Majestic Care of Whitehall

Inspectors wroteBased on medical record review, interviews, and observations, the facility failed to ensure appropriate infection control practices were followed during catheter care. This affected one Resident (#24) of the two residents reviewed for catheter care. The facility census was 124.

Inspectors wroteBased on observation, review of food temperatures, and staff interview, the facility failed to ensure food was served at appetizing temperatures. This affected 19 residents (#100, #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, #118) of 19 residents residing on the 200 short hall. The census was 118.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure residents received beneficiary notices. This affected six (Resident #46, #146, #92, #147, #142, and #144) of eight residents reviewed for beneficiary notices. The facility census was 123 residents.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure staff could communicate with a Spanish speaking resident. This affected one (Resident #122) of one resident reviewed for communication. The facility census was 123.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a safe, clean, and homelike environment. This affected one (Resident #113) of five residents reviewed for environment. The facility census was 123.

Inspectors wroteBased on interview, medical record review, and facility policy review, the facility failed to conduct care planning meetings with the resident and/or their representative. This affected two residents (Resident #104 and #125) of thirty three records sampled. The facility census was 123 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure wound treatments were initiated timely for a resident with a skin alteration. This affected one (Resident #36) of three residents reviewed for pressure ulcers. The facility census was 123.

Inspectors wroteBased on observation, interviews, and medical records, the facility failed to provide appropriate fall interventions, including placing the bed in a low position and use of a fall mat, for Resident #134. This affected one resident (#134) of the six residents reviewed for accidents. The facility census was 123.

Inspectors wroteBased on interview and record review, the facility failed to ensure weekly and daily weights were completed as ordered, failed to notify the physician of significant weight changes, failed to ensure contradictory weight orders were not in place, and failed to ensure reweights were completed timely and orders were transcribed correctly. This affected three residents (Resident #1, Resident #43, and Resident #90) out of seven residents reviewed for nutrition. The facility census was 123.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper administration of oxygen and failed to ensure a valid physician order was in place for oxygen use. This affected two (Resident #90 and #87) out of three residents reviewed for oxygen administration. The facility census was 123.

Inspectors wroteBased on observations, interviews, and medication records, the facility failed to appropriately manage pain for Resident #122. This affected one resident (#122) of the three residents reviewed for pain management. The facility census was 123.

Inspectors wroteBased on interview and record review, the facility failed to address pharmacy recommendations or initiate medication changes in a timely manner. This affected two (Residents #55 and #90) out of five residents reviewed for pharmacy recommendations. The facility census was 123.

Inspectors wroteBased on observation, interview, record review, medication administration observation, and facility policy review, the facility failed to ensure staff administered medication following infection control procedures. This affected one (Resident #73) of four residents reviewed for infection control. The facility census was 123. Review of the medical record for Resident #73 revealed an admission date of 09/06/18 with diagnoses of end stage renal disease, hyperlipidemia, gastroesophageal reflux disease, polyneuropathy, hypertension, heart failure, and paroxysmal atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #73 is cognitively intact and requires set up or clean up assistance with eating. Observation of medication administration on 04/02/26 from 8:16 A.M. to 8:24 A.M. [...]

Inspectors wroteBased on medical record review and interview, the facility failed to ensure physician appointments were arranged as ordered. This affected one (Resident #16) of four sampled residents. The census was 118.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a safe and functional environment when the transition strips (slim strips fitted at the base of doorways to bridge the gap between different floor surfaces or levels) were not in place to level the resident room floor and the hallway floor. This had the potential to affect eight residents (#14, #35, #41, #64 #65, #70, #105, and #115) of 22 residents residing on the [NAME] hallway. The facility census was 118. Findings Include: On 11/04/24 at 9:27 A.M., observations of Resident #14, #35, #41, #64 #65, #70, #105, and #115 rooms revealed the transition strips were missing in the doorway causing an unleveled surface entering and exiting the resident rooms. On 11/06/24 at 12:05 P.M., interview with the Director of Nursing (DON) revealed the facility had removed carpet and replaced with different floor. [...]

