Majestic Care of Fairfield LLC

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Oct 20, 2021

  Based on closed medical record review, review of emergency medical services (EMS) run report, review of the facility abuse policy and procedure, staff interview, and Emergency Medical Technician (EMT) interview, the facility failed to ensure Resident #151 was free from abuse and neglect by not providing timely care and services to ensure respectful and dignified treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .M. On [DATE] at approximately 9:30 A.M. Licensed Practical Nurse (LPN) #17 and LPN #18 initiated Cardiopulmonary Resuscitation (CPR) to Resident #151, four hours after he had been deceased and after post mortem care was already provided. […]

• Immediate jeopardy, isolatedF678Oct 20, 2021

  Based on closed medical record review, staff interview, local Emergency Medical Technician (EMT) interview, review of the local Emergency Medical Service (EMS) care report, review of the facility witness statements, review of the facility policy, and review of American Heart Association guidelines, the facility failed to initiate timely Cardiopulmonary Resuscitation (CPR) or call nine-one-one (911) to EMS. This resulted in Immediate Jeopardy when Resident #151, who was a Full Code, was found unresponsive without vital signs around 5:30 A.M. At approximately 9:30 A.M., Licensed Practical Nurse (LPN) #17 and LPN #18 initiated CPR on Resident #151 and called 911. The EMS arrived at 9:50 A.M. and took over care. At 10:17 A.M., Resident #151 was pronounced dead. […]

• Actual harm, isolatedF689Jan 12, 2023

  Based on medical record review, staff interview, review of the facility's fall investigation, review of the hospital notes, and review of the facility policy, the facility failed to ensure a resident was safely transferred using a mechanical lift (Hoyer) and failed to accurately identify the root cause of the incident. This resulted in Actual Harm when Resident #163 fell from a Hoyer lift during a transfer sustaining a left communicated, nondisplaced humeral head fracture, and an acute nondisplaced C3 (neck) fracture. This affected one (Resident #163) of three residents reviewed for accidents. The facility census was 162. Findings include: Review of the medical record revealed Resident #163 was readmitted to the facility on [DATE]. […]

• Actual harm, isolatedF777Jan 12, 2023

  Based on medical record review, staff interview, review of the facility's fall investigation, and review of the facility policy, the facility failed to ensure a resident received timely radiology services for a fractured left femur. This resulted in Actual Harm when Resident #112, who after experiencing an unwitnessed fall, had a delay of x-ray services and Resident #112 being admitted to the hospital for surgical repair of the fractured left femur. Resident #112 had a physician order for an x-ray and the x-ray was not obtained until two days after the fall. After the x-ray was obtained, the results of an acute, displaced left femoral fracture was not reported to the physician until three days after the fall. […]

• Actual harm, isolatedF697Nov 23, 2022

  Based on record review, staff interview, pharmacy staff interview, and policy review, the facility failed to ensure a resident experiencing pain, with a diagnoses of chronic pain syndrome and post fixation of a fracture to her left ankle, had an acute care plan in place with interventions to manage pain and treat pain when displayed. This resulted in actual harm when Resident #196 on 07/22/22 at 5:25 P.M., was assessed by the Certified Nurse Practitioner to be lying in bed, moaning with pain and reported the pain level as a 10 out of 10 (with 10 being the worst). The medical record contained no documentation of nonpharmacological or pharmacological interventions attempted to relieve pain. […]