Majestic Care of Middletown LLC

Inspectors wroteBased on record review, staff interview, review of self-reported incident (SRI), and facility policy review, the facility failed to ensure residents were free from verbal abuse. This affected one, (Resident #152) out of three (Residents #07, #45, #152) reviewed for abuse. The facility census was 128.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure safe resident smoking. This affected two Residents (#103, #152) out three Residents (#57, #103, #152) reviewed for smoking. The facility identified 22 Residents (#01, #07, #08, #11, #15, #25, #30, #38, #40, #43,#45,#48, #53, #55,#57, #67, #68, #72, #79, #91, #101, #112) who are smokers at the facility. The facility census was 128. Findings Include:1. Medical record review for Resident #103 revealed he was admitted to the facility on [DATE]. Resident #103 did reside on the memory care secured unit from 07/02/25 until he was moved off the memory care unit effective 10/12/25. His diagnoses include chronic obstructive pulmonary disease (COPD), emphysema, atherosclerotic heart disease, hyperlipidemia, insomnia, anxiety disorder, and vascular dementia. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure food storage areas were clean and food items were store appropriately. This had the potential to affect all residents that eat food from the kitchen. The facility identified eight (Residents #57, #89, #92, #101, #108, #122, #134, and #139) residents that did not eat food from the kitchen. The facility also failed to ensure resident refrigerators were clean. This affected Resident #36. The census was 148.

Inspectors wroteBased on record review, observation, interview and policy review, the facility failed to have a Legionella prevention program. This had the potential to affect all residents of the facility. The facility also failed to to ensure staff changed gloves and washed their hands appropriately during incontinence care. This affected one (Resident #97) of three residents reviewed for incontinence. The census was 148.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure a safe, functional, and homelike environment for the residents. This affected three (Residents #54, #81 and #116) of the three residents reviewed for a homelike environment. The facility census was 148.

Inspectors wroteBased on observation, record review, and interview, the facility failed to nail care for residents. This affected two (Residents #32 and #100) of three residents reviewed for care and services. The facility census was 148.

Inspectors wroteBased on record review and staff interview, the facility failed to followed ordered pharmacy recommendations. This affected one (Resident #135) of five residents review for unnecessary medications. The census was 148.

Inspectors wroteBased on observation, record review, staff interviews, and policy review, the facility failed to ensure insulin vials were properly labeled and stored. This affected three (Residents #23, #29 and #128) of the 26 residents with medications stored in the Aspen medication cart. The facility census was 148.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and policy review, the facility failed to ensure a resident with a colostomy was provided appropriate and adequate care. This affected one (#10) of three residents reviewed for ostomies. The census was 128.

Inspectors wroteBased on observation, record review, resident interviews, staff interviews, and policy review, the facility failed to ensure the outdoor smoking area was reasonably accessible to residents and had protection from weather. This directly affected one (#110) of three residents reviewed for accommodation of needs while smoking, with the potential to affect 26 unsupervised residents who smoke. The facility identified a total of 33 residents smoking. The facility census was 134.

Inspectors wroteBased on medical record review, staff interviews and policy review, the facility failed to notify a resident representative of change in health care status. This affected one (#137) of three residents reviewed for change in condition. The facility census was 35.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure care conferences were completed as required. This affected one (#137) of three residents reviewed for care conferences. The facility census was 135.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to follow physicians' orders for medication administration with blood pressure parameters which resulted in significant medication errors. This affected one (#37) of three residents reviewed for medication administration. The facility census was 135.

Inspectors wroteBased on medical record review, observation, staff interview and policy review, the facility failed to implement their infection control policy during medication administration. This affected one (#114) of three residents observed for medication administration. The facility census was 135.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to perform timely and adequate incontinence care and failed to ensure physician orders were followed for use of incontinence products. This affected four (#14, #43, #108 and #116) out of five residents reviewed for incontinence. The facility census was 142.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to notify the physician or nurse practitioner of significant weight changes and wound treatment refusals. This affected one (#26) of three residents reviewed for nutrition and one (#108) of three residents reviewed for wounds. The facility census was 142.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and policy review, the facility failed to provide residents with a palatable meal with appetizing temperatures. This affected two (#69 and #113) of three residents reviewed for meals. The facility census was 142.

