Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Majestic Care Of Point Place during CMS and state inspections, most recent first.
A resident with epilepsy and intact cognition, who was on multiple scheduled anticonvulsants and had a PRN order for intranasal Midazolam for prolonged seizures, experienced a seizure after reporting an aura via call light to a CNA. The CNA ensured the resident was safe in bed and attempted to locate the nurse but could not find her and then sought help from the DON while the resident convulsed. Although PRN Midazolam doses were present on the med cart, the nurse had gone on break with the med cart keys, leaving staff unable to access the medication, and the resident did not receive the ordered PRN seizure medication during the event.
A CNA provided incontinence care to a resident with severe cognitive impairment and multiple medical conditions, but cleansed the perineal area from back to front instead of front to back, contrary to facility policy and infection prevention standards. The CNA acknowledged the error during interview, and the deficiency was identified during complaint investigations.
Staff failed to consistently follow infection prevention and control protocols during care for three residents, including improper hand hygiene, failure to change gloves between tasks, and not using required PPE such as gowns and gloves during wound care, incontinence care, and g-tube medication administration. These lapses were confirmed by staff interviews and were not in accordance with facility policies and posted precautions.
Failure to Care Plan for Hearing Aids: A resident with intact cognition and documented moderate hearing loss was not care planned for hearing aids, and the resident's hearing aids were not maintained in working order because they needed new batteries. Staff were unaware the resident required hearing aids, while the MDS noted the need for them and the care plan did not address hearing loss or hearing aid use.
Failure to provide timely showers and hair care: A resident with vascular dementia, CKD, and TIA required supervision or touch assist for bathing, but records showed extended gaps between showers and no documentation of shower refusals. The resident was observed with long, unkempt hair and stated he had not been showered regularly and needed a haircut, while a CNA reported second shift staff failed to complete showers timely.
The facility failed to timely respond to a pharmacist recommendation for one resident with DM2, hypertensive heart disease, and CHF. A pharmacy recommendation requested an HbA1c lab check, the MD approved it, but the lab was not drawn until much later. The DON confirmed the delay and stated the HbA1c should have been completed within seven days of the MD's approval.
A facility failed to provide appropriate portions and all required menu items for two residents on a pureed diet. Staff prepared only a 4-ounce serving of pureed turkey and dumplings with pureed green beans, and meal trays were observed without bread. Review of the menu spreadsheet confirmed the pureed diet should have included a larger portion and one slice of pureed white bread.
Inaccurate order transcription and untimely documentation The facility failed to accurately transcribe several physician orders and failed to timely document a resident assessment and hospital transfer. Orders for lidocaine patches and Percocet were entered inconsistently or redundantly, and an LPN did not enter a progress note after observing a resident’s worsening toe wound, contacting the physician, and sending the resident to the hospital. The resident had pain, drainage, redness, swelling, and odor noted during the dressing change, and the facility policy required documentation at the time of service.
A resident with Alzheimer’s disease, dementia, depression, severely impaired cognition, and documented high risk for both elopement and falls was care-planned with elopement precautions and a Secure Care bracelet, yet was able to leave the building through a dining room exit door that was neither locked nor alarming due to a failed power supply and drained backup battery following storms. The resident, last seen in the room by a CNA about an hour before being discovered missing on rounds, propelled in a manual wheelchair into the grass, attempted to walk, and fell, sustaining an acute mildly displaced distal fibula fracture with associated ankle and knee pain and a hand bruise.
Two residents' care plans were not updated to address identified needs and interventions related to sexual behavior and expression after an incident where both were found in bed together naked. One resident had severe cognitive impairment and a history of reaching out to others, while the other was cognitively intact with behavioral symptoms. The care plans did not include specific interventions for sexual behavior, despite facility policy requiring comprehensive, person-centered care planning.
The facility failed to ensure proper hand hygiene among staff, affecting all residents. An RN did not sanitize hands after patient care and medication administration, lacking hand sanitizer on her cart. An STNA carried trash with gloves post-incontinence care without hand hygiene, using a keypad with unclean hands. The facility's hand washing policy was not followed.