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure Resident #59 was treated with respect and dignity. This affected one resident (#59) of nine sampled residents. The facility census was 118.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure Resident #133's physician was notified of a blood pressure outside of the physician ordered parameters. This affected one (Resident #133) of nine sampled residents. The facility census was 118.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure sutures were removed as physician ordered for Resident #133. This affected one resident (#133) of nine sampled residents. The facility census was 118. Findings Include: Review of the medical record for Resident #133 revealed an initial admission date of 05/31/24 with the latest readmission of 08/21/24 with the diagnoses including but not limited to end stage renal disease (ESRD), puncture wound with foreign body of thorax, osteonecrosis of multiple sites, chronic obstructive pulmonary disease (COPD), stenosis of vascular prosthetic devices, implants and grafts, dependence on hemodialysis, renal osteodystrophy, chronic kidney disease (CKD), endocarditis, atrial fibrillation, seasonal allergic rhinitis, bipolar disorder, hypertension, hyperlipidemia, constipation, anemia and nicotine dependence. [...]

Inspectors wroteBased on observation, staff interview and facility policy review, the facility failed to maintain appropriate infection control practices during the administration of eye drops to prevent potential infection. This affected one resident (#70) of two residents observed for eye drop administration. The facility census was 118. Findings Include: On 11/04/24 at 9:33 A.M., observation of medication administration revealed Licensed Practical Nurse (LPN) #210 applied (donned) a pair of gloves at the medication administration cart, gathered Resident #70's medications which included a nasal spray and eye drops and entered the resident's room. The LPN assisted Resident #70 to take her oral medications. The LPN then used a tissue and wiped the tip of the Fluticasone 50 micrograms (mcg) nasal spray applicator. The LPN then administered two sprays of the Fluticasone 50 mcg in each nostril. [...]

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to maintain a safe, clean and comfortable environment. This affected two rooms on the 400 unit (room [ROOM NUMBER] and 408). The census was 137.

Inspectors wroteBased on observations, medical record review, and staff interview, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition and personal hygiene. This affected three of five residents reviewed for personal hygiene (Residents #9, #24, and #30). The facility census was 137.

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to ensure a resident was provided with proper treatment and assistive devices to maintain vision. This affected one of eight open sampled records reviewed (Resident #55). The facility census was 137.

Inspectors wroteBased on observations, record review, resident interview, and staff interview, the facility failed to ensure a resident received physician ordered assistance devices to prevent falls. This affected one of three residents reviewed for falls (Resident #89). The facility census was 137.

Inspectors wroteBased on medical record review, observation, staff interview, review of the infection control log and facility policy and procedure, the facility failed to ensure proper infection control techniques were maintained when providing incontinence care. This affected one resident (#9) observed for incontinence care. The census was 137.

Inspectors wroteBased on observations, record review, and staff interview, the facility failed to ensure a resident with a gastrostomy tube received the appropriate enteral feeding as ordered by the physician. This affected one of seven open sampled records reviewed (Resident #24). The facility census was 137.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure residents were adequately monitored while receiving medications for blood pressure control. This affected two (Residents #71 and #140) of five residents reviewed for medication administration. The census was 137.

Inspectors wroteBased on observations, record review, and staff interview, the facility failed to ensure medication rates were not five percent or greater. The medication error rate was 10 percent (three errors of 29 opportunities for error). This affected two of five residents observed during medication administration (Residents #8 and #52). The facility census was 137.

Inspectors wroteBased on review of the facility policy, review of the hospital records, review of water temperature logs, record review, American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) recommendations and Center for Disease Control (CDC) guidance, and interviews with the local health department and staff, the facility failed to maintain a complete and accurate water management program to prevent the spread of Legionella. This affected one (Resident #9) of three residents reviewed for pneumonia and had the potential to affect all 129 residents residing in the facility.

Inspectors wroteBased on record review, staff interview, review of the police report, and review of the facility policy, the facility failed to provide adequate supervision and a safe environment to prevent a resident from recurrent overdosing in the facility. This affected one (Resident #88) of one resident reviewed for safe environment. The facility census was 129.

Inspectors wroteBased on record review, observation, staff and resident interviews, and policy review, the facility failed to timely provide one resident (#63) with an operating electric wheelchair. This affected one (Resident #63) of three residents reviewed for accomodation of needs. The facility census was 130.

