Inspection Reports for Majestic Care of Bedford
2111 NORTON LN, BEDFORD, IN, 47421
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 12, 2025, identified one deficiency related to incomplete maintenance and testing documentation for the sprinkler system. Earlier inspections showed a pattern of issues with sprinkler system maintenance and emergency preparedness, as well as deficiencies in resident notification for transfers and discharges, fall prevention, and sanitary food storage. Complaint investigations were mostly unsubstantiated, except for one substantiated case involving failure to immediately report verbal abuse, which was corrected upon revisit. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s recent inspections suggest some ongoing challenges with facility maintenance and documentation, although complaint investigations have not indicated widespread compliance problems.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
145% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
55% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Re-Inspection
Census: 105
Capacity: 190
Deficiencies: 1
Date: Jun 12, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/30/25 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 NFPA 101 Life Safety Code. The building is fully sprinklered except for one detached storage building, and has appropriate fire alarm and smoke detection systems. A temporary waiver was approved for sprinkler system maintenance and testing until 09/01/25.
Deficiencies (1)
Sprinkler System - Maintenance and Testing requirement not met as evidenced by missing information on last sprinkler system check, system test provider, and water system supply source.
Report Facts
Facility capacity: 190
Census: 105
Inspection Report
Complaint Investigation
Census: 103
Capacity: 103
Deficiencies: 0
Date: May 22, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00459619 and IN00459624.
Complaint Details
Complaint IN00459619 and Complaint IN00459624 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations in complaints IN00459619 and IN00459624 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 103
Total Capacity: 103
Medicare Census: 3
Medicaid Census: 80
Other Payor Census: 20
Inspection Report
Annual Inspection
Census: 104
Capacity: 190
Deficiencies: 2
Date: Apr 30, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies were identified related to sprinkler system maintenance and testing, and electrical equipment testing and maintenance.
Deficiencies (2)
Failed to maintain automatic sprinkler systems in accordance with NFPA 25; missing Hydraulic Nameplate on sprinkler system reports.
Failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE).
Report Facts
Certified beds: 190
Census: 104
Deficiency completion date: Sep 1, 2025
Deficiency completion date: Jun 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Scott Swaby | Laboratory Director or Provider/Supplier Representative | Signed the report. |
| Maintenance Director | Interviewed regarding sprinkler system and electrical equipment deficiencies. | |
| Maintenance Assistant | Involved in education and maintenance activities related to deficiencies. | |
| Executive Director | Participated in exit conference discussing findings. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 21, 2025
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey.
Findings
Majestic Care of Bedford was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00456700 and IN00457396.
Complaint Details
Complaint IN00456700 and Complaint IN00457396 were investigated; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00456700 and IN00457396 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF: 3
Census Bed Type - SNF/NF: 101
Total Census: 104
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 90
Census Payor Type - Other: 9
Inspection Report
Annual Inspection
Census: 102
Capacity: 102
Deficiencies: 4
Date: Mar 28, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00455844.
Complaint Details
Complaint IN00455844 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found deficient in ensuring written notification for transfer/discharge and bed-hold policy was provided to residents and representatives for some residents. Additionally, the facility failed to document and implement new interventions to prevent falls for one resident and failed to ensure food was stored in a sanitary manner in the kitchen.
Deficiencies (4)
Failed to ensure written notification required for transfer and discharge was provided to the resident and resident representative for 2 of 3 residents reviewed for hospitalization.
Failed to ensure notification of the bed-hold policy was provided in writing to the resident or resident representative for 1 of 3 residents reviewed for hospitalization.
Failed to document and implement new interventions to prevent falls for 1 of 5 residents reviewed for accidents.
Failed to ensure food was stored in a sanitary manner; food was not discarded by discard date and food was stored under the condenser fan.
Report Facts
Residents reviewed for hospitalization: 3
Residents reviewed for accidents: 5
Residents served food from kitchen: 85
Census: 102
Total capacity: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Scott Swaby | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding transfer/discharge and bed-hold notification deficiencies and provided facility policies | |
| Dietary Manager | Interviewed regarding food storage deficiencies and provided facility policies | |
| Corporate Nurse Consultant | Provided facility policy on safe food handling |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 98
Deficiencies: 0
Date: Feb 17, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00453226.
Complaint Details
Complaint IN00453226 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 6
Medicaid census: 32
Other payor census: 60
Inspection Report
Complaint Investigation
Census: 99
Capacity: 99
Deficiencies: 0
Date: Dec 23, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448056.
Complaint Details
Complaint IN00448056 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 86
Census Payor Type - Other: 11
Inspection Report
Complaint Investigation
Census: 93
Capacity: 93
Deficiencies: 0
Date: Aug 22, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00441083 and IN00441152.
Complaint Details
Investigation of Complaints IN00441083 and IN00441152 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00441083 and IN00441152 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 93
Total Capacity: 93
Medicare Census: 6
Medicaid Census: 77
Other Payor Census: 10
Inspection Report
Re-Inspection
Census: 96
Capacity: 190
Deficiencies: 0
Date: Aug 19, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 07/01/24.
Findings
At this PSR survey, Majestic Care of Bedford was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility was fully sprinklered except for one detached storage building, and had appropriate fire alarm and smoke detection systems.
Report Facts
Certified beds: 190
Census: 96
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 25, 2024
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure Survey.
Findings
Majestic Care of Bedford was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure Survey.
Inspection Report
Annual Inspection
Census: 94
Capacity: 190
Deficiencies: 6
Date: Jul 1, 2024
Visit Reason
An Annual Life Safety Code Recertification and State Licensure Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and emergency preparedness regulations.