A resident with multiple diagnoses and a high risk of falling experienced two falls due to the facility's failure to implement ordered fall prevention interventions, specifically the absence of perimeter edges on a low air loss mattress. This deficiency was confirmed through observations and staff interviews.
A facility failed to ensure proper incontinence care for a resident, who was at risk for UTIs. An STNA did not properly cleanse the resident's perineal area, failing to use soap, retract the foreskin, or rinse with clean water, contrary to facility policy. This deficiency was confirmed by the ADON and observed during an investigation.
Failure to Administer PRN Seizure Medication Due to Inaccessible Med Cart
Penalty
Summary
The deficiency involves the facility’s failure to administer an ordered PRN seizure medication when a resident experienced a seizure. The resident had a history of epilepsy and other conditions including type 2 diabetes mellitus, moderate persistent asthma, anxiety, orthostatic hypotension, and peripheral vascular disease. Her MDS indicated intact cognition with a BIMS score of 14, and she was receiving multiple scheduled anticonvulsant and seizure medications, including Divalproex Sodium, Levetiracetam, Primidone, and Topiramate, as well as a PRN order for Midazolam nasal solution to be given for seizures lasting more than two minutes. The care plan directed staff to administer medications as ordered and to observe for side effects of anticonvulsant use. On the day of the incident, the resident experienced an aura and used her call light, telling a CNA that she was about to have a seizure. The CNA ensured she was safe in bed and then went to get the nurse on duty but was unable to locate the nurse. The CNA then went to the DON’s office for help. During this time, the resident proceeded to have a seizure, which the CNA estimated lasted approximately 10 to 12 minutes. The DON later reported that when she arrived, the resident was convulsing in bed, and the DON turned her onto her side and monitored her airway, which remained clear, and the seizure lasted about five minutes by the DON’s account. Record review showed that prior to the seizure, the resident had received all scheduled seizure medications as ordered, but the PRN Midazolam was not documented as administered during the seizure. Observation of the medication cart confirmed that four doses of the PRN Midazolam were available. Staff interviews revealed that the nurse on duty had gone on break and had taken the medication cart keys, leaving no one able to access the cart and obtain the Midazolam when the seizure occurred. The DON verified that the resident did not receive the ordered PRN Midazolam during the seizure because the medication cart could not be accessed in the nurse’s absence.
Improper Perineal Care Technique During Incontinence Care
Penalty
Summary
A deficiency was identified when a certified nurse assistant (CNA) provided incontinence care to a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, chronic obstructive pulmonary disease, and dysphagia. The resident was always incontinent of bowel and bladder and required substantial to maximal assistance for hygiene. During observed care, the CNA performed hand hygiene, donned gloves, and used a cloth washcloth to cleanse and rinse the resident after urinary incontinence. However, the CNA cleansed the perineal area from back to front, both during cleaning and rinsing, contrary to best practices for infection prevention. The CNA confirmed in an interview that she should have cleansed the resident from front to back, as specified in the facility's perineal care policy. The policy states that female residents should be cleansed from the pubic area toward the anus to promote cleanliness and prevent infection. This failure to follow proper perineal care technique constituted non-compliance and was identified during the investigation of two complaints.
Failure to Follow Infection Prevention and Control Protocols During Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed during care for three residents. For one resident with multiple diagnoses including hemiparesis, diabetes, and a stage three pressure ulcer, an LPN performed wound care without performing hand hygiene between glove changes and used scissors from her pocket without cleaning them before cutting gauze that was placed in the resident's sacral wound. Both the LPN and the infection control nurse confirmed these lapses during an interview, and facility policy required infection prevention during wound management. Another resident with severe cognitive impairment, incontinence, and a feeding tube was under Enhanced Barrier Precautions (EBP) per physician order. During incontinence care, a CNA wore gloves but did not change them between tasks, did not wear a required gown, and failed to perform hand hygiene after glove removal and before leaving the room to obtain additional supplies. The CNA acknowledged these failures during an interview, and facility policy required handwashing after glove removal and after contact with potentially contaminated items. A third resident with Huntington's disease and a feeding tube also required EBP. An RN administered medications and water flushes through the resident's g-tube while wearing gloves but did not wear a gown as required. The RN stated she was unclear about the PPE requirements for this procedure, and the infection preventionist confirmed that both gown and gloves were required. Facility policy and posted signage indicated that EBP, including gown and gloves, should be used for high-contact care activities.
