Mayflower Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach and appropriate to the resident's physical ability for three of three sampled residents (Residents 25 49 and 54). These failures had the potential for Residents 25, 49 and 54 not to receive necessary care or receive delayed services to meet Residents 25, 49 and 54's needs.

Inspectors wroteBased on interview and record review, the facility failed to develop a specific and individualized care plan to meet the residents' needs for two of two sampled residents (Residents 4 and 5) by failing to:a. Ensure a care plan (CP) was developed for Resident 4 on the use of Buspirone (a medication used to treat anxiety).b. Ensure a CP was developed for Resident 5 on the use of Seroquel (an antipsychotic medication helps to stabilize moods and reduce psychotic symptoms) and Lexapro (a medication used to treat depression and anxiety). These failures had the potential for Residents 4 and 5 not to receive necessary care, treatment, and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by failing to ensure food items were dated when they were first opened and prepared in one of one facility freezer. These deficient practices placed the residents at risk for food borne illnesses (infections caused by ingesting contaminated food or beverages).

Inspectors wroteBased on interview and record review, the facility failed to prevent unnecessary use of psychotropic medication (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility's policies and procedures (P&P) titled Antipsychotic Medication Use and Psychotherapeutic Medications for one of five sampled residents (Resident 5). This deficient practice had the potential to result in significant adverse (harmful) consequences to Resident 5 for the use of Seroquel (medication used to treat mental health condition).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide required assistance during activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) for one of one sampled resident (Resident 51). This failure placed Resident 51 at risk for accidents/injury during bed mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were kept secure by failing to lock one of two medication carts (Med Cart) that contained residents' medications, when not attended to and outside the view of the licensed staff. This deficient practice had the potential for residents' medications to be accessible to others not authorized to have access to the medications and increased the risk for loss of safety and security of all medications necessary to meet the health needs of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the privacy of one of one sampled resident (Resident 53) when Licensed Vocational Nurse 2 (LVN 2) left the computer screen unattended, exposing Resident 53's medication information. This deficient practice violated Resident 53's right to privacy and confidentiality.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a care plan (CP - summary of a person's health condition, care needs, treatments, goals of treatment, and specific interventions for each identified condition or care need) for one of four sampled residents (Resident 1) when: 1. Resident 1 did not have a care plan for Resident 1's diagnosis of multiple myeloma (a type of blood cancer). 2. Resident 1 did not have a care plan for Resident 1's diagnosis of osteopenia (bones are weaker than normal). These failures had the potential for Resident 1 to receive inappropriate care and services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nursing staff assisted with cleaning eye discharge around both eyes and underneath the eyes on the resident's face for one of three sampled residents (Resident 2). This deficient practice had the potential to negatively impact Resident 2's dignity and result in the resident not being treated with respect, kindness, and dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 3 developed and implemented a person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for one of three sampled residents (Resident 2) after Resident 2 was observed with skin discoloration on the left upper extremities, the left side of the body, and the right forearm on 12/1/2025. This deficient practice had the potential for Resident 2 to receive inadequate and inappropriate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for two of two sampled residents (Residents 24 and 1). These failures had the potential to result in Residents 24 and 1 to not receive necessary care or receive delayed services.

