Majestic Care of Point Place

Inspectors wroteBased on observation, record review, review of emergency medical services (EMS) run reports, review of crash cart audit logs, review of cardiopulmonary resuscitation certification documentation, review of a medication administration audit report, review of a vital documentation audit report, review of the American Heart Association (AHA) guidance for adult Cardiopulmonary Resuscitation (CPR), staff interview, EMS staff interviews, and review of facility policy, the facility failed to provide Resident #77, who had a full code status (advance directives), with basic lifesaving interventions on [DATE] by not immediately initiating rescue breathing or ventilations while performing chest compressions. [...]

Inspectors wroteBased on observation, review of the crash cart checklist logs, staff interview, and policy review, the facility failed to ensure the two facility crash carts were properly maintained. This had the potential to affect all residents. The facility census was 76.

Inspectors wroteBased on observation, record review, review of weekly skin assessments, resident interview, staff interview, and review of facility policy the facility failed to ensure routine skin assessments were completed and physician ordered wound interventions were implemented. This affected two (#29 and #12) of three residents reviewed for wounds. The facility identified a total of 18 residents as having wounds. The facility census was 76.

Inspectors wroteBased on review of the medical record, review of a facility statement, review of Emergency Medical Services incident run reports, interview, and policy review, the facility failed to ensure accurate and thorough documentation in the medical record. This affected two (#14, #77) of three residents reviewed for medical documentation. The facility census was 76.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to maintain required infection control standards during a dressing change. This affected one (#49) of three residents reviewed for wounds. Additionally, the facility failed to ensure bedpans and basins were properly stored in a sanitary manner. This affected one (#34) of three residents reviewed for activities of daily living. The facility identified eight residents utilizing bedpans. The facility census was 76.

Inspectors wroteBased on review of the daily posted staffing information, review of staff time cards, interview, and policy review, the facility failed to ensure a Registered Nurse (RN) was present for eight consecutive hours in the facility. This had the potential to affect all residents. The facility census was 76.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, resident interview, observation of the 100-hall medication cart, and policy review, the facility failed to administer an as needed seizure medication for a resident having a seizure. This affected one (#17) of three residents reviewed for as needed seizure medications. The facility census was 64.

Inspectors wroteBased on observation, resident interview, staff interview, and policy review the facility failed to ensure a residents were care planned for hearing aids which resulted in the facility failing to ensure resident hearing aids were maintained and in good working order. This affected one (#61) of two residents reviewed for comprehensive care planning. The facility census was 63. Review of Resident #61's medical record revealed an admission date of 02/14/25. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus, atrial fibrillation, dementia, Parkinson's, and transient ischemic attack. Review of Resident #61's significant change Minimum Data Set (MDS) dated [DATE] revealed the resident had an intact cognition, had moderate hearing loss and required the use of hearing aids. [...]

Inspectors wroteBased on observation, resident interview, staff interview, and policy review revealed the facility failed to ensure one Resident (#18) was showered and received haircuts timely. This had the ability to affect all residents. The facility census was 63. Review of Resident #18's medical record revealed an admission date of 08/25/22. Diagnoses included vascular dementia, convulsion, chronic kidney disease, and transient ischemic attack. Review of Resident #18's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a moderately intact cognition. He required supervision or touching assistance for showers. Review of the most recent care plan revealed Resident #18 required minimal assistance with activities of daily living related to dementia and a history of falls. Nail care was to be completed on bath days and as necessary. [...]

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure appropriate incontinence care. This affected one (#03) of three residents reviewed for incontinence. The facility census was 63. Review of the medical record for Resident #03 revealed an admission date of 06/02/17 with a readmission date of 11/04/22, diagnoses included pneumonia, protein-calorie malnutrition, chronic obstructive pulmonary disease, Alzheimer's disease, anxiety, dysphagia, and depression. Review of the 5-day Minimum Data Set (MDS) assessment, dated 12/10/25, revealed Resident #03 had severely impaired cognition, required substantial/maximal assistance for rolling from left to right and for toileting hygiene, was always incontinent of bowel and bladder, and had a feeding tube. Observation on 12/17/25 at 12:20 P.M. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to timely respond to pharmacist recommendations. This affected one (#63) of five residents reviewed for pharmacist recommendations. The facility census was 63. Review of the medical record for Resident #63 revealed an admission date of 02/06/25 with diagnoses of type II diabetes mellitus, hypertensive heart disease, and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/08/25, revealed Resident #63 had intact cognition and received hypoglycemic medications. Review of the pharmacy recommendation to prescriber, dated 08/10/25, revealed a recommendation to check Resident #63's hemoglobin A1c (HbA1c) laboratory value. Further review revealed the physician responded 08/15/25 with a statement ok to draw lab. [...]

