Majestic Care of Toledo SNF

In the surveyor’s words

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

• Actual harm, isolatedF686Oct 19, 2023

  Based on review of the medical record, observations, staff interview, policy review, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to assess newly identified skin breakdown, notify the physician of skin breakdown, and implement treatments to aid in the healing of skin breakdown. This resulted in Actual Harm when Resident #28 was found to have an open area that was not assessed or treated for two days and then was assessed as a stage three pressure ulcer to the coccyx. Additionally, the facility failed to assess a newly identified skin breakdown for Resident #7, which placed the resident at risk for more than minimal harm that did not result in actual harm. This affected two (#7 and #28) of two residents reviewed for pressure ulcers. […]

• Actual harm, isolatedF684Apr 25, 2022

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review and staff interview, the facility failed to provide care and services in a timely manner to treat a Urinary Tract Infection ([CONDITION(S)]). This resulted in actual harm for Resident #34 who displayed symptoms of a [CONDITION(S)] for fifteen days prior to a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (Resident #34) of three residents reviewed for UTIs. The facility census was 66. Findings include: Review of Resident #34's medical record revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Oct 19, 2023

  Based on observation, medical record review, staff interview, review of the facility policy, and review of the manufacturer's guidelines, the facility failed to ensure proper hand hygiene was performed during food service on the third floor. This affected Resident #30 and had the potential to affect all residents on the third floor except Resident #44 who received no food from the kitchen. The facility identified 31 residents on the third floor. Additionally, the facility failed to ensure the dishwasher in the main kitchen washed dishes at the appropriate temperature. This had the potential to affect all residents in the facility except Resident #44 who received no food from the kitchen. […]

• No harm, potential for more than minimal, widespreadF880Oct 19, 2023

  Based on staff interview, review of facility monitoring logs, Legionella Risk Assessment review, and review of the policy, the facility failed to ensure monitoring for Legionella was completed. This had the potential to affect all 80 residents in the facility. The facility census was 80. Findings include: Review of the facility's undated Legionella Risk Assessment revealed the facility identified the incoming water supply and the building's hot and cold-water distribution systems as areas at risk for Legionella growth. Review of the facility monitoring logs dated January 2023 through October 2023 revealed rooms throughout the facility were monitored weekly and vacant rooms were identified. The log did not identify whether the sink or shower faucets were tested . […]

• No harm, potential for more than minimal, widespreadF881Oct 19, 2023

  Based on staff interview, review of monitoring logs, review of the medical record, and review of policy, the facility failed to ensure an antibiotic stewardship program was implemented to ensure infections and antibiotics were accurately being tracked. This had the potential to affect all 80 residents in the facility. The facility census was 80. Findings include: Review of the Infection Surveillance Monthly Report (ISMR) dated August 2023 revealed line items for 45 identified infections. Further review revealed the log did not include the type of infection for 30 infections and did not include the signs and symptoms of the infection for 37 infections. Review of the ISMR dated September 2023 revealed line items for 64 identified infections. […]