Majestic Care of Manchin

Inspectors wroteBased on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for resident Room identifiers: #218, #212, and #205. This was a random opportunity for discovery. Census: 25.

Inspectors wroteBased on Electronic Medical Record review and staff interview, the facility failed to develop a care plan for non-pharmacological interventions and implement a toileting care plan for two (2) residents. This had the potential to affect more than a limited number of residents who were reviewed for care plans. Resident identifiers: #14, #4, #20. Facility census: 25.

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #22 was found to have a razor in his bathroom. For residents #25 and #27, Facility Reported Incidents (FRIs) revealed the facility failed to to ensure each resident received adequate supervision to prevent accidents and elopements. For Resident #27 the facility staff failed to respond to a wander guard alarm. During Resident #5's medication administration, the medication cart was left unlocked. These were random opportunities for discovery. Resident identifiers: #22, #25, #27, and #5. Facility Census: 25.

Inspectors wroteBased on observation and staff interviews, the facility failed to Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This was a random opportunity for discovery and had the potential to affect multiple residents of the facility. Facility census 25.

Inspectors wroteBased on observation and staff interviews the facility failed to maintain kitchen equipment in safe operating condition. This was a random opportunity for discovery. Facility census: 25. Findings Include: a) On 04/22/25 11:20 AM, during the kitchen food temperature testing, observation revealed the burner knobs were not on the stove. The kitchen staff was preparing lunch causing the grilled cheeses to burn. The cook stated the grill was set too high and was unable to adjust the grill temperatures until he replaced the missing knobs with control knobs from the other burners to adjust the grill temperatures. This left the other burners without control knobs. On 04/22/25 at 11:25 AM, In an interview with the facility cook he stated the knobs fell off and were probably under the stove somewhere. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure privacy and confidentially for Resident #5 during medication administration. Resident identifier: #5. Facility Census: 25.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure Resident #4 was free from restraints. This was true for one (1) of the two (2) residents reviewed under the care area of falls. Resident Identifier: #4. Facility Census: 25. Findings Include: a) Resident #4 On 04/22/25 at 2:45 PM, a record review was completed for Resident #4 regarding multiple falls. The review found the resident had a physician's order dated 06/21/24 for a self releasing seat belt for improve safety/cues to resident upon standing attempts to help with fall prevention. However, the physician's order did not contain the information to release the restraint every two (2) hours. Upon further review, the care plan under the focus area of at risk for falls related to past history of falls, did list the self releasing seat belt as an intervention. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessment indicated the use of restraints. This was true for one (1) of two (2) residents reviewed under the care area of falls. Resident identifier: #4. Facility Census: 25. Findings Include: a) Resident #4 On 04/22/25 at 2:45 PM, a record review was completed for Resident #4 regarding multiple falls. The review found the resident had a physician's order dated 06/21/24 for a self-releasing seat belt for improve safety/cues to resident upon standing attempts to help with fall prevention. However, the physician's order did not contain the information to release the restraint every two (2) hours. Upon further review, the care plan under the focus area of at risk for falls related to history of falls, did list the self-releasing seat belt as an intervention. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to revise the care plan regarding restraint use for Resident #4 and actual skin breakdown for Resident #12. This was true for two (2) of 15 residents reviewed during the survey process. Resident Identifiers: #4 and #12. Facility Census: 25. Findings Include: a) Resident #4 On 04/22/25 at 2:45 PM, a record review was completed for Resident #4 regarding multiple falls. The review found the resident had a physician's order dated 06/21/24 for a self releasing seat belt for improve safety/cues to resident upon standing attempts to help with fall prevention. The care plan does indicate an intervention of the self releasing seat belt under the focus area of risk for falls due to a history of falls; however, the care plan was not revised to indicate the self releasing seat belt is a restraint. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to follow physician's orders for toileting schedules for Resident #4 and Resident #20. This was true for two (2) of 15 residents reviewed during the survey process. Resident Identifiers: Resident #4 and #20. Facility Census: 25. Findings Include: a) Resident #4 On 04/22/25 at 9:20 AM, a toileting sheet was observed hanging on Resident #4's bathroom door. The toileting sheet was scheduled for every two (2) hours. The toileting sheet was noted for 04/19/25 through 04/25/25. No documentation was found from 8:00 AM through 10:00 PM. A physician's order dated 01/16/25 stated, Will ask resident if they need to void q2h (every two hours) while awake to help with toileting needs. (Typed as written.) On 04/22/25 at 9:30 AM, an interview with held with Registered Nurse (RN) #22. RN #22 stated, the resident is on a toileting program. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to complete the daily staff posting. This was a random opportunity for discovery. Facility Census: 25. a) Daily Staff Posting On 04/22/25 at 9:00 AM, an observation of the daily staff posting which was hanging at the nurses' station was made. The staff posting dated 04/22/25 did not have the 7:00 AM to 7:00 PM shift completed with the census, nursing hours, actual nursing hours worked and staffing totals. On 04/22/25 at 9:12 AM, the Administrator was at nurses' station. The Administrator was notified the posting was not completed. The Administrator confirmed the posting was not complete.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an accurate and complete record for Resident #4's hospice notes and a nursing assessment regarding contractures for Resident #12. This was true for two (2) of 15 residents reviewed during the survey process. Resident identifiers: #4 and #12. Facility Census: 25. Findings Include: a) Resident #4 On 04/22/25 at 8:45 AM, a review of the hospice notes was completed for Resident #4. During the review, Resident #9's hospice notes were found in Resident #4's medical record. On 04/22/25 at 8:50 AM, the Administrator was notified and confirmed the wrong resident's notes were scanned into Resident #4's medical record. The Administrator stated, We will get this taken care of immediately. b) Resident #12 On 04/22/25 at 4:00 PM, a record review was completed for Resident #12. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Infection Prevention Control Program (IPCP) was reviewed annually. This was discovered during the review of the IPCP. This had the potential to affect all residents. Facility census: 25.

