facility failed to ensure this resident was free from abuse due to misappropriation of medications. For Resident #1, the facility failed to transfer the resident in the correct manner, resulting in neglect. For Resident #20, the facility failed to ensure this resident was free from neglect by failing to ensure the seatbelt was fastened while being transferred in the van. [...]

Inspectors wroteBased on a resident council meeting, observation, and staff interview, the facility failed to ensure each resident had access to and was able to file an anonymous grievance and/or concern with the facility. This was discovered during the resident council meeting and has the potential to affect more than a limited number of residents currently residing in the facility. Facility Census: 61. Findings Include: a) A resident council meeting was held on 03/04/25 at 2:30 PM. During this meeting the residents agreed they did not know how or where the forms were located to file a grievance. They were asked if they were able to file a grievance at the facility anonymously and they did not know. Review of the facility grievance log found they had not had a grievance or complaint filed since 07/18/24. [...]

Inspectors wroteBased on record review, policy review, observation and staff interview the facility failed to implement their abuse and neglect policy by failing to report all allegations of abuse and/or neglect to the appropriate state agencies. For resident #2 and #56 the facility failed to identify a resident with a history of sexually predatory behavior and put into place interventions to prevent the sexual abuse of other residents. This was true for five (5) of 16 residents reviewed for the care area of abuse during the long termcare survey process. Resident Identifiers: #1, #20,#12, #2, and #56. Facility Census: 61. Findings Include: a) Policy review A review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation reporting and investigating with a policy accepting date of 03/2023 found the following pertaining to the reporting of alleged allegations: [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure all allegations of abuse and or neglect were reported to all state agencies as required. This was true for three (3) of 16 residents reviewed for the care area of abuse during the long term care survey process. Resident Identifiers: #1, #12, and #20. Facility Census: 61. Findings Include: a) Resident #1 On 03/04/25 at 9:20 PM Nurse Aide (NA) #107 was observed transferring Resident #1 from his recliner in the hallway to his wheelchair. NA #107 completed the transfer by himself and had the assistance of no other staff members. No devices were used for this transfer. The resident was wearing no skid sock during this transfer. On 03/04/25 at 9:29 PM, NA #107 was again observed transferring Resident #1 from his wheelchair to his recliner in the hallway. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to develop and implement a comprehensive person-centered care plan for resident #54 by not providing a goal in the care plan. Resident #20 for accident hazards, and Resident #49 for comfort care process. This was found true for three (3) of 34 residents care plans reviewed during the long term care survey process. Resident Identifier: #54, #20, and #49. Facility Census: 61.

Inspectors wroteBased on record reviews and staff interviews the facility failed to revise care plans related to activities. This was found true for four (4) of 34 care plans reviewed during the long-term care survey process. Resident identifiers: #21, #46, #32, and #15. Facility census:61.

Inspectors wroteBased on observation, record review, resident interview, and staff interview the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental and psychosocial well-being of each resident. This failed practice was found true for four (4) of six (6)residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers #15, #21, #46, and #32. Facility census 61.

Inspectors wroteBased on record review and staff interview, the facility failed to follow physician's orders relating to medication administration for Resident #33, #50, #51, #62, #46, #216, #38 #6, #35, #17 and #43 as well as 15-minute observations and weekly skin assessments, and comfort care as well as documentation of an allegation of neglect for Resident #11. This is true for 13 of 34 residents reviewed during the survey process. Resident identifiers: #33, #50, #51, #62, #46, #216, #38, #6, #35, #17, #43, #49, and #11. Facility census: 61. Findings Include: a) Resident #33 On 03/03/25 at 2:32 PM, a review of a facility-reported incident (FRI) dated 07/17/24 found Licensed Practical Nurse (LPN) #134 did not follow physician's orders regarding medication administration and neurological (neuro) checks on the A wing. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to deploy sufficient staff to meet the needs of the residents residing at the facility. This has the potential to affect all residents residing in the facility. Resident identifiers: 2, 56, 214, 31. Facility census: 61.

Inspectors wroteBased on observation, staff interview and resident interview the facility failed to notify residents of changes on the menu. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifier #57. Facility census 61. Findings Include: a) Resident #57 During the initial interview on 03/04/25 at 9:23 AM, Resident #57 stated, The food sucks, It's the same old stuff. Like today is soup and sandwich but they don't tell us what the soup or the sandwich is. I am not sure if I like it or not, so I ordered grilled cheese and tomato soup. They change the menu all the time and don't tell us what the change is. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to maintain infection control standards during incontinence care for Resident #1, who was on enhanced barrier precautions, by not wearing the appropriate PPE, by throwing soiled clothing, linens and a brief on the floor of the shower room, and continuing to wear soiled gloves throughout the unit after the incontinence care was provided for Resident #1; and, storing clean linen in the shower room, and did not maintain contact/droplet precautions during an influenza outbreak. Resident identifier: #1. Facility Census: 61. Findings Include: a) Resident #1 On 03/04/25 at 9:20 PM, Resident #1 was observed sitting in a recliner with visible signs of urinary signs of urinary incontinence on Resident #1's pants. The resident was transferred from recliner to the wheelchair. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to complete required yearly education for two (2) Nurse Aides (NAs) at the facility. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 61.