Inspectors wroteBased on observation, staff interview, and review of the menu spreadsheet, the facility failed to provide appropriate portions and all menu items for residents on a pureed diet. This affected two (#4 and #64) of two residents identified on a pureed diet. The facility census was 63. Observation in the kitchen on 09/30/25 at 4:05 P.M. revealed [NAME] #195 preparing pureed meals for the evening meal. [NAME] #195 used an 8-ounce scoop to portion out turkey and dumplings for preparation. Concurrent interview with [NAME] #195 confirmed he only needed one 8-ounce scoop for two pureed portions of turkey and dumplings. [NAME] #195 stated only two residents, Resident #4 and Resident #64, were on pureed diets. Continued observation revealed [NAME] #195 prepared pureed turkey and dumplings and pureed green beans. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review the facility failed to accurately and timely document in the medical records. This affected one Resident (Resident #37) out of ten residents reviewed for documentation. Additionally, the facility failed to transcribe physician orders. This affected four residents (#04, #37, #05, and #63) out of six reviewed for physician orders. The facility census was 63. 1. Review of the medical record for Resident #04 revealed an admission date of 07/27/22, diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left side, gastrostomy status, and acquired absence of left leg above the knee. [...]

Inspectors wroteBased on observation, medical record review, staff interviews, and review of facility policies, the facility failed to ensure infection prevention measures were correctly utilized when providing care to residents. This affected three (Residents #03, #22, and #71) of six resident reviewed for infection control. The facility census was 63. 1. Review of the medical record for Resident #22 revealed she was admitted on [DATE]. Diagnoses included hemiparesis to the right side following a stroke, type two diabetes mellitus, dysphagia, aphasia, hypertension, neurogenic bladder, colostomy, and stage three pressure ulcer. Review of the Minimum Data Set 3.0 assessment dated [DATE] for Resident #22 revealed the resident was unable to communicate and was severely cognitively impaired, displayed no behaviors at the time of the assessment and was dependent for all care. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interviews, review of a self -reported incident, review of facility investigation, review of in-service records, and policy review, the facility failed to ensure supervision and a safe environment was provided to prevent the elopement of a resident. Actual harm occurred on 07/29/25, when Resident #47 eloped from the facility through an unalarmed and unlocked exit door in the dining room. Resident #47 fell, sustaining an acute mildly displaced fracture of the right distal fibula at the ankle. This affected one (Resident #47) of three residents reviewed for elopement. The facility census was 65.

Inspectors wroteBased on medical record review, staff interview, review of the facility Self-Reported Incident (SRI) and review of the facility policy, the facility failed to ensure comprehensive person center care plans were updated to include identified resident needs and appropriate interventions. This affected two (#48 and #60) of three residents reviewed for comprehensive care plans. The facility census was 64.

Inspectors wroteBased on observation, staff interview and review of the facility policy, the facility failed to ensure staff practiced proper hand hygiene. This had the potential to affect all 62 residents in the facility.

Inspectors wroteBased on observation, medical record review, staff interview, review of facility fall investigations and review of facility policy, the facility failed to ensure fall prevention interventions were implemented as ordered and care planned. This affected one (#1) of three residents reviewed for falls. The facility census was 61.

Inspectors wroteBased on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure incontinence care was properly administered to prevent infection. This affected one (#1) of three residents reviewed for the provision of incontinence care. The facility census was 61.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure residents who required assistance with eating were provided a dignified dining experience. This affected two residents (#44 and #35) of nine residents observed eating lunch in the main dining room. The facility census was 65. Findings Included: Observation on 03/04/24 at 11:18 A.M., of the main dining room, found nine residents seated at four tables. Two residents, Resident #44 and Resident #35, were seated at a square table. The Director of Nursing (DON) was observed standing over Resident #44 and spooning bites of his lunch into his mouth. Interview on 03/04/24 at 11:22 A.M. with the DON verified she was standing to feed Resident #44. The DON reported she was feeding him chicken and dumplings, green beans, a roll, and a cream dessert. Continued observation on 03/04/24 at 11:23 A.M. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure the physician was notified when blood glucose levels were outside of established parameters as ordered. This affected one (#36) of three residents reviewed for insulin. The facility census was 65.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure orders to discontinue psychotropic medications were followed according to the physician order. This affected one resident (#44) of five residents reviewed for unnecessary medications. The facility census was 65. Findings Include: Review of Resident #44's medical record revealed an admission date of 12/01/22. Diagnoses included neurocognitive disorder with lewy bodies (dementia), schizoaffective disorder, chronic kidney disease, cognitive communication deficit, muscle weakness, chronic pain, depressive episodes, and anxiety disorder. Review of Resident #44's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three indicating Resident #44 was severely cognitively impaired. [...]

Inspectors wroteBased on medical record review, staff interview, and review of a facility policy, the facility failed to maintain a complete and accurate medical record. This affected one (#51) of 16 resident medical records reviewed. The facility census was 65.

Inspectors wroteBased on medical record review, observations, resident interview, and staff interviews, the facility failed to ensure admission orders were obtained to provide care and treatment to a resident with a suprapubic urinary catheter. This affected one (#8) of one resident identified with a suprapubic catheter. The facility census was 67.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure wound treatments were applied as ordered by the physician. This affected one (#9) of three residents reviewed for the application of wound treatments. The facility census was 67.

