Mayfair Village Nursing Care Center

In the surveyor’s words

From the most serious findings on record at Mayfair Village Nursing Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 21, 2025

  Based on closed medical record review, hospital record review, toxicology report review, review of the facility admission policy, review of the facility assessment and interviews, the facility failed to ensure Resident #82 received adequate, timely and appropriate treatment and continuity of care following admission to the facility resulting in a situation of neglect. This resulted in Immediate Jeopardy and serious life-threatening harm/subsequent death beginning on [DATE] at 8:30 P.M. when Resident #82, who had been hospitalized prior to admission, arrived at the facility for placement and staff failed to obtain physician orders for medications/treatments or contact the physician/medical director regarding the resident's admission. […]

• Immediate jeopardy, isolatedF686Nov 9, 2022

  Based on medical record review, hospital record review, policy review for Prevention of Pressure Injuries, review of the National Pressure Injury Advisory Panel (NPIAP) guidelines, and staff interviews, the facility failed to implement a comprehensive and effective pressure ulcer treatment program for one newly admitted resident (Resident #84). This resulted in Immediate Jeopardy and serious life-threatening harm and/or injuries on 09/14/22, when the facility failed to ensure Resident #84 had admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (#84) of three residents reviewed for pressure sores. The facility identified nine current residents with pressure ulcers in a facility census of 83. […]

• Actual harm, isolatedF686Sep 15, 2022

  Based on observation, resident and staff interview, record review, and policy review, the facility failed to timely assess and provide treatments for a resident's pressure ulcer and failed to ensure interventions were implemented to prevent the development of a pressure ulcer. This resulted in Actual Harm when Resident #23 developed an unstageable pressure ulcer with eschar. A treatment was being applied to the ulcer without a physician order, no notification of the physician of the presence of the ulcer and no interventions implemented to prevent the pressure ulcer. This affected one (Resident #23) of three residents reviewed with pressure ulcers. The facility census was 87. Findings include: Review of medical record for Resident #23 revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF921Aug 12, 2024

  Based on observation and staff interview, the facility failed to have a carbon monoxide detector in the kitchen with a gas stove present. This had the potential to affect all 90 residents residing in the facility. Findings Include: Observation on 08/05/24 at 9:30 A.M. revealed in the facility main kitchen, there was a gas stove within the kitchen area. There was no carbon monoxide detector in this area. Interview with Food Service Director #195 on 08/05/24 at 9:32 A.M. confirmed they did not have a carbon monoxide detector in the kitchen with a permanently installed fuel burning appliance (stove). She confirmed there is a designated spot in place to have a carbon monoxide detector, but it was not in place. She confirmed she did not know how long it had not been in place.

• No harm, potential for more than minimal, widespreadF725Jul 18, 2023

  Based on observation, medical record interview, interviews, resident/family concern review and facility policy review, the facility failed to ensure adequate staffing to meet resident needs. This had the potential to affect all 91 residents residing in the facility. Findings Include: 1. On 06/26/23 at 9:37 A.M. observation of the 400 hallway revealed four call lights (rooms 403, 408, 411 and 412 were activated. Further observation revealed at 10:37 A.M. room [ROOM NUMBER] was answered. On 06/26/23 at 10:41 A.M., interview with Licensed Practical Nurse (LPN) #176 verified the call lights were not answered in a timely manner. The LPN revealed the hallway was only staffed with one State tested Nursing Assistant (STNA). […]