Inspectors wroteBased on medical record reviews, review of a Self-Reported Incident investigation, policy review, and staff interviews, the facility failed to timely notify the responsible party and physician of an elopement incident from the secured unit for Resident #4. This affected one (#4) of three residents reviewed for elopement. The facility census was 130.

Inspectors wroteBased on medical record reviews, review of a Self-Reported Incident (SRI) investigation, policy review, and staff interviews, the facility failed to ensure staff provided adequate supervision to prevent a resident, with altered mental status and exhibited exit seeking behaviors, from leaving the facility unsupervised. This affected one (Resident #6) of three residents reviewed for elopement. The facility census was 130.

Inspectors wroteBased on medical record reviews, policy review, and interviews with residents, staff, and physician, the facility failed to provide a resident with timely physician services. This affected one (Resident #115) of seven residents reviewed for physician services. The facility census was 130.

Inspectors wroteBased on personnel record review, staff interview, and facility policy review, the facility failed to administer and read tuberculin (TB) tests for newly hired staff as required. This had the potential to affect all 126 residents residing in the facility.

Inspectors wroteBased on resident and staff interviews, observations, and review of the facility policy, the facility did not maintain a safe and sanitary living environment for the residents who utilized the common area refrigerators. This had the potential to affect all residents in the facility except for the 22 residents residing on the memory care unit. The facility census was 126.

Inspectors wroteBased on observation, staff interview, review of manufacture guidelines, and review of facility policy, the facility failed to remove two expired vials of Tubersol (tuberculin (TB) solution) from circulation. This had the potential to affect 66 residents who the facility identified were new admits to the facility in the last six months. The facility census was 126.

Inspectors wroteBased on resident and staff interviews, observations, review of the facility's pest invoices, and review of the facility policy, the facility failed maintain effective pest control within the facility. This affected three residents (#7, #96, and #113) and had the potential to affect all residents in the facility except for the 22 residents residing on the memory care unit. The facility census was 126.

Inspectors wroteBased on record review and staff interview, the facility failed to provide notice to residents and or resident representative when the resident funds account reached $200 less than the Supplemental Security Income (SSI) resource limit for one person. This affected three (Residents #14, #55, and #87) of five residents reviewed for resident funds. The facility census was 126 residents.

Inspectors wroteBased on staff interview and record review, the facility failed to assess, document, and complete a transfer of a resident to the hospital for evaluation and treatment. This affected one (Resident #123) of one resident reviewed for hospitalizations. The facility census was 126.

Inspectors wroteBased on medical record review, observations, resident and staff interview, and facility policy review, the facility failed to ensure residents who smoked had a personalized smoking care plan. This affected two (Residents #94 and #113) of the two residents reviewed for smoking. The facility census was 126.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to provide a resident who required assistance from staff with activities of daily living (ADL) adequate assistance with eating. This affected one (Resident #56) of four residents reviewed for ADLs. The facility census was 126.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to complete accurate pressure ulcer assessments. This affected one (Resident #24) of the three residents reviewed for pressure ulcer care. The facility census was 126.

Inspectors wroteBased on observations, staff interview, review of the facility policy, and record review, the facility failed to ensure a resident received treatment and care for good foot health. This affected one (Resident #99) of one resident reviewed for podiatry. The facility census was 126 residents.

Inspectors wroteBased on medical record review, observations, resident and staff interviews, and facility policy review, the facility failed to ensure residents were evaluated for safe smoking and provide adequate supervision and monitoring of residents who smoke. This affected two (Resident #94 and #113) of two residents reviewed for safe smoking. The facility census was 126.

Inspectors wroteBased on medical record review, observation, resident and staff interview, and review of the facility policy, the facility failed to ensure a resident had physician orders for oxygen administration. This affected one (Resident #94) of three residents reviewed for respiratory care. The facility census was 126.

Inspectors wroteBased on record review, staff interviews, review of hospital records, and policy review, the facility failed to properly assess and treat Resident #11's pain after a fall with major injury. This affected one (#11) of two residents reviewed for pain management. The facility census was 126.

Inspectors wroteBased on medical record review, and staff interview, this facility failed to ensure residents with a diagnosis of post-traumatic stress disorder (PTSD) had the appropriate assessment and documented triggers regarding this diagnosis. This affected three (Residents #33, #92, and #104) of five residents reviewed for emotional needs and behaviors. The facility census was 126.

