Inspection Reports for
Majestic Care of Avon

The facility was found not in compliance with several Life Safety Code requirements including failure to document sprinkler system inspections, failure to inspect portable fire extinguishers monthly, failure to conduct quarterly fire drills on all shifts, failure to inspect one fire door assembly annually, and improper storage of combustible materials near oxygen storage equipment.

The facility was found deficient in multiple areas including failure to complete resident self-administration medication assessments, inadequate response to resident council grievances about call light wait times, inaccurate coding of falls on MDS, failure to follow non-smoking policy, insufficient licensed nurse staffing on weekends, lack of appropriate assessments and care plans for residents with dementia in relationships, and improper labeling and storage of medications.

The investigation was triggered by complaints IN00417543, IN00418144, IN00418880, IN00419455, IN00420138, and IN00429558. Deficiencies related to complaint IN00418144 were substantiated with federal/state deficiencies cited at F744. Other complaints had no deficiencies related to the allegations.

The facility failed to provide adequate person-centered care, supervision, and engaging activities in the secured memory care unit, resulting in resident-to-resident altercations and accidents. Several residents experienced injuries due to wandering and aggressive behaviors, and the facility lacked sufficient activity programming and supervision to prevent these incidents.

The investigation was triggered by complaints IN00427703 and IN00427705 alleging abuse of Resident B. The complaints were substantiated based on video evidence and staff/family interviews.

The facility failed to ensure a non-verbal, cognitively impaired resident (Resident B) was free from abuse by staff. Video evidence showed CNA 12 physically abusing Resident B during care, and staff failed to immediately report the abuse to the Administrator. The facility took corrective actions including termination of involved staff and staff education on abuse prevention and reporting.

The facility was found not in compliance with Life Safety Code requirements. Deficiencies were identified related to kitchen hood extinguishing system coverage, semiannual kitchen exhaust system inspections, quarterly fire drills, fire alarm signal transmission during drills, and proper securing of oxygen cylinders.

The facility was found deficient in multiple areas including failure to respond to Resident Council grievances, inadequate posting of Ombudsman information, unsafe water temperatures in memory care resident rooms, cleanliness and homelike environment issues, inaccurate resident assessments, delayed toileting assistance, fall prevention interventions, medication safety, respiratory care, nurse staffing posting, dietary staffing and meal timeliness, food safety and pest control, and memory care director qualifications.

Complaint IN00404698 had no deficiencies related to the allegations. Complaint IN00405358 was substantiated with federal/state deficiencies cited related to pharmacy services.

The facility failed to ensure routine medications were available, dispensed according to physician's orders, and stored in an organized manner for 3 of 4 residents reviewed. Specific issues included missing medications, incorrect medication doses, and delays in medication administration.

Complaint IN00395451 - Substantiated with no deficiencies cited. Complaint IN00400251 - Substantiated with deficiencies cited at F684 and F686. Complaint IN00400314 - Unsubstantiated due to lack of evidence. Complaint IN00400697 - Substantiated with deficiencies cited at F684 and F686.

The facility failed to assess, document, and treat a non-pressure wound to the posterior head for one resident and failed to prevent, assess, and accurately document pressure ulcers for another resident. Several deficiencies related to quality of care and treatment of pressure ulcers were substantiated.

Six complaints were investigated. Five complaints (IN00377486, IN00378911, IN00380381, IN00385448, IN00386545) were unsubstantiated due to lack of evidence. Complaint IN00388116 was substantiated but no deficiencies related to the allegations were cited.

The investigation found five complaints unsubstantiated due to lack of evidence and one complaint substantiated with no deficiencies related to the allegations cited. An unrelated deficiency was cited regarding failure to ensure wound care treatments were implemented as ordered for four residents with pressure ulcers.