Mayfair Manor

Inspectors wroteBased on interview, record review, and review of the facility's document and policies, the facility failed to provide resolutions and/or provide precise documentation on resolutions related to reported missing items for 3 out of 13 sampled residents, Resident (R) 30, R95, and R119. R30 and R95 reported in the Resident Council meeting, on 02/10/2026, they had made grievances to staff related to missing items of clothing without ever having their grievances resolved. Review of the facility's document Grievance Logs, dated 09/17/2025, also revealed R119 reported missing items of clothing, and the resident was discharged on 09/26/2025 without having the resident's grievance resolved.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to implement the comprehensive person-centered care plan for 1 of 18 sampled residents, Resident (R) 7.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents were adequately assisted to prevent accidents from occurring for 1 of 7 sampled residents, Resident (R) 7.

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 of 6 medication/treatment carts, a North Hall medication cart.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the facility's documents, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 18 residents sampled for infection control, Resident (R) 66. Observation on [DATE] revealed Resident (R) 66, who was not on contact isolation for Clostridium Difficile (C-diff), was residing in a room with R62, who was on contact isolation for C-diff. According to CDC guidelines, residents who were positive for C-diff should be roomed with other C-diff positive residents when single patient rooms were not available.

Inspectors wroteBased on interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidance, and review of the facility's document and policies, the facility failed to ensure each resident was offered and provided the COVID-19 vaccine for 1 of 18 sampled residents, Resident (R) 79. R79 requested COVID-19 vaccination; however, this was not ordered or provided.

Inspectors wroteBased on interview and review of the facility's binder, the facility failed to ensure survey results, certification results, and results of complaints made during the three preceding years, and any related plan of correction was made available for any individual to view upon request.

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to have an effective system in place to ensure residents were free from exploitation. As the representative payee for Resident (R) 17, the facility failed to properly manage and account for the R17's personal funds for one of four sampled residents (Resident (R)17). Review of R17's financial record titled Resident Statement Landscape which provided documentation of Resident Fund Management Service (RFMS), revealed large amounts of withdrawals, without a check and balancing system, beginning 12/22/2021 through 12/19/2023. Immediate Jeopardy (IJ) was identified on 11/15/2024 at 5:16 PM and was determined to exist on 12/22/2021 and Substandard Quality of Care (SQC) was identified at 42 CFR 483.12, Freedom from Abuse and Neglect, F602, related to KY00044055. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure there was sufficient qualified staff available at all times to provide nursing and related services to meet the residents' needs in a manner that promoted each resident's rights, physical, mental and psychosocial wellbeing. On 11/12/2024 observation and interviews revealed only two nurse aides scheduled for 7:00 AM to 7:00 PM on the South Hall, with a census of 37 residents.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to honor the resident's right to make choices about aspects of his or her life in the facility that were significant to the resident for one of eight residents investigated for choices, Resident (R) 63. The facility failed to honor the resident's choice of days for a bath.

Inspectors wroteBased on observation, interview, record review, review of the facility's job description, and review of the facility's policies, the facility failed to provide R46 with devices necessary to maintain hearing for 1 of 3 residents investigated for hearing device use, Resident (R) 46. The facility failed to provide alternate communication devices to R46 when his hearing aid was not functioning appropriately, starting in 07/2024. This adversely affected R46's ability to receive private information and participate in life-enrichment activities from 07/20/2024 until 11/13/2024 because he did not have a supplemental communication device. As a result of not providing a more private method of communication, and the staff resorting to yelling in the resident's ear, his care needs and any personal information was exposed to everyone in the area.

Inspectors wroteBased on observation, interview, record review, review of the facility's policies, and review of the Centers for Disease Control and Prevention (CDC) signage, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases for 3 out of 83 current residents, Resident (R) 2, R65, and R30. Observations on 11/11/2024 revealed Certified Nurse Aide 11 (CNA11) delivered a food tray to another room while still wearing her contaminated face shield that had been worn in a droplet/contact isolation room; and, CNA11 did not use the correct procedure to don (put on) and doff (remove) personal protective equipment (PPE) in a droplet/contact isolation room.