Inspectors wrote3. Review of the medical record for Resident #83 revealed an admission date of 02/04/22. Medical diagnosis included hypertensive heart disease with heart failure. Review of quarterly Minimum Data Set (MDS) assessment, dated 05/01/24, revealed Resident #83 had severely impaired cognition. Review of Resident #83's physicians orders revealed an order dated 03/25/24 for hydralazine (a medication to lower blood pressure) 30 milligrams (mg) by mouth three times daily. The order included parameters to hold for a systolic blood pressure less than 100 or a heart rate greater than 100 beats per minute. Review of Resident #83's April 2024, May 2024, and June 2024 Medication Administration Record (MAR) revealed no correlating blood pressure or heart rate documented prior to medication administration. [...]

Inspectors wroteBased on medical record review, staff interview, review of the facility's infection control log, and facility policy review, the facility failed to provide adequate justification and monitoring regarding the use of an antibiotic. This affected one (Resident #38) of five residents reviewed for medications. The facility census was 126.

Inspectors wroteBased on personnel file review, staff interview, and facility policy review, the facility failed to ensure new hired staff had reference checks completed prior to employment. This had the potential to affect all 126 residents residing at the facility.

Inspectors wroteBased on record review and staff interview, the facility failed to provide evidence of the completion of nurse aide performance reviews. This affected two State Tested Nursing Assistants (STNAs) out of four STNA personnel files reviewed and had the potential to affect all 126 residents residing in the facility.

Inspectors wroteBased on medical record review, resident and staff interviews, review of a Self-Reported Incident (SRI), review of the activity log, and facility policy review, the facility failed to ensure residents were free from verbal abuse by another resident. This resulted in actual Psychosocial Harm when Resident #63 was cursed at, physically intimidated, and called inappropriate names by Resident #128 resulting in Resident #63 becoming afraid of Resident #128 and not attending activities or leaving her room for two days following the incident. This affected one (Resident #63) of five residents reviewed for abuse. The facility census was 128.

Inspectors wroteBased on review of infection control records, observation, staff and resident interview, and policy review, the facility failed to ensure to residents were permitted to eat in the dining room. This affected two (Resident #12 and #17) of two residents reviewed for dining services. This had the potential to affect all 128 residents in the facility who receive meals from the kitchen. The census was 128.

Inspectors wroteBased on staff and resident interviews, review of the facility handbook, review of timesheets, and facility policy review, the facility failed to ensure a qualified social worker was on-site full-time when the facility had greater than 120 beds. This had the potential to affect all 128 residents who resided in the facility. The census was 128.

Inspectors wroteBased on medical record review, staff and resident interview, and policy review, the facility failed to ensure care conferences were provided for residents. This affected five (Resident #32, #41 #48, #56, and #86) of five residents reviewed for care conferences. The census was 128.

Inspectors wroteBased on medical record review, resident and staff interviews, review of incident reports, review of Self-Reported incidents (SRIs), and facility policy review, the facility failed to implement their abuse policies and procedures. This affected four (Residents #63, #72, #93 and former Resident #128) of six residents reviewed for abuse. The facility census was 128.

Inspectors wroteBased on medical record review, resident and staff interviews, review of incident reports, review of Self-Reported incidents (SRIs), and facility policy review, the facility failed to ensure allegations of abuse were reported to the state survey agency. This affected four (Residents #63, #72, #93, and former Resident #128) of six residents reviewed for abuse. The facility census was 128.

Inspectors wroteBased on medical record review, resident and staff interviews, review of incident reports, review of Self-Reported incidents (SRIs), and facility policy review, the facility failed to timely investigate allegations or suspected incidents of abuse. This affected four (Residents #63, #72, #93, and former Resident #128) of six residents reviewed for abuse. The facility census was 128.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure residents were provided appropriate supervision while smoking. This affected one (#49) out of three residents reviewed for accidents. Additionally, the facility failed to provide safe smoking areas. This had the potential to affect all 36 residents (#1, #5, #12, #13, #14, #16, #19, #20, #23, #28, #30, #31, #33, #34, #37, #45, #49, #52, #55, #61, #62, #64, #71, #80, #81, #83, #86, #93, #98, #101, #104, #122, #126, #128, #129, and #130) identified by the facility who smoke. The census was 128.

