Majora Lane Ctr for Rehab & Nsg Care Inc

Inspectors wroteBased on observation, medical record review, Self-Reported Incident review, witness statement review, policy review, and interview, the facility failed to ensure Resident #21, who was diagnosed with dementia with behaviors, was assessed as severely cognitively impaired and had a history of sexually inappropriate behaviors, had appropriate care-planned interventions in place to protect Resident #23's right to be free from alleged sexual abuse by Resident #21. This affected one resident (#23) of four residents reviewed for abuse. The census was 52.

Inspectors wroteBased on medical record review, Self-Reported Incident review, witness statements, policy review, and interview, the facility failed to ensure staff immediately reported an allegation of mistreatment to the Administrator. This affected one (Resident #27) of four residents reviewed for abuse and had the potential to affect all 14 residents (#2, #6, #7, #8, #9, #17, #20, #26, #27, #28, #29, #30, #34, and #47) who resided on the Speret hall (the secured memory care unit) whom the alleged perpetrator cared for. The census was 52.

Inspectors wroteBased on observation, medical record review, Centers of Disease Control guidance, policy review and interview, the facility failed to implement written infection control policies and procedures for Enhanced Barrier Precautions (EBP) during a two-person staff transfer of Resident #27 within the resident's room. This affected one (Resident #27) of three residents reviewed for transfers. The census was 52.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on review of a closed medical record, review of a self-reported incident, facility investigation, and interviews, the facility failed to ensure residents were free of misappropriation when a staff member accepted financial gifts from Resident #65. This affected one (Resident #65) out of three residents reviewed for misappropriation. Facility census was 60.

Inspectors wroteBased on record review, observation and interview, the facility failed to monitor and record dishwasher temperatures and Quatinary sanitizer solution levels. This had the potential to affect 61 residents receiving meals from the facility. The facility further failed to ensure appropriate drying times after cleaning equipment prior to preparing pureed meals for two residents. The facility census was 62. Findings Include: 1. Review on 01/05/25 during the initial kitchen tour between 8:55 A.M. and 9:20 A.M. of the facilities monthly dishwasher temperature check log revealed for the month of January 2026 three slots each day (breakfast, lunch, and dinner) to record temperature checks of the high temperature dishwasher. Further review revealed no temperatures recorded for breakfast, lunch, or dinner on 01/02/26 and 01/03/26. There was no temperature recorded for breakfast on 01/04/26. [...]

Inspectors wroteBased on observations, record review, interview, and policy review, the facility failed to ensure the secured unit provided meaningful activities to meet Resident #9's needs. The facility also failed to ensure Resident #11 received preferred activities. This affected two residents (Resident #9 and #11) of three residents reviewed for activities but had potential to affect all 14 residents (#9, #10, #18, #20, #28, #31, #36, #37, #38, #40, #45, #49, #58, and #61) who resided on the secured unit. The facility census was 62.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure Resident #11 was provided accommodations to ensure appropriate and dignified seating and had access to fluids if needed This affected one resident (#11) out of three residents reviewed for dignity. The facility census was 62. Findings Include: Review of Resident #11's medical record revealed an admission date of 12/11/25 with diagnoses including legally blind, cognitive communication deficit, difficulty walking, and high blood pressure. Review of Resident #11's physician orders revealed an order dated 12/12/25 for a regular texture diet with thin liquids. Observation on 01/05/26 at 2:20 P.M. revealed Resident #11 was lying in a recliner in the common area near the front desk and the facility main entrance. [...]

Inspectors wroteBased on record review, observation and interviews, the facility failed to maintain range of motion for a resident with contracture. This affected one resident (#17) out of three residents reviewed for range of motion and positioning. The facility census was 62. Findings Include: Review of Resident #17 ' s medical record revealed an admission date 04/30/24 with diagnoses including but not limited to stroke, contractures, vascular dementia, high blood pressure, depression and anxiety. Resident #17 required assistance from staff to complete Activities of Daily Living (ADL) tasks and had intact cognition. Review of Resident #17 ' s physician orders revealed an order dated 11/08/24 for a Left hand palm protector to be applied in A.M. and removed at bedtime (HS). [...]

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to implement fall interventions for a fall risk resident. This affected one resident (#50) out of six residents reviewed for falls. The facility census was 62. Findings Include: Review of Resident #50 ' s medical record revealed admission date 09/02/25 with diagnoses including but not limited to high blood pressure, hallucinations, weakness and cognitive communication deficit. Review of Resident #50 ' s Falls Risk Observation dated 09/02/25 revealed Resident #50 was at moderate risk for falls with a score of eight, (a score of 10 or higher represents a high risk for falls). Further review revealed Resident #50 ' s Falls Risk Observation dated 10/09/25 revealed Resident #50 was at a high risk for falls with a score of 14. [...]