Inspectors wroteBased on interview, record review, review of the facility's policies, and review of the facility's investigation, the facility failed to have an effective system to ensure residents' baseline care plans were developed and implemented to include instructions needed to provide person-centered care related to residents assessed to be at possible risk of elopement for 1 of 39 sampled residents, Resident (R) 6, who exited the facility on 07/10/2023 without staff knowledge. On 07/18/2024 at 7:27 PM, the Chief Executive Office (CEO) and Regional Nurse Consultant (RNC) were provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the failure to ensure elopement risk interventions were added to R6's baseline care plan to prevent elopement is likely to cause serious injury, impairment, or death and constituted IJ at 42 CFR 483.21 (F655). [...]

Inspectors wroteBased on interview, record review, review of the facility's policies, review of the facility's investigation, and review of the website Weatherchannel.com, the facility failed to have an effective system in place to ensure residents' safety for 1 of 39 sampled residents (Resident (R) 6). On [DATE], R6 eloped from the facility unescorted, unsupervised, and without staff knowledge. On [DATE] at 7:27 PM, the Chief Executive Officer (CEO) and Regional Nurse Consultant (RNC) were provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the failure to ensure residents were provided supervision and protected from further elopement is likely to cause serious injury, impairment, or death and constituted IJ at 42 CFR 483.25 F689. The IJ at F689 also constituted Substandard Quality of Care (SQC) at 42 CFR 483.25. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to provide a safe, clean, comfortable, and home like environment for all of the 77 current residents. Observation throughout the survey dates, 07/15/2024 to 07/30/2024, revealed gnats were in the building and observed in resident rooms [ROOM NUMBERS], the conference rooms, hallways in the North and South Wings, the kitchen, the day room on the North Wing, and in the dining room. Interviews with residents and staff revealed gnats had been an ongoing concern in the facility.

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to maintain correct recordkeeping of all controlled drugs on four of four medication carts, which ensured an accurate inventory of medications by accounting for controlled medicines the facility received, dispensed, and administered affecting 77 out of 77 residents. The facility failed to ensure individual residents' narcotic records were documented as signed when a controlled substance was administered for 2 of 39 sampled residents (Resident (R) 8 and R18). Additionally, the facility failed to provide pharmaceutical services, including dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 1 out of 39 sampled residents (R30). [...]

Inspectors wroteBased on observation, interview, record review, and review of the contracted company's policies and documents, it was determined the facility failed to maintain the kitchen in a safe and sanitary manner. This affected all 77 current residents. Observation of the kitchen revealed areas under counters, sinks, and prep areas were dirty with debris and dirty build up. Observation of the kitchen wash area revealed food stains on the walls, the floor, the area around the window, sink area, and under the sink. There was debris on the floor. Further observation revealed gnats flying near the dirty sink area.

Inspectors wroteBased on observation, interview, record review, review of the facility's policies, review of the Center for Medicare and Medicaid Services (CMS) memo, and review of the directions for use (DFU) of disinfecting products, the facility failed to identify and correct problems related to infection prevention practices for 3 out of 39 sampled residents (Resident (R) 4, R31, and R32). This failure placed the residents at increased risk for healthcare-associated infections (HAI). Observation of R4's room revealed there was a personal protective equipment (PPE) container outside of the room. There was no sign on the door indicating it was a Contact/Droplet isolation room. Interviews revealed R4 was tested and suspected to be COVID-19 positive. [...]

Inspectors wroteBased on observation, interview, record review, review of the facility's policies, and review of the audit findings from Kentucky Protection and Advocacy, the facility failed to protect Resident (R) 15 from exploitation of personal funds. The facility did not keep adequate accounting documentations to ensure R15 was safeguarded from misappropriation of funds.

