Majestic Care of Cedar Village.

In the surveyor’s words

From the most serious findings on record at Majestic Care of Cedar Village., in the surveyor’s own words.

• Actual harm, isolatedF689Aug 27, 2026

  Based on record review, staff and resident interview, observation, and policy review, the facility failed to ensure a resident was provided adequate supervision during incontinence care resulting in a fall from the bed. This resulted in Actual Harm to Resident #20 when Certified Nursing Assistant (CNA) #224 rolled the resident on her side and left the bedside to gather incontinence supplies. Resident #20 fell out of bed resulting in a laceration to her forehead and one broken toe. This affected one (Resident #20) of three residents reviewed for falls. The facility census was 152.Findings include: Record review revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included muscular dystrophy, chronic obstructive pulmonary disease (COPD) and spinal stenosis. […]

• Actual harm, isolatedF686Apr 17, 2024

  Based on medical record review, hospital record review, staff interview, and facility policy review, the facility failed to ensure residents received the necessary treatment and services to promote healing and prevent infections for a pressure ulcer. This resulted in Actual harm when Resident #20 ' s weekly skin assessments were not completed and subsequently led to hospitalization for a wound infection and possible osteomyelitis. This affected one (Resident #20) of three residents reviewed for pressure ulcers. The facility census was 132. Findings include: Review of the medical record for Resident #20 revealed an admitted to the facility on [DATE] and a discharge date to the hospital on 04/09/24, and as of 04/16/24 Resident #20 is still hospitalized . […]

• Actual harm, isolatedF610May 17, 2023

  Based on record review, observation, resident and staff interview, review of facility documents and review of the facility policy titled Abuse Prevention Program, the facility failed to ensure residents were protected from abuse during an investigation and failed to conduct a thorough abuse investigation. This resulted in psychosocial harm for Resident #94 after the facility failed to protect and thoroughly investigate Resident #94's allegation of emotional and verbal abuse resulting in Resident #94 being afraid to leave her room, was agitated, and tearful. This affected one (Resident #94) of three residents reviewed for abuse. The facility census was 148. Findings include: Review of the medical record for Resident #94 revealed an admitted [DATE]. […]

• Actual harm, isolatedF689Feb 21, 2023

  Based on record review, staff interviews, review of Emergency Medical Services (EMS) run report, review of hospital records, review of facility investigation, and review of facility policy, the facility failed to provide necessary supervision for Resident #108, who was assessed by the facility to be a moderate fall risk. Actual harm occurred on 12/03/22 when Resident #108 sustained an unwitnessed fall with injury. Facility staff failed to provide adequate supervision during the overnight hours, resulting in Resident #108 not being found on the floor until 12/04/22 (EMS arrived on 12/04/22 at 6:35 A.M.). […]

• Actual harm, isolatedF689Jul 14, 2022

  Based on medical record review, staff interview, and review of facility policy, the facility failed to conduct thorough root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury. This resulted in Actual Harm when a resident experienced repeated falls resulting in fracture and closed head injury. This affected one (#104) of three residents reviewed for falls. Facility census was 160. Findings include: Review of the medical record for Resident #104 revealed an admitted [DATE] with a diagnosis of [CONDITION(S)] with behavioral disturbance. […]