Mayfair Manor

In the surveyor’s words

From the most serious findings on record at Mayfair Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF602Nov 26, 2024

  Based on interview, record review, and review of the facility's policies, the facility failed to have an effective system in place to ensure residents were free from exploitation. As the representative payee for Resident (R) 17, the facility failed to properly manage and account for the R17's personal funds for one of four sampled residents (Resident (R)17). Review of R17's financial record titled Resident Statement Landscape which provided documentation of Resident Fund Management Service (RFMS), revealed large amounts of withdrawals, without a check and balancing system, beginning 12/22/2021 through 12/19/2023. […]

• Immediate jeopardy, isolatedF655Jul 30, 2024

  Based on interview, record review, review of the facility's policies, and review of the facility's investigation, the facility failed to have an effective system to ensure residents' baseline care plans were developed and implemented to include instructions needed to provide person-centered care related to residents assessed to be at possible risk of elopement for 1 of 39 sampled residents, Resident (R) 6, who exited the facility on 07/10/2023 without staff knowledge. On 07/18/2024 at 7:27 PM, the Chief Executive Office (CEO) and Regional Nurse Consultant (RNC) were provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the failure to ensure elopement risk interventions were added to R6's baseline care plan to prevent elopement is likely to cause serious injury,… […]

• Immediate jeopardy, isolatedF689Jul 30, 2024

  Based on interview, record review, review of the facility's policies, review of the facility's investigation, and review of the website Weatherchannel.com, the facility failed to have an effective system in place to ensure residents' safety for 1 of 39 sampled residents (Resident (R) 6). On [DATE], R6 eloped from the facility unescorted, unsupervised, and without staff knowledge. On [DATE] at 7:27 PM, the Chief Executive Officer (CEO) and Regional Nurse Consultant (RNC) were provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the failure to ensure residents were provided supervision and protected from further elopement is likely to cause serious injury, impairment, or death and constituted IJ at 42 CFR 483.25 F689. […]

• Immediate jeopardy, isolatedF657Apr 22, 2022

  Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure the Comprehensive Care Plan was revised as determined by the resident's needs for one (1) of seventeen (17) sampled residents (Resident #1). Record review revealed Resident #1 had an exit attempt, on [DATE] at 8:00 AM, during which he/she was able to get his/her feet through the threshold of the facility's door, which triggered the egress door alarm. Record review revealed staff performed an Elopement Risk Evaluation (ERE), on [DATE], and assessed Resident #1 to be at high risk for elopement. Review of the Progress Notes revealed this evaluation was conducted due to increased wandering, as well as exit seeking behavior. […]

• Immediate jeopardy, isolatedF689Apr 22, 2022

  Based on observation, interview, record review, review of manufacturer's user guides, review of the facility's policies, and review of the facility's investigation, it was determined the facility failed to have an effective system to ensure each resident received adequate supervision and monitoring to prevent elopement for one (1) of seventeen (17) sampled residents (Resident #1). Resident #1's Admission Elopement Risk Evaluation (ERE), dated [DATE], the day of admission, revealed he/she was at low risk for elopement. However, after Resident #1's new onset of exit seeking behaviors, on [DATE], a repeat ERE assessed him/her to be at high risk for elopement. […]