Inspectors wrotec. During a review of Resident 24's admission Record (AR), the AR indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and osteoarthritis (OA, a progressive disorder of the joints, caused by gradual loss of cartilage). During a review of Resident 24's Minimum Data Set (MDS, a resident assessment tool), dated 5/4/2025, the MDS indicated, Resident 24 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 24 was dependent (helper did all the effort, resident did none of the effort to complete the activity) with eating, oral hygiene, toileting, shower, upper and lower body dressing and personal hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure policies and procedures for oxygen administration were implemented for two of two sampled residents (Resident 49 and Resident 46) by failing to: a. Ensure Resident 49's nasal cannula tubing was not touching the floor when in use. b. Ensure Resident 46's nasal cannula tubing was labeled and was receiving oxygen according to physician's order. These failures had the potential to result in contamination of Resident 49's and Resident 46's care equipment, placing the residents at risk for infection and could have caused complications associated with oxygen therapy for Resident 46.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedures (P&P) titled, Physical Restraint, for four of four sampled residents (Residents 29, 57, 7 and 49) by failing to: a. Ensure to obtain an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) before the installation of side rails. b. Ensure appropriate alternative interventions to side rails/bed rails (adjustable metal or rigid plastic bars attached to the bed) were attempted and did not meet the needs of Resident 57 and ensure the side rails/bed rails pads for Resident 57 were free from damage and wear and tear. c. Ensure Resident 7 had padded bedside rails for seizures as ordered by the physician. d. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food storage and sanitation standards by failing to: a. Ensure there were no expired items stored in the refrigerator: one bag of tortillas, four cheese sandwiches, and seven peanut butter and jelly sandwiches. b. Ensure one tray of apple sauce (20 individual serving containers), and one tray of fruit cocktail (26 individual serving containers) were stored with a preparation date label. c. Ensure monitoring and documenting logs for the Dish machine temperature log, Quat Sanitizer log, and the Refrigerator & Freezer temperature logs for June 2025 were completed. These failures had the potential to result in foodborne illness (illness caused by consuming contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy for one of one sampled resident (Resident 10) when staff did not close the privacy curtain while changing Resident 10's clothes. This deficient practice violated Resident 10's right to bodily privacy and resulted in unnecessary exposure of Resident 10's upper chest area. This deficient practice had the potential to affect Resident 10's psychosocial (mental and emotional) well-being, self-esteem, and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 46), Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment related to respiratory treatments - oxygen therapy was accurately documented to reflect the resident's use of oxygen. This failure had the potential to negatively affect Resident 46's plan of care and delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided with a communication device in a language that the resident understood for one of one sampled resident (Resident 30). This failure had the potential to affect Resident 30's communication with the staff and had the potential to result in a delay in the provision of care, treatment, and services to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to a resident who used a plate guard (a dining aid that can help people with limited control, grip, or dexterity eat with one hand and reduce the risk of spills) during meals for one of one sampled resident (Resident 39). This failure had the potential to result in Resident 39's decline in nutritional status and inability to maintain independence during mealtimes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nurse Assistants 1 and 2 (CNA 1 and CNA 2) donned (put on) the required personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while providing care to one of one sampled resident (Resident 10) who was on Enhanced Barrier Precaution (EBP, an approach for the use of PPE to reduce transmission of multidrug-resistant organisms [MDRO] between residents in skilled nursing facilities). This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for the residents and the staff that could result in a widespread infection in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the wheelchair pad alarm was functional to alert the staff for one of one sampled resident (Resident 51) as indicated in the facility's policy titled Alarm Monitor and plan of care. This failure had the potential to result in Resident 51 not receiving care or receiving delayed services to meet the residents' needs and had the potential to result in a fall or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 12 of 28 residents (12 residents) in the dining room were encouraged to engage in activities of their choice and/or encouraged to participate in the activity program. This failure had the potential to negatively impact the residents' physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident environment remained as free of accident hazards as is possible as indicated in the facility's policies and procedures (P&P) titled, Policy & Procedure: Accident/Incident Prevention, and Policy: Call Lights, by failing to: 1. Ensure call light was within reach for two of 11 sampled residents (Residents 1 and 2) in the resident's room. 2. Ensure call light pull cords were within reach for 10 of 11 sampled residents (Residents 1, 2, 4, 5, 6, 7, 8, 9, 10, and 11) when using the bathroom. 3. Ensure call lights were functioning for three of 11 sampled residents (Residents 2, 6, and 7) when using the bathroom. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functioning and accessible call light system as indicated in the facility's policy and procedure titled, Policy: Call Lights, by failing to: 1. Ensure call light was within reach for two of 11 sampled residents (Residents 1 and 2) in the resident's room. 2. Ensure call light pull cords were within reach for ten of 11 sampled residents (Residents 1, 2, 4, 5, 6, 7, 8, 9, 10, and 11) when using the bathroom. 3. Ensure call lights were functioning for three of 11 sampled residents (Residents 2, 6, and 7) when using the bathroom. These deficient practices had the potential to delay the provision of care for Residents 1, 2, 4, 5, 6, 7, 8, 9, 10, and 11 and negatively affect the residents' well-being when the residents were unable to call staff for assistance.