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to store portable oxygen tanks in an oxygen storage area. This deficient practice affected one resident (#1) out of two residents reviewed for respiratory care. The facility census was 62. Findings Include: Review of Resident #1 ' s medical record revealed admission date 11/01/25 with diagnoses including but not limited to cerebral infarction, dysphagia, hemiplegia, Chronic Obstructive Pulmonary Disease (COPD), and anemia. Review of Resident #1 ' s physician orders revealed no orders for oxygen use. Review of Resident #1 ' s care plan dated 11/07/25 revealed no implementation of oxygen use for any disease process. Observation on 01/05/26 at 10:15 A.M. [...]

Inspectors wroteBased on record review, self-reported incident review, interviews, facility assessment review, and dementia training review, the facility failed to ensure staff had the skills necessary to provide direct care in a way to relieve and accommodate Resident #38's distress. The facility also failed to ensure staff approached Resident #59 appropriately after a behavior occurred. This affected two (Residents #38 and #59) of two residents reviewed for dementia care. The facility census was 62.

Inspectors wroteBased on medical record review and staff interview the facility failed to maintain accurate medical records. This affected three residents (Resident #10, Resident #41, and Resident #43) of twenty-five residents reviewed for accurate medical records. The facility census was 62.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to maintain transmission-based precautions. This deficient practice affected two residents (#17 and #70) out of three residents reviewed for transmission-based precautions. The facility census was 62. Findings Include: 1. Review of Resident #17 ' s medical record revealed admission date 04/30/24 with diagnoses including but not limited to stroke, contractures, vascular dementia, high blood pressure, depression and anxiety. Resident #17 required assistance from staff to complete Activities of Daily Living (ADL) tasks and had intact cognition. Review of Resident #17 ' s physician orders revealed an order dated 11/04/25 for enhanced barrier precautions (EBP) related to chronic wounds and urinary catheter use. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to ensure the residents' environment in the secured unit was clean and homelike. This had the potential to affect all 17 residents (#6, #9, #11, #19, #22, #24, #26, #27, #28, #33, #35, #38, #41, #44, #46, #51, and #57) residing in the secured unit. The facility census was 62.

Inspectors wroteBased on interview, record review, and review of the facility policy, the facility failed to notify the physician and/or responsible party of a change in condition. This affected three residents (#7, #35, and #46) of four residents reviewed for notification of change in condition. The facility census was 62.

Inspectors wroteBased on interview, record review, and review of the facility policy, the facility failed to ensure Resident #35 was free from physical restraints. This affected one resident (#35) of one resident reviewed for physical restraints. The facility census was 62.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident, Resident #7, was provided with timely incontinence care. This affected one resident, (Resident #7) of three residents reviewed for incontinence care. The facility census was 62.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to timely assess and notify the physician when Resident #7 was noted to have blood in her urine. This affected one resident, Resident #7 of three resident reviewed for incontinence care. The facility census was 62.

Inspectors wroteBased on interview, record review, and review of the facility policy, the facility failed to ensure injuries for two residents (#35 and #46) were recorded in each resident's medical record. This affected two (#35 and #46) of three residents reviewed for documentation. The facility census was 62.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure appropriate food storage in the kitchen's dry storge area. Additionally, the facility failed to ensure the Robo-coupe (food processor) was clean and dry prior to pureeing Resident #21 and #23 meals and ensure a contained spoon was not placed into the mixture. This affected two residents (#21 and #23) and had the potential to affect 56 of 56 residents who received meals from the kitchen. The facility identified two residents (#1 and #30) who received nothing by mouth (NPO) and had NPO diet orders The facility census was 58.

Inspectors wroteBased on observation, record review, facility policy review and interview the facility failed to prevent a potential accident hazard when a compressed gas cylinder (oxygen tank) was not properly stored/secured in Resident #34's room. This affected one resident (#34) of 58 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to ensure Enhanced Barrier Precautions (EBP) were in place while completing wound care for Resident #27. This affected one resident (#27) of one resident observed for wound care. The facility census was 58. Findings Include: Review of the medical record for Resident #27 revealed an admission date of 11/16/22. Diagnoses include a Stage III pressure ulcer to the residents left buttock, Alzheimer's Disease, and acute respiratory failure with hypoxia. Review of Resident #27's September 2024 physicians orders revealed an order for use Enhanced Barrier Precautions for pressure injury on left buttock. Review of Resident #27's care plan dated 09/23/24 revealed the resident required enhanced barrier precautions related to a chronic wound (pressure ulcer). [...]

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #31's redness and excoriation to the buttocks was documented and treated timely. This affected one resident (#31) out of three residents reviewed for incontinence care. The facility census was 64.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #43's pain was accurately documented and treated timely. This affected one resident (#43) out of three residents reviewed for pain. The facility census was 64.

Inspectors wroteBased on medical record review, observation and interview, the facility failed to ensure fall interventions/physician orders were implemented for one (Resident #33) of three residents reviewed for falls. The facility census was 59.

Inspectors wroteBased on review of the medical record, review of the facility investigation, and interview with staff the facility failed to safely transport Resident #57 in a wheelchair resulting in Resident #57 falling out of her wheelchair and hitting her head. This affected one resident (#57) of three residents reviewed for accidents/hazards. The facility census was 60.