Inspectors wroteBased on medical record review, death certificate review, policy review, dialysis center record review, physician interview, staff interview, and dialysis center staff interview, the facility failed to ensure Resident #06, with a diagnosis of end-stage renal disease (ESRD), received scheduled hemodialysis treatments as ordered by the physician. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death when Resident #06 went four days without hemodialysis treatments due to the facility's failure to communicate and coordinate continuity of care with the dialysis center, failure to transport the resident to hemodialysis treatments and failure to notify the physician of the resident not receiving ordered treatments. Resident #06 suffered cardiopulmonary arrest and expired in the facility on 01/21/24. [...]

Inspectors wroteBased on medical record review, resident interview, staff interview, the facility failed to ensure the physician was notified when medications were not available due to a national shortage. This affected one (Resident #65) of three residents reviewed. The census was 138.

Inspectors wroteBased on medical record review, resident interview, staff interview, review of facility self-reported incidents (SRI), and review of facility policy, the facility failed to prevent physical abuse. This affected one (Resident #65) of three residents reviewed. The census was 138.

Inspectors wroteBased on medical record review, review of hospital documentation, review of a fall investigation, observations, staff interviews, and policy review, the facility failed to provide adequate assistance and supervision while a resident was sitting on the side of the bed, to prevent the resident from falling. This resulted in Actual Harm when Resident #06 was left unassisted on the side of the bed and the resident had an avoidable fall off the bed. Resident #06 sustained fractures of the femur and humerus which required surgical intervention. The affected one (#06) out of three residents reviewed for falls. Additionally, the facility failed to provide adequate supervision to Resident #91 while he smoked, which placed the resident at risk for more than minimal harm. This affected one (#91) of three resident reviewed for smoking. The facility census was 145.

Inspectors wroteBased on medical record reviews, staff interview, and policy review, the facility failed to ensure quarterly care conferences were completed. This affected five (#36, #76, #80, #87, and #122) out of five residents reviewed for care conferences. The facility census was 145.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure resident's nutritional needs were met as care planned. This affected five (#9, #43, #87, #201 and #202) of eight residents reviewed for weight changes. The facility census were 145.

Inspectors wroteBased on review of personnel records, review of training documents and staff interviews, the facility failed to ensure that nursing staff had the competencies and skill set to perform their job regarding care for residents with ventilators. This had the potential to affect four (#39, #43, #45 and #48) residents on ventilators. Facility census was 145.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure preadmission screening was completed for a resident prior to admission to the facility. This affected one (#98) out of five residents reviewed for preadmission screening. The facility census was 145.

Inspectors wroteBased on medical record review, review of Hospice documentation, interviews with facility staff, Hospice provider and pharmacy representative, and policy review, the facility failed to ensure staff were able to access medications from the facility's electronic medication dispenser (Ebox). This affected one (#203) out of four reviewed for medication administration. Facility census was 145.

Inspectors wroteBased on record review, observations, staff interview and review of a facility policy, the facility failed to ensure staff used the appropriate personal protective equipment (PPE) while in a residents room who was in isolation. This affected one (#43) of three residents reviewed for infection control. The facility census was 145.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to administer influenza vaccine timely. This affected one (#122) out of five residents reviewed for vaccinations. The facility census was 145.

Inspectors wroteBased on record review and staff and physician interviews, the facility failed to notify the physician of abnormal laboratory (lab) results in a timely manner which resulted in a delay of treatment. This affected two (#84 and #162) of four residents reviewed for timely care and treatment. The facility census was 147.

Inspectors wroteBased on medical record review, observations, resident and staff interviews the facility failed to ensure residents received timely incontinence care. This affected two (#20 and #154) of three residents reviewed for incontinence care. The facility census was 147.