Inspectors wroteBased on observation, family interview, and staff interviews the facility failed to allow family members to visit with residents in the residents room. This failed practice was found true for (1) one of (2) two residents reviewed for dignity during the Long-Term Care Survey Process. Resident identifier: #40. Facility census: 61. Findings Include: a) Resident #40 During a phone interview on 03/04/25 at 11:53 AM, the Medical Power of Attorney (MPOA) for Resident #40 stated, They told me that I am not allowed to go to her room, we only get to visit in the lobby. I think that is a bunch of (b***sh*t.) The State Agency (SA) asked MPOA, How long has it been since you were allowed in Resident #40's room? The MPOA stated, I come every other day and it has been like this since Covid started. An observation on 03/04/25 at 11:04 AM, revealed the MPOA and Resident #40 sitting in the lobby visiting. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that a the circumstances surrounding a facility initiated discharge was approprialtey documented in a resident's record and that information regarding their unwillingness to readmit him was conveyed to the acute care facility he was transferred/discharged to at the time of the transfer/discharge. The facility discharged Resident #214 from and refusedto accept the resident back from the hospital after sending him out. This was true for one (1) of two (2) residents reviewed for discharges during the survey process. Resident identifier: #214. Facility census: 61.

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure they referred one (1) of three (3) residents reviewed for Preadmission Screening and Resident Review (PASARR) for a Level II PASARR evaluation and determination after the resident had a newly evident mental disorder. Resident identifier #15. Resident census: 61.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Pre-admission screening (PAS) included all psychiatric diagnoses for Resident #50. This is true for one (1) of one (1) resident reviewed during the initial screening process of the survey. Resident #50. Facility Census: 61. Findings Include: a) Resident #50 On 03/03/25 at 3:28 PM, a record review was completed. The review found the PAS was not available on the electronic medical record (EMR). On 03/10/25 at 2:31 PM, the PAS dated 02/15/22 was reviewed. There was no documentation found for the diagnoses of anxiety disorder, unspecified; depressed mood, unspecified; PTSD; and hallucinations. On 03/10/25 at 2:48 PM, the Director of Social Services #11 was interviewed. The Director of Social Services stated, we received this from (Name of an acute psychiatric facility). [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure an accurate system of medication records that enabled periodic accurate reconciliation and accounting for all controlled medications for prompt identification of loss or potential diversion of controlled medications for 3 of 3 medication carts inspected.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure medications, used in the facility, were stored, in accordance with current accepted professional practices. This was true for medications stored in one (1) of two (2) medication storage rooms. The facility failed to ensure the temperature of the refrigerator was maintained at the manufacturer's acceptable temperature range for storage. This practice had the potential to effect more than a minimum number of residents. Facility census: 59.

Inspectors wroteBased on facility documentation and staff interviews the facility failed to provide an attendance signature form to show all required members attended at least one (1) Quality Assessment and Assurance (QAA) meeting every quarter. This failed practice had the potential to affect more than a limited number of residents who currently reside at the facility. Facility census 59.

Inspectors wroteBased on facility documents and staff interview the facility failed to accurately monitor for waterborne pathogens. This failed practice had the potential to affect more than a limited number of residents who currently reside at the facility, Facility census 59.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure each resident received privacy during a treatment. This was based on a random opportunity for discovery and was true for Resident #32, who was not provided privacy during an enteral feeding. Resident identifier: #32. Census: 59.

Inspectors wroteBased on observation and staff interviews the facility failed to ensure all resident has a right to a safe, clean, comfortable and homelike environment. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Facility census 59.

Inspectors wroteBased on record review and staff interview the facility failed to complete a discharge assessment for Resident #43. This was true for one (1) of one (1) resident reviewed for Resident Assessments. Resident identifier: #43. Facility census: 59.

Inspectors wroteBased on record review and staff interview the facility failed to have an accurate assessment to reflect the residents' status. This was true for one (1) out of 17 reviewed for accurate Minimum Data Set (MDS). Resident identifier: # 45. Facility census 59.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of one (1) resident reviewed for the category of PASARR, during the long-term care survey. Resident identifier #16. Census 59.

Inspectors wroteBased on record reivew and staff interview the facility failed to ensure one (1) resident who had unwitnessed falls had neurological checks completed as instructed on the assessment flow sheet. Resident identifier: #45. Facility census: 59.

Inspectors wroteBased on resident interview, record review, and staff interview the failed to implement interventions, including adequate supervision consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident. Resident identifier: # 45. Facility census 59.

Inspectors wroteBased on observation, medical record review, and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. A physician's order for oxygen was not followed. This was a random opportunity for discovery, during the Long-Term Care Survey Process (LTCSP). Resident Identifier: #18. Facility Census: 59.

Inspectors wroteThe facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice in regard to monitoring pain levels. This was true for one (1) of one (1) resident reviewed for Pain. Resident Identifier: #7. Facility census: 59.