Majestic Care of Whitehall

In the surveyor’s words

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

• Actual harm, isolatedF600Oct 13, 2022

  Based on medical record review, resident and staff interviews, review of a Self-Reported Incident (SRI), review of the activity log, and facility policy review, the facility failed to ensure residents were free from verbal abuse by another resident. This resulted in actual Psychosocial Harm when Resident #63 was cursed at, physically intimidated, and called inappropriate names by Resident #128 resulting in Resident #63 becoming afraid of Resident #128 and not attending activities or leaving her room for two days following the incident. This affected one (Resident #63) of five residents reviewed for abuse. The facility census was 128. Findings include: Review of Resident #63's medical record revealed an admitted [DATE]. […]

• Actual harm, isolatedF686Jun 6, 2022

  Based on observation, record review, facility policy and procedure review and interview the facility failed to implement adequate and individualized interventions to prevent the development of a deep tissue injury (DTI) (purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) pressure ulcer to Resident #103's left heel. Actual harm occurred on 03/10/22 when Resident #103, who was severely cognitively impaired, required extensive assistance from two staff for bed mobility and had increased pain and decreased mobility of the left leg was found to have a DTI to the left outer heel. […]

• Actual harm, isolatedF684May 17, 2021

  Based on record review and interview, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (Resident #5) out of three residents reviewed for monitoring of medication levels. Harm occurred to Resident #5 when orders for [MEDICATION(S)] (mood stabilizer) levels were not completed as ordered 15 days prior to the resident being sent to the hospital. Resident #5 developed symptoms of [MEDICATION(S)] toxicity seven days prior to being admitted to the hospital on 04/29/21. Findings include: Review of the medical record revealed Resident #5 was admitted on [DATE]. Resident #5 was discharged to the hospital on 04/29/21 and returned to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF686Apr 13, 2021

  Based on observation, closed record review, staff interview and facility policy and procedure review the facility failed to implement individualized, comprehensive and effective interventions to prevent the worsening of a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer, failed to ensure timely assessments were completed, failed to modify treatment when the ulcer deteriorated and failed to prevent the development of three new pressure ulcers for Resident #115. This affected one resident (#115) of three residents reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. […]

• No harm, potential for more than minimal, widespreadF880Aug 14, 2024

  Based on review of the facility policy, review of the hospital records, review of water temperature logs, record review, American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) recommendations and Center for Disease Control (CDC) guidance, and interviews with the local health department and staff, the facility failed to maintain a complete and accurate water management program to prevent the spread of Legionella. This affected one (Resident #9) of three residents reviewed for pneumonia and had the potential to affect all 129 residents residing in the facility. Findings include: Review of the medical record for Resident #9 revealed she was admitted to the facility on [DATE] with a diagnosis of chronic kidney disease stage IV. […]