Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.