Failure to Care Plan for Hearing Aids
Penalty
Summary
The facility failed to ensure Resident #61 was care planned for hearing aids, and the resident's hearing aids were not maintained in good working order. Resident #61 was admitted on 02/14/25 with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, atrial fibrillation, dementia, Parkinson's, and transient ischemic attack. The significant change MDS dated [DATE] documented intact cognition, moderate hearing loss, and the need for hearing aids. The resident's most recent care plan did not address hearing loss or the need for hearing aids, and the physician order dated 02/14/25 indicated the resident should be seen by an audiologist. During interview on 09/29/25, Resident #61 stated he was unable to wear his hearing aids because they needed new batteries and that he had told the nurses he needed new batteries. On 09/30/25, Nurse #206 and MDS Coordinator #163 stated the resident's family had requested an audiology visit, but they were unaware the resident needed new hearing aid batteries. CNA #158 also stated she was unaware the resident required hearing aids. The facility policy titled Comprehensive Care Plan stated the comprehensive care plan would be developed within 7 days after completion of the comprehensive MDS assessment and that all CAAs triggered by the MDS would be considered in developing the plan of care.
Failure to Provide Timely Showers and Hair Care
Penalty
Summary
The facility failed to ensure Resident #18 received showers and haircuts in a timely manner. Resident #18 was admitted on 08/25/22 and had diagnoses including vascular dementia, convulsion, chronic kidney disease, and transient ischemic attack. His quarterly MDS indicated moderately intact cognition and that he required supervision or touching assistance for showers. The care plan stated he needed minimal assistance with ADLs related to dementia and a history of falls, and that nail care was to be completed on bath days and as necessary, with supervision and touch assist for showering and bathing. Review of the resident’s shower records showed gaps in bathing, including no shower from 08/31/25 through 09/07/25, a shower on 09/10/25, and no shower again until 09/20/25. The progress notes from 08/31/25 through 09/20/25 contained no documentation related to showers or shower refusals. The shower schedule indicated the resident was to receive showers every Wednesday and Saturday. During observation on 09/29/25, the resident had long, unkempt hair and stated he had not been showered timely and wanted regular showers; he also said he needed a haircut. A CNA stated that second shift staff failed to complete showers timely. The facility policy on ADLs stated residents unable to carry out ADLs would receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
Delayed Response to Pharmacist Recommendation for HbA1c Testing
Penalty
Summary
The facility failed to timely respond to pharmacist recommendations for one resident reviewed for pharmacist recommendations. Resident #63 was admitted with diagnoses of type II diabetes mellitus, hypertensive heart disease, and congestive heart failure, and the quarterly MDS dated 12/08/25 showed intact cognition and use of hypoglycemic medications. A pharmacy recommendation to the prescriber dated 08/10/25 requested that Resident #63's HbA1c laboratory value be checked, and the physician responded on 08/15/25 with approval to draw the lab. However, the HbA1c was not drawn until 10/02/25. During interview on 12/17/25, the DON confirmed that no HbA1c was drawn between 08/15/25 and 10/02/25 and stated the test should have been completed within seven days of the physician signing the recommendation.
Pureed Diet Meals Missing Required Portion and Bread
Penalty
Summary
The facility failed to provide appropriate portions and all menu items for residents on a pureed diet, affecting two residents identified as being on pureed diets. During observation in the kitchen, staff were seen preparing pureed turkey and dumplings and pureed green beans for the evening meal. The dietary staff member used an 8-ounce scoop to portion the food and confirmed that only two residents were on pureed diets. He then placed a 4-ounce portion of pureed turkey and dumplings and a 4-ounce portion of pureed green beans on each of the two residents’ plates, and confirmed that these two items were the only items residents on a pureed diet would receive except for dessert. Further observation of meal tray delivery showed one resident’s tray contained only a main dish and vegetable, along with nutrition supplements, but no bread serving. Another staff member confirmed there was no bread on the other resident’s tray. Interview and review of the menu spreadsheet confirmed residents on a pureed diet should have received a portion of two #10 scoops, totaling 6.5 ounces, rather than the 4 ounces provided, and should also have received one slice of pureed white bread. The dietary staff member and dietary manager confirmed that no pureed bread was prepared or provided to either resident.