Inspectors wroteBased on observation, policy review, and staff interview, the facility failed to ensure the environment was free from accident hazards over which it had control. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifier: #5. Facility census: 32.

Inspectors wroteBased on observation and staff interview, the facility failed to respect the Residents right to be treated with respect and dignity. This was a random opportunity for discovery. Resident Identifier: #27. Facility Census:

Inspectors wroteBased on medical record review and staff interview, the facility failed to conduct an accurate initial minimum data set (MDS) assessment. This is true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #32. Facility census: 32.

Inspectors wroteBased on record review, review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual and staff interview, it was determined that the facility failed to ensure that Resident 10's Quarterly MDS was submitted during the prescribed timeframe. This was a random opportunity for discovery. Resident identifier: #10. Facility census: 32. Finding Included: a) MDS 3.0 Resident Assessment Instrument (RAI) User's Manual Review of the MDS 3.0 RAI Manual (October 2019) Chapter 5 Submission and Correction of the MDS Assessments, subsection 5.2 revealed in part the following: Assessment Schedule: An OBRA (Omnibus Budget Reconciliation Act) assessment (comprehensive or Quarterly) is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between OBRA assessments. [...]

Inspectors wroteBased on record reviews and staff interviews, the facility failed to complete accurate Minimum Data Set (MDS) assessments. This was true for three (3) of 15 sample residents. Resident #1 was coded for a wrong diagnosis, Resident #16's assessment indicated there was a urinary tract infection (UTI) and Resident #32 had an incorrect gradual dose reduction (GDR) date. Resident identifiers: #1, #16, and #32. Facility census: 32.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to develop comprehensive person-centered care plans. This was true for two (2) of 15 sample resident's care plans reviewed. Resident #16's care plan was not developed for anticoagulant therapy and Resident #32's was not developed for Hospice services. Resident identifiers: #16 and #32. Facility census: 32.