Inspectors wroteBased on record review and staff and physician interviews, the facility failed to timely notify the physician of abnormal laboratory (lab) results which resulted in a delay of treatment for a resident's positive Clostridioides difficile (C-diff) results. This affected one (#162) of four residents reviewed for timely care and treatment. The facility census was 147.

Inspectors wroteBased on record review and staff interviews, the facility failed to notify the physician of abnormal laboratory (lab) results in a timely manner which resulted in a delay of treatment for a resident's urinary tract infection (UTI). This affected one (#84) of four residents reviewed for timely care and treatment. The facility census was 147.

Inspectors wroteBased on record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, and interviews, the facility failed to ensure medications administered Intravenously (IV) were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This deficiency affected four (Residents #27, #89, #85, and #30) of four reviewed for IV administration. [...]

Inspectors wroteBased on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, and interview the facility failed to ensure medications were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This deficiency affected four of four Residents (#27, #89, #85, and #30) reviewed for medications administered by a contracted ancillary provider. This affected 23 current Residents (#146, #64, #38, #23, #65, #96, #70, #13, #8, #27, #89, #66, #75, #85, #30, #88, #87, #55, #61, #63, #16, #67, and #145) and 18 discharged Residents (#180, #181, #182, #183, #184, #185, #186, #187, #188, #189, #190, #191, #192, #193, #194, #195, #196, and #197). The census was 160.

Inspectors wroteBased on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, review of facility policy, and interview the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This deficiency affected four of four Residents (#27, #89, #85, and #30) reviewed for medications administered by a contracted ancillary provider. This affected 23 current Residents (#146, #64, #38, #23, #65, #96, #70, #13, #8, #27, #89, #66, #75, #85, #30, #88, #87, #55, #61, #63, #16, #67, and #145) and 18 discharged Residents (#180, #181, #182, #183, #184, #185, #186, #187, #188, #189, #190, #191, #192, #193, #194, #195, #196, and #197). The census was 160.

Inspectors wroteBased on record review, staff interviews, and review of facility policy, the facility failed to ensure medication administration was signed off by appropriate staff. This affected two (Residents #27 and #85) of four reviewed for Intravenous (IV) administration of medications. The census was 160.

Inspectors wroteBased on record review, observation and interview, the facility failed to store, serve, and prepare food in a sanitary manner and monitor refrigerator and dishwasher temperatures. This had the potential to affect 167 residents who received food from the kitchen. The facility census was 173.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean and safe homelike environment in the main dining room and in resident rooms. This affected six (Residents # 21, #151, #10, #131 #163 and #145) residents. This had the potential to affect all residents. The facility census was 173.

Inspectors wroteBased on record review, observation and interview, the facility failed to provide food portions as planned by a Registered Dietitian. This affected four (Residents #115, #6, #7 and #172) who received a puree diet, and one (Resident #177) of 11 residents reviewed for fluid restrictions. 167 residents received food from the kitchen. The census was 173.

Inspectors wroteBased on interview, record review and policy review, the facility failed ensure residents had written authorizations for the facility to manage their personal funds. This affected two (Residents #45 and #81) of five residents reviewed for personal funds. 173 residents had personal funds accounts. The facility census was 173.

Inspectors wroteBased on interview and record review, the facility failed to notify residents that the amount of funds in their accounts was 200 dollars less than the social security income resource limit and that the residents may lose eligibility for Medicaid or social security income. This affected two (Residents #45 and #81) of five residents reviewed for personal funds. The facility census was 173.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure a potential incident of misappropriation of resident property was reported to the State Agency (SA). This affected one (Resident#145) of two residents reviewed for abuse. The facility census was 173.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure a potential incident of misappropriation of resident property was thoroughly investigated. This affected one (Resident#145) of two residents reviewed for abuse. The facility census was 173.

Inspectors wroteBased on record review and interview, the facility failed to complete a preadmission screening resident review (PASARR) on a newly admitted residents that had an expired hospital exemption and a history of mental illness. This affected one (Resident #136) of five residents reviewed for preadmission screening resident review (PASARR). The facility census was 173.