Inaccurate order transcription and untimely documentation
Penalty
Summary
The facility failed to accurately and timely document in the medical record for Resident #37 and failed to transcribe physician orders for Residents #04, #05, #37, and #63. The report states that one resident was affected by the documentation issue and four residents were affected by the physician order transcription issue. The facility census was 63, and the review included medical record review, staff interviews, and policy review. For Resident #04, the record showed an admission with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left side, gastrostomy status, and acquired absence of the left leg above the knee. The resident had left shoulder pain related to a fall, and the provider note included a lidocaine patch order written as apply to the left shoulder topically every morning and at bedtime, remove every 12 hours. The DON stated that the lidocaine order dated 07/31/25 was inaccurately ordered, and the order was later corrected to apply in the morning for 12 hours on and 12 hours off. For Resident #05, the record showed diagnoses including COPD, type 2 diabetes mellitus, bipolar disorder, OCD, depression, anxiety, coronary angioplasty implant and graft, toxic liver disease, IBS, and hepatitis C. Pharmacy recommendations stated lidocaine patches should be removed for 12 hours each day, and the attending provider signed this recommendation; however, the physician order dated 09/16/25 was transcribed as a lidocaine patch to the left ribs every 12 hours as needed for pain. For Resident #63, the record showed redundant Percocet orders, including one order for two tablets every four hours as needed for moderate to severe pain and another order for one tablet every four hours as needed for mild pain, plus an additional order for two tablets every four hours as needed for severe pain. The DON confirmed the duplicate Percocet orders, and the MAR showed the resident received two tablets from both active orders on multiple days without exceeding the 24-hour maximum. For Resident #37, the record showed diagnoses including orthopedic aftercare following amputation, major depressive disorder, and chronic pain syndrome, and the resident was cognitively intact and required substantial ADL assistance. The resident reported that an LPN changed the dressing on the left second toe and observed significant discharge, pain, redness, and swelling, then contacted the physician and sent the resident to the hospital, but no progress note was entered by that LPN about the wound or the hospital transfer. Another note later documented that the resident was sent to the hospital due to a red and swollen wound on the left second toe. The LPN later stated the resident had pain, bleeding, excessive discharge, odor, swelling of all toes and the top of the foot, and redness extending to the bottom of the left leg, and admitted no progress note was entered because she was busy and never got around to it. The facility policy required documentation at the time of service, no later than the shift in which care occurred.
Elopement and Fall Injury Due to Unalarmed, Unlocked Exit Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a safe environment to prevent the elopement of a resident who was known to be at risk for wandering and elopement. The resident had diagnoses including Alzheimer’s disease, dementia, and depression, with a recent MDS showing severely impaired cognition and a need for assistance with all functional abilities. Multiple elopement risk assessments over several months identified the resident as being at risk for elopement, and the care plan reflected this risk with interventions such as assessing for unmet needs when wandering or exit seeking, redirecting and distracting the resident, and use of a Secure Care alarming bracelet device. The resident was also assessed as being at high risk for falls, with care plan interventions addressing fall prevention, including appropriate footwear, clear pathways, and assistance with transfers and toileting. Despite these identified risks and care-planned interventions, the resident was able to leave the building through an exit door in the main dining room that was neither locked nor alarming at the time of the incident. The resident was last seen in her room at approximately 2:00 A.M. by a CNA and was discovered missing at 3:00 A.M. during staff rounds. A search was initiated, and the resident was found at 3:15 A.M. lying in the grass on facility property to the rear of the building. The resident had been propelling herself in a manual wheelchair through the grass and, when attempting to walk, her foot became stuck, causing her to fall to the ground. The investigation determined that the resident exited through a dining room exit door whose alarm and lock failed due to a loss of power. The main power supply to the door had failed, and the backup battery, which should have maintained the lock and alarm, had been drained because the power supply in the attic was intermittently dislodged following storms earlier in the week. Although the maintenance director reported that he had checked all doors after a prior power outage and found no doors beeping on backup power, the specific dining room door later showed no illuminated panel, indicating a power issue. As a result of exiting through this unalarmed and unlocked door, the resident sustained an acute mildly displaced fracture of the right distal fibula at the ankle, as confirmed by x-ray, and also had swelling and pain in the right ankle and knee and a bruise on the right palm.