Inspectors wroteBased on interview and record review the facility failed to implement its policy on Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand and plan for future healthcare decisions when individuals were no longer able to make their own healthcare decisions) for five of five sampled residents (Residents 14, 26, 36, 44, 48). These failures had the potential for the facility staff to provide medical care and services against the resident's will.

Inspectors wroteBased on interview and record review the facility failed to develop and implement an individualized person-centered care plan (CP) to meet the residents' specific needs for two of two sampled residents (Residents 10 and 48 ) by failing to: a. Develop an individualized and person- centered care plan for Resident 48 who had a diagnosis of psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) and major depressive disorder (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities). b. Develop an individualized and person- centered care plan for Resident 10 who was on oxygen therapy (supplemental oxygen, a treatment that provides people with breathing problems. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's care plans (CP) were revised according to the resident's needs for two of two sampled residents (Residents 10 and 36). These failures had the potential risks for Resident's 10 and 36 not to receive interventions specific to the residents' needs.

Inspectors wroteBased observation, interview, and record review the facility failed to ensure the resident was provided with communication device with the language that the resident understood in accordance to facility's policy titled Accommodation of Needs Related to Communication and the residents plan of care for two of two sampled residents (Residents 19 and 52). These deficient practices had the potential for Residents 19 and 52 to not be able to express their needs and receive necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's physician of a resident's refusal to follow the physician's order for fasting blood sugar (FBS, measures blood glucose after fasting) test on 6/5/24, 6/14/24, 6/17/24, 6/18/24, 6/19/24, 6/21/24, 6/22/24, 6/24/24, 6/25/24, 6/26/24, 6/27/24, 6/28/24 and 6/30/24 for one of one sampled resident (Resident 1). This failure had the potential for Resident 1 not to receive necessary treatment and services that would result to adverse consequences for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to : a. Ensure one of one walk-in freezer used for food storage was kept clean and sanitary. b. Ensure one fly and two gnats were not found in the kitchen area. These deficient practices had the potential for cross contamination that could lead to foodborne illnesses (illness caused by consuming contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's call light was within reach for one of one sampled resident (Resident 38). This deficient practice had the potential for Residents 38 not to receive or received delayed care to meet the resident's needs.

Inspectors wroteBased on interview and record review, the facility failed to provide notification to the Long-term care Ombudsman (agency who advocates for residents) of a facility-initiated discharge for one of one sampled resident (Resident 29). This failure had the potential risk to result in inappropriate discharge of Resident 29 without the protection from the Ombudsman.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the care plan (CP) intervention to provide night light was implemented for one of two sampled residents (Resident 36) who had a history of falls. This failure had the potential risk for Resident 36 to experience repeated falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer oxygen therapy (treatment that provides supplemental oxygen) in accordance with the physician's order for one of one sampled resident (Resident 10). This deficient practice placed Resident 10 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which could lead to serious complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper waste disposal in one of two trash (garbage) bins. This deficient practice had the potential to harbor pests and placed the facility at risk for diseases and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Policy and Procedures (P&P) titled Hand Washing and Enhanced Barrier Precaution (EBP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, bacteria that are resistant to one or more classes of antibiotics] ) for one of one sampled resident (Resident 44) when Licensed Vocational Nurse 1 (LVN 1) did not wear gloves before touching Resident 44's indwelling Foley catheter (FC - thin, sterile tube inserted into the bladder to drain urine into a bag outside the body) and did not perform hand hygiene before touching Resident 44's Gastrostomy Tube (GT, surgical insertion of a tube, creating an artificial external opening into the stomach for nutritional support) feeding. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (PP) titled, Homelike Environment, for 19 of 22 sampled residents (Residents 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19, 20, 21, and 22) by failing to: Ensure Residents 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19, 20, 21, and 22 were provided bedside tables (adjustable table on wheel that can fit over a resident's bed used for eating, personal items and a table for treatment by nursing staff) to use according to each resident's needs. This deficient practice could result in a decline in Residents 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19, 20, 21 and 22's well-being due to failure to promote a homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs and preferences of one of 22 sampled residents (Resident 1) by failing to ensure Resident 1's bedside tray was within reach and not broken for Resident 1 to use. This deficient practice had the potential to result in a decline in Resident 1's psychosocial well-being due to possible loss of homelike environment and maintaining independence to the extent possible.