Inspectors wroteBased on record review and interview, the facility failed to ensure a discharge summary was completed and provided to the resident upon a resident's discharge home. This affected one (Resident #175) of three residents reviewed for discharges. The facility census was 173.

Inspectors wrote2. Record review revealed Resident #63 was admitted to the facility on [DATE]. Diagnoses for Resident #63 include Alzheimer's disease, osteoporosis, and cataracts. Review of the MDS comprehensive assessment dated [DATE] revealed the resident had impaired cognition and required extensive assistance of one staff for personal hygiene. During observation on 03/23/23 a 9:05 A.M., Resident #63 had heavy hair growth above her upper lip. During interview at the time of the observation, Resident #63 stated she did not like the hair above her lip had been waiting two days for the hair to be removed. During interview on 03/23/23 at 9:09 A.M., STNA #250 verified Resident #63 had hair growth above her upper lip and the STNA assignment included removal of facial hair. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure activities were provided to residents consistent with their interests. This affected two (Residents #120 and #13) of four residents reviewed for activities. The census was 180.

Inspectors wroteBased on record review and interview, the facility failed to ensure podiatry services were provided as ordered. This affected one (Resident #10) of 24 sampled residents. The census was 173.

Inspectors wroteBased on record review, interview and policy review, the facility failed to obtain daily and weekly weights upon admission and as ordered. This affected three (Residents #110, #145 and #177) of four residents reviewed for nutrition. The facility census was 173. 1. Review of the medical record for Resident #110 revealed an admission date of 11/21/22. Diagnoses included type 2 diabetes mellitus, cerebral infarction, legal blindness, generalized anxiety disorder, weakness, COVID-19, hyperlipidemia, and depression. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #110, dated 01/23/23, revealed the resident had an impaired cognition. Resident #110 required extensive assistance with hygiene, toileting, dressing, locomotion on/off unit, and walking in room/corridor. The resident required limited assistance from staff for bed mobility, transfers, and eating. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a dental appointment was scheduled for tooth extractions. This affected one (Resident #13) of two residents reviewed for dental services.

Inspectors wroteBased on record review, interview and policy review, the d facility policy the facility failed to accurately document a resident's weight bearing status and accurately assess a resident's need for therapy services. This affected one (Resident #15) of two residents reviewed for therapy services. The facility census was 173.

Inspectors wroteBased on medical record review, observation, staff interview and review of medication storage policy, the facility failed to properly label drugs and biologicals used in the facility. One vial of Tuberculin purified protein derivative (PPD) was opened and undated. This had the potential to affect all residents. There were also four inhalers stored in medication carts that were opened and undated. This directly affected four (#39, #80, #97, and #115) of four residents medications that were observed. Facility census was 171.

Inspectors wroteBased on closed medical record review, and staff interview, the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) when Medicare Part A residents were discharged from the facility to home with skilled days remaining. This affected two (#327 and #328) of four residents reviewed for beneficiary protection notification. The facility census was 171.

Inspectors wroteBased on record review, staff interview and review of facility policy, the facility failed to implement their abuse policy in regards to an allegation of sexual abuse. This affected two (#16 and #35) of 34 resident's records reviewed during the initial pool stage. Facility census was 171.

Inspectors wroteBased on record review, staff interview and review of facility policy, the facility failed to report an allegation of sexual abuse to the Ohio Department of Health. This affected two (#16 and #35) of 34 resident's records reviewed during the initial pool stage. Facility census was 171.

Inspectors wroteBased on record review, staff interview and review of facility policy, the facility failed to thoroughly investigate an allegation of sexual abuse. This affected two (#16 and #35) of 34 resident's records reviewed during the initial pool stage. Facility census was 171.

Inspectors wroteBased on medical record review, observation, resident and staff interviews, and review of the facility policy, the facility failed to provide residents assistance with Activities of Daily Living (ADLs) this affected two Residents (#75 and #173) of four reviewed for dignity and/or ADLs. The facility census was 171.

Inspectors wroteBased on medical record review, resident and staff interview, the facility failed to timely obtain hearing services for residents. This affected one (#80) of one resident reviewed for hearing services. The census was 171.