Failure to Update Care Plans for Sexual Behavior/Expression
Penalty
Summary
The facility failed to ensure that comprehensive, person-centered care plans were updated to address identified resident needs and appropriate interventions, specifically regarding sexual behavior and expression. For one resident with severe cognitive impairment due to dementia, the care plan noted a tendency to reach out to people to hold and kiss hands and faces, but did not include any further interventions or information addressing sexual behavior or expression, despite an incident where the resident was found in bed naked with another resident. The care plan was not updated to reflect the behaviors identified during the facility's self-reported incident investigation. Similarly, another resident, who was cognitively intact and had a history of chronic medical conditions and behavioral symptoms such as verbal aggression and inappropriate sexual comments, had a care plan that only included redirection for inappropriate sexual comments. The care plan lacked additional interventions or information related to sexual behavior or expression, even after the incident involving both residents was investigated. The facility's policy required comprehensive care plans to be developed and updated based on resident needs, but this was not followed in these cases.
Failure in Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices among its staff, which had the potential to affect all 62 residents. During an observation, a Registered Nurse (RN) was seen taking a resident's blood pressure and administering medication without performing hand hygiene afterward. The RN confirmed that she did not sanitize her hands after providing care to the first resident and before starting the medication pass for another resident. Additionally, it was noted that the RN did not have hand sanitizer on her medication cart, which contributed to the lapse in hand hygiene. Another observation revealed a State Tested Nurse Aide (STNA) carrying a bag of trash while wearing disposable gloves after providing incontinence care to a resident. The STNA admitted to not performing hand hygiene after removing soiled gloves and before putting on a new pair. She used the keypad to unlock a shower room door with unclean hands and did not wash her hands until later. The facility's policy on hand washing, revised in May 2021, mandates washing hands before and after each resident contact, which was not adhered to in these instances.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure fall prevention interventions were implemented as ordered and care planned for Resident #1. The resident, who had multiple diagnoses including dementia, malnutrition, and polyneuropathy, was at risk of falling and had a physician's order for a low air loss (LAL) mattress with perimeter edges. Despite this, observations revealed that the perimeter edges were not in place on the LAL mattress. This failure was confirmed by both a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON). Resident #1 experienced two falls, one on 04/12/24 and another on 04/19/24, both times without injury. The falls occurred despite the interventions being noted as in place, which included the LAL mattress and call light. However, the perimeter edges, a critical part of the fall prevention plan, were not applied to the mattress as required. This deficiency was identified during a complaint investigation and was corroborated by staff interviews and medical record reviews.
Improper Incontinence Care Leading to Risk of Infection
Penalty
Summary
The facility failed to ensure proper incontinence care for Resident #1, who was frequently incontinent of bowel and bladder and at risk for skin breakdown and urinary tract infections (UTIs). During an observation, a State tested Nurse Aide (STNA) did not properly cleanse the resident's perineal area. The STNA used a washcloth from a basin with soap and water but did not use soap, did not retract the resident's foreskin, and did not rinse with clean water. This improper technique was confirmed by the STNA and the Assistant Director of Nursing (ADON), who acknowledged that the resident had returned from the hospital following treatment for a UTI and was at risk for further UTIs. The facility's policy on incontinence care for male residents requires the foreskin to be retracted and the area to be cleansed thoroughly from the tip of the penis downward, followed by the scrotum and anal area. The STNA's failure to follow this procedure was observed and verified, indicating non-compliance with the facility's policy. This deficiency was investigated under Complaint Number OH00153377 and affected one of three residents reviewed for incontinence care, with the facility census being 61.
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