Inspectors wroteBased on medical record review, staff and resident interview, review of the daily staffing sheet and time punches, review of the activity calendar, review of participation logs, and policy review, the facility failed to ensure there was sufficient nursing staff to meet the residents needs. This affected one (#41) of one reviewed for activities and had the potential to affect all 45 residents on the 200 hall (#3, #7, #8, #12, #17, #18, #19, #22, #23, #26, #28, #32, #34, #40, #41, #42, #46, #48, #50, #56, #57, #60, #68, #74, #79, #81, #85, #86, #87, #88, #93, #94, #96, #97, #100, #109, #110, #114, #116, #118, #121, #122, #127, #129, and #382). [...]

Inspectors wroteBased on medical record review, observation, staff and resident interview, and facility policy review, the facility failed to properly store and label medication as well as ensure medication was not expired. This affected two (#9 and #105) residents and had the potential to affect six residents (#2, #10, #13, #95, #112, and #285) with medications stored in the 100 hall medication storage room refrigerator, four residents (#18, #46, #81, and #85) who received medication from the 200 Short Hall medication cart, and 11 residents (#9, #25, #31, #53, #55, #61, #66, #70, #99, #112, and #119) who received medications from the 300 hall medication cart. The facility census was 128.

Inspectors wroteBased on medical record review, staff interview, and review of beneficiary notices, the facility failed to provide the appropriate beneficiary notices (Notice of Medicare Non-Coverage and Advanced Beneficiary Notice) to three residents. This affected three (Residents #44, #92, and #115) of three residents reviewed for beneficiary notices. The facility census was 128.

Inspectors wroteBased on observation, staff and resident interview, and facility policy review, the facility failed to ensure a homelike environment was provided for residents. This affected one (#9) out of 128 residents reviewed during the screening process. The census was 128.

Inspectors wroteBased on medical record review, staff interview, review of Pre-admission Screening and Resident Reviews (PASARRs), and review of facility policy, the facility failed to ensure an updated PASSAR was completed after a resident experienced a significant change or was diagnosed with a newly evident serious mental disorder. This affected three (Residents #7 #48, and #110) of six residents reviewed for PASARR screenings. The facility census was 128.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASARR) were completed timely. This affected one (Resident #41) of six residents reviewed for PASARR screenings. The facility census was 128.

Inspectors wroteBased on medical record review, observation, staff interview, and resident interview, the facility failed to get ensure residents who were dependent on staff assistance for activities of daily living were provided assistance with getting out of bed. This affected one (#37) out of four residents reviewed who were dependent on staff assistance for activities of daily living. The census was 128.

Inspectors wroteBased on medical record review, staff and resident interview, review of a activity calendar, review of participation records, and policy review, the facility failed to ensure activities were provided to meet the needs/interests of the residents. This affected one (#41) of one resident reviewed for activities. The census was 128.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure wound treatments were completed according to physician orders. This affected two (#9 and #56) of seven residents reviewed for wound treatments. The census was 128.

Inspectors wroteBased on observation, medical record review, staff and resident interview and policy review, the facility failed to ensure pressure ulcer interventions and treatments were initiated timely. This affected two residents (#29 and #106) out of six residents reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. The census was 128.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure nutritional supplements were provided as ordered and weights were obtained as ordered. This affected one (#58) of four residents reviewed for nutrition. The facility identified there were 19 residents with unplanned significant weight loss. The census was 128.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure residents who utilized oxygen had a physician order for oxygen. Additionally, the facility failed to ensure oxygen tubing was dated. This affected two (#60 and #86) of two residents reviewed for respiratory care. The facility identified 20 residents who received oxygen therapy. The census was 128.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure residents received appropriate dialysis management services. This affected two residents (#105 and #106) out of two residents reviewed for dialysis. The facility identified 11 residents who received dialysis services. The census was 128.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure a medication error rate of less than five percent (%). Out of 29 opportunities, three errors were observed which equaled an error rate of 10.34%. This affected one (Resident #48) out of three residents observed during medication administration. The census was 128.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure an indwelling Foley catheter was cleaned in accordance with proper infection control procedures. This affected one (#56) of one resident reviewed for catheter care. The facility identified there were four residents in the facility with catheters. The census was 128.