Inspectors wroteBased on observation, medical record review, staff and resident interview, and policy review, the facility failed to provide consistent care and treatment to a resident identified with a suprapubic catheter. This affected one (#8) of one resident identified with a suprapubic catheter. The facility census was 67.

Inspectors wroteBased on medical record review, staff interview, and laboratory contract review and policy review, the facility failed to obtain laboratory blood testing within physician ordered timeframes. This affected one (#6) of three sampled residents reviewed for laboratory blood testing. The facility census was 67.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to notify physician timely of critical laboratory blood testing results. This affected one (#6) of three sampled residents reviewed for laboratory blood testing. The facility census was 67.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure staff wore proper personal protective equipment (PPE) in a COVID positive environment and changed PPE after exposure. This had the potential to affect 11 (#57, #58, #60, #62, #63, #64, #65, #66, #67, #68, and #69) non infected residents of the 12 residents on Resident #59's hall. The facility census was 69.

Inspectors wroteBased on observations, medical record review, staff interview, and resident interviews, the facility failed to ensure timely response to call lights and providing care per personal preference. This affected two (#30 and #61) of three residents reviewed for call light responses. Facility census was 69.

Inspectors wroteBased on observations, medical record review, staff interview, and resident interview, the facility failed to provide timely incontinence care to a dependent resident. This affected one (#30) of three residents reviewed for assistance with care and treatment. The facility census was 69.

Inspectors wroteBased on Self-Reported Incident (SRI) review, in-service record review, policy review, and staff interview, the facility failed to ensure the completion of preventative and corrective action measures after a verbal abuse allegation was substantiated including staff education. This has the potential to affect 69 of 69 residents residing in the facility. The facility census was 69.

Inspectors wroteBased on observation, resident and staff interviews, medical record review, and policy review, the facility failed to ensure a resident who was self-administering medications was safely disposing of used syringes. This affected one (#27) of one resident who self-administers injectable medication. The facility identified nine residents (#4, #12, #20, #22, #26, #29, #33, and #35), who resided on the 200 hall, who were cognitively impaired and independently mobile. The facility census was 66.

Inspectors wroteBased on observation, resident and staff interviews, medical record review, and policy review, the facility failed to ensure medications were secured and not left at the beds side unattended. This affected one (#27) of one resident who self-administers injectable medication. The facility identified nine residents (#4, #12, #20, #22, #26, #29, #33, and #35), who resided on the 200 hall, who were cognitively impaired and independently mobile. The facility census was 66.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure behavioral health needs were appropriately addressed or monitored. This affected one (Resident #1) of three residents reviewed for behavioral health services. The facility census was 66.

Inspectors wroteBased on observation, staff interview, and review of facility policies, the facility failed to ensure foods stored in the refrigerator and freezer were stored in a safe and sanitary manner. This had the potential to affect all residents with the exception of three (#38, #102, and #156) residents identified by the facility as receiving no food from the kitchen. The facility census was 59.

Inspectors wroteBased on observation, resident and staff interview, and medical record review, the facility failed to honor a resident's preference to be transferred to bed. This affected one (#38) of one residents reviewed for choices. The facility census was 59.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure a resident's advance directives for code status were consistent throughout the medical record. This affected one (#25) of nine residents reviewed for advance directives. The facility census was 59.

Inspectors wroteBased on medical record review, observation, resident and staff interview, and review of a facility policy, the facility failed to ensure a resident dependent for care received assistance with shaving and nail care. This affected one (#38) of four residents reviewed for activities of daily living. The facility census was 59.

Inspectors wroteBased on medical record review, observation, and resident and staff interview, and review of a facility policy, the facility failed to provide timely incontinence care for a resident. This affected one (#38) of three residents reviewed for incontinence care. The facility census was 59.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure a resident's tube feeding was administered per physician order. This affected one (#38) of one residents reviewed for tube feeding. The facility census was 59.

Inspectors wroteBased on medical record review, resident and staff interview, and review of a facility policy, the facility failed to timely respond to a request for pain medication changes. This affected one (#11) of one residents reviewed for pain management. The facility census was 59.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner. This affected one (#14) of five residents reviewed for unnecessary medication. The facility census was 59.

Inspectors wroteBased on medical record review, observation, resident and staff interview, resident guardian interview, and review of a facility policy, the facility failed to ensure timely dental care. This affected one (#26) of one residents reviewed for dental care. The facility census was 59.

Inspectors wroteBased on observation and resident and staff interview, the facility failed to ensure substitutions of similar nutritional value were offered timely to residents. This affected one (#18) of one residents reviewed for food preferences. The facility census was 59.

Inspectors wroteBased on medical record review, staff interview, facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidance the facility failed to ensure pneumococcal vaccinations were offered and administered per recommendations. This affected two (#33 and #34) of five residents reviewed for immunizations. The facility census was 59.