Inspectors wroteBased on interview, record review and review of the facility's policy, the facility failed to document grievances related to reported missing items for 2 out of 39 sampled residents, Resident (R) 21 and R28. R21 and R28 reported missing items to staff. However, these items were not documented on the grievance log, found, or replaced by the facility.

Inspectors wroteBased on interview, record review, review of the facility's investigation, and review of the facility's policy, the facility failed to place items in a safe place to ensure the items could be returned to Resident (R) 21 after discharge for 1 out of 39 sampled residents. R21 stated she left her belongings at the facility after she was discharged on 06/25/2023. R21 stated the former Social Worker (SW) told her she would keep R21's belongings, which consisted of a box of clothes and a pink cane, in her office for safekeeping. R21 stated when she returned to pick up her belongings, they could not be found by staff at the facility, and the facility did not reimburse R21.

Inspectors wroteBased on observation, interview, and review of the facility's policies, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety as determined by observations, on 06/22/2021, of dietary staff in the kitchen and equipment used by staff in the kitchen and dining room. Continued observations of the kitchen, on 06/22/2021, revealed staff not wearing a face mask correctly, touching clothing with gloved hands, not hand washing between glove changes, and using an improper technique for taking temperatures on the tray line. Further observation revealed the can opener had the appearance of dried food debris on the blade and there was a Styrofoam bowl left in the sugar bag in the ingredient bin. [...]

Inspectors wroteBased on observation, interview, medical record review, and review of the facility's Resident Rights, it was determined the facility failed to ensure each resident was treated with respect and dignity and care provided in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the residents for one (1) of twenty-four (24) sampled residents (Resident #10). Observations, on 06/22/2021 and 06/23/2021, of Resident #10 revealed the resident had facial hair noted on his/her chin. Further, interview with Resident #10 revealed the resident preferred not to have facial hair because he/she was self-conscious and felt uncomfortable when there was hair on his/her face.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to provide notification of discharge/transfer to the Ombudsman for one (1) of twenty-four (24) residents (Resident #71). On 05/17/2021 and on 06/04/2021, Resident #71 was transferred from the Long Term Care facility to an acute hospital and subsequently was admitted ; however, interview with the Ombudsman revealed she had not been notified of resident transfers and discharges at the facility since February 2021. Further, interview with facility Administration revealed no documented evidence the Ombudsman had been notified of resident transfers or discharges.

Inspectors wroteBased on interview, record review, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two (2) of twenty-four (24) residents (Resident #10 and Resident #74). The Comprehensive Care Plan (CCP), related to non-pressure related skin alterations, was not implemented in Weekly Skin Assessments. (Refer to F-684) 1. Resident #10's CCP revealed an intervention to complete weekly Skin Assessments; however, review of the medical record revealed inconsistencies in weekly assessments. 2. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for two (2) of twenty-four (24) residents (Resident #10 and Resident #74). 1. Resident #10 had a history of Chronic Cellulitis to his/her bilateral lower extremities and required daily dressing changes. Record review revealed discrepancies in weekly Skin Assessments related to Resident #10's bilateral lower extremities. The facility failed to have a system in place to ensure staff consistently documented non-pressure skin alterations on weekly Skin Assessments. 2. Resident #74 had a history of Diabetes and severe contractures of all fingers on both hands. [...]

Inspectors wroteBased on observation, interview, review of the Material Safety Data Sheet, and review of the facility's policy, it was determined the facility failed to ensure the residents' environment was free of accident hazards as determined by observation, on 06/23/2021, which revealed an open black bag at the end of the North Hall with a disinfectant chemical available to residents. Observation, on 06/23/2021 at 11:15 AM, revealed the State Survey Agency (SSA) Life Safety Code (LSC) Surveyor observed an open black bag at the end of the North Hall containing a bottled and labeled disinfectant chemical accessible to residents. The SSA LSC Surveyor immediately alerted another SSA Surveyor to the potential hazard of the chemical if used inappropriately by residents.