Inspectors wroteBased on record review and staff interview, the facility failed to review and revise the care plan related to skin assessment/breakdown. This was true for one (1) of fifteen (15) care plans reviewed. Resident #12 Facility Census: 32 Findings Included: a) Resident #12 On 11/06/23 at 1:09 PM it was observed that Resident #12 had a small open area to the dorsum of her right foot. It was open to air. On 11/07/23 at 10:06 AM record review shows the Incident/Accident Report dated 11/04/23 at 10:00 AM, describes the injury as small open area to outer/lateral right foot measures 1.2 x 0.8, appears possible pressure from button on brown slipper socks. There was an order dated 11/04/23 which reads: Cleanse area to right outer lateral foot with wound wash, pat dry, apply thin layer of bacitracin and leave open to air twice a day (BID) until healed. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure nurse staffing information was posted and readily accessible. This was a random opportunity for discovery and had the potential to affect all residents and visitors wishing to view the information. Facility census: 32.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident receiving psychotropic medications was monitored for behaviors and side effects of the medications. This is true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #5. Facility census: 32.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a locked permanently affixed compartment for storage of controlled drugs and other drugs subject to abuse. This practice had the potential to affect a limited number of residents. Facility Census: 32. Findings Included: a) Medication Storage Room On 11/07/23 at 9:00 AM during the medication storage room observation in the presence of Register Nurse (RN) #45 it was found that the medication refrigerator had no permanently affixed locked box for controlled drugs (narcotic/benzodiazepines) in the medication refrigerator. There was a sealed 30 milliliter (ml) bottle of Lorazepam (a benzodiazepine) 2 milligram (mg)/ml in the refrigerator which was not secured. This was confirmed on 11/07/23 at 9:00 AM by RN #45 and then with the Director of Nursing on 11/07/23 at 9:14 AM. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered the trash can at the hand washing sink was not operational, and two (2) freezer floors were heavily soiled. This deficient practice had the potential to affect any resident receiving nourishment from the kitchen. Facility census: 32.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to ensure complete and accurate medical records. The facility failed to ensure the Physician's Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virginia Center for End-of-Life Care. This was true for two (2) of 15 residents reviewed. Resident Identifiers: #16 and #15. Facility Census: 32.

Inspectors wroteBased on observation, policy review and staff interview, the facility failed to ensure the environment remained as free of accident hazards as possible. A medication cart was left unlocked during medication pass. Resident identifiers: #13 and #16 Facility census 27.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to ensure the medication error rate was not five% (5 percent) or greater. There was no order to crush medications, an extended release capsule was opened and administered and bare hands touched a medication. This was discovered for nine (9) of the 28 medications observed during medication pass. Resident identifiers: #21, #16 and #26. Facility census: 27. Findings Included: a) Resident # 21 On 04/26/22 at 8:00 AM Registered Nurse (RN) #12 was observed crushing the following medications for Resident #21: 1. Tramadol 50 milligrams (mgs) 2. Lisinopril 10 mgs 3. Amlodipine 5 mgs 4. Sertraline 50 mgs 5. Diclofenac 50 mgs 6. Metoprolol 25 mgs 7. Feosol 65 mgs On review of Resident #21's medical record, found no order for allowing medications to be crushed. [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure the Dishwasher Temperature Log was completed. This was a random opportunity for discovery. The failed practice had the potential to effect more than an unlimited number of Residents. Facility census: 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's right to self-determination, and reassessment of mental capacity was completed once it was clear the resident's cognition had improved. This was true for one (1) of 27 residents reviewed during the long-term care process. Resident identifier: #18. Facility census: 27.

Inspectors wroteBased on observation, interview, and review of medical records, the facility failed to provide necessary treatment services, consistent with professional standards of clinical practice by not administering skin protective devices as ordered by a physician. This was true for one (1) of 27 residents reviewed in the annual long-term care survey process. Resident identifier: #5. Facility census: 27.

Inspectors wroteBased on record review, observation and staff interview the facility failed to place heel protectors on a Resident to promote the prevention of pressure ulcer development. The failed practice was true for one (1) of one (1) Residents reviewed for pressure ulcers. Resident identifier: #13. Facility census: 27.

Inspectors wroteBased on observation and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice. An oxygen humidifier bottle was not changed as ordered. This observation was a random opportunity for discovery. Resident identifier: #5. Facility census: 27.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to post accurate and detailed nurse staffing information on a daily basis. This was true for eleven (11) out of 26 daily nurse staffing postings reviewed. The postings either were lacking the facility census, or the hours worked. This was a random opportunity for discovery. Facility census: 27.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to ensure that a Resident w free of a significant medication error. This was done by allowing an extended release capsule to be opened and administered. This was true for one (1) of 28 medications reviewed during the Long Term Care Survey Process. Resident Identifier #16 Facility Census 27 Findings Included: a) Resident #16 Facility drug book named nursing 2022 Drug Handbook found the following: Page 931 .memantine hydrochloride extended-release capsules must be swallowed whole and never crushed, divided or chewed . On 04/26/22 at 8:10 AM this surveyor observed RN #12 open Resident #16 Memantine ER 28 mg capsule and place the contents of the capsule in the with the rest of the morning crushed medications. RN #12 preceded to administer the medications to Resident #16 in the hallway. [...]

Inspectors wroteBased on record review and staff interview the facility failed to accurately document nursing services in a Resident's medical record. The failed practice was true for one (1) of 12 sampled Residents. Resident identifier: #3. Facility census: 27.