Findings
The facility was found substantially compliant with emergency preparedness requirements but had deficiencies in maintaining and updating emergency preparedness plans, policies, communication plans, and training/testing programs. Additionally, the facility failed to maintain sprinkler systems per NFPA 25 standards and did not conduct fire drills on each shift for 3 of 4 quarters.
Deficiencies (6)
Failed to develop and maintain an emergency preparedness plan reviewed and updated at least annually.
Failed to develop and implement emergency preparedness policies and procedures reviewed and updated at least annually.
Failed to develop and maintain an emergency preparedness communication plan reviewed and updated at least annually.
Failed to develop and maintain an emergency preparedness training and testing program reviewed and updated at least annually.
Failed to maintain automatic sprinkler systems in accordance with NFPA 25; accelerator repair not completed and sprinkler head with bent deflector not replaced.
Failed to conduct fire drills on each shift for 3 of 4 quarters as required.
Report Facts
Certified beds: 190
Census: 94
Deficiencies cited: 6
Date of last sprinkler system inspection: May 7, 2024
Plan of Correction Completion Date: Jul 26, 2024
Plan of Correction Completion Date: Aug 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joe Cox | Maintenance Director | Named in relation to emergency preparedness plan review and sprinkler system maintenance |
Inspection Report
Annual Inspection
Census: 95
Capacity: 95
Deficiencies: 9
Date: Jun 13, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00436114.
Complaint Details
Complaint IN00436114 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found to have deficiencies related to failure to provide written transfer/discharge notices, failure to provide bed-hold policy notifications, failure to transmit MDS assessments timely and accurately, failure to develop comprehensive care plans for behaviors, failure to provide services to prevent decline in range of motion, failure to label opened insulin vials with open dates, failure to ensure timely laboratory services, and failure to complete new hire tuberculosis screening.
Deficiencies (9)
Failed to ensure written notification of transfer/discharge was provided to resident and representative for 3 residents.
Failed to ensure notification of bed-hold policy was provided in writing for 3 residents transferred to hospital.
Failed to transmit Minimum Data Set (MDS) assessment within 14 days for 1 resident.
Failed to ensure residents received accurate MDS assessments reflective of their status for 2 residents.
Failed to develop a comprehensive care plan for a resident with behaviors.
Failed to provide treatment or services to prevent further decrease in range of motion for 3 residents.
Failed to label an open vial of insulin with an open date for 1 resident.
Failed to ensure laboratory services were provided timely for a resident with an order for blood draws every six months.
Failed to complete new hire tuberculosis screening (2-step test) for 5 employees.
Report Facts
Census: 95
Total Capacity: 95
Residents reviewed for transfer/discharge notice deficiency: 3
Residents reviewed for bed-hold policy notification deficiency: 3
Residents reviewed for MDS transmission deficiency: 1
Residents reviewed for MDS accuracy deficiency: 2
Residents reviewed for care plan deficiency: 1
Residents reviewed for range of motion deficiency: 3
Residents reviewed for insulin vial labeling deficiency: 1
Residents reviewed for laboratory services deficiency: 1
Employees reviewed for tuberculosis screening deficiency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joe Cox | Executive Director | Signed the inspection report |
| Human Resources Director | Interviewed regarding tuberculosis screening deficiencies | |
| Nurse Practitioner | Interviewed regarding laboratory services deficiency | |
| RN 1 | Registered Nurse | Observed administering insulin and interviewed about insulin vial labeling |
| COTA 1 | Certified Occupational Therapist Assistant | Interviewed regarding range of motion restorative program deficiencies |
| DHS | Director of Health Services | Interviewed regarding range of motion and care plan deficiencies |
| Administrator | Provided facility policies and interviewed about transfer/discharge and bed-hold notification deficiencies | |
| DNS/Designee | Director of Nursing Services or Designee | Interviewed regarding MDS submission and care plan deficiencies |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 86
Deficiencies: 0
Date: Feb 19, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00427954.
Complaint Details
Complaint IN00427954 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00427954 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 4
Medicaid census: 71
Other payor census: 11
Inspection Report
Complaint Investigation
Census: 88
Capacity: 88
Deficiencies: 0
Date: Feb 5, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00427254.
Complaint Details
Investigation of Complaint IN00427254 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Report Facts
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 65
Census Payor Type - Other: 21
Inspection Report
Complaint Investigation
Census: 87
Capacity: 87
Deficiencies: 0
Date: Jan 23, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00425641 and IN00426089.
Complaint Details
Complaint IN00425641 - No deficiencies related to the allegations are cited. Complaint IN00426089 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in Complaints IN00425641 and IN00426089 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 66
Census Payor Type - Other: 18
Inspection Report
Complaint Investigation
Census: 83
Capacity: 83
Deficiencies: 0
Date: Jan 2, 2024
Visit Reason
This visit was conducted for the investigation of four complaints: IN00421564, IN00424025, IN00424344, and IN00424646.
Complaint Details
Complaints IN00421564, IN00424025, IN00424344, and IN00424646 were investigated and no deficiencies related to the allegations were found.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 83
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 78
Census Payor Type - Other: 4
Total Census: 83
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 17, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00419692 completed on October 26, 2023.
Complaint Details
Complaint IN00419692 was investigated and the facility was found to be in compliance.
Findings
Majestic Care of Bedford was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the complaint investigation.
Inspection Report
Complaint Investigation
Census: 96
Capacity: 96
Deficiencies: 2
Date: Oct 26, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00419692 and IN00419672. Complaint IN00419692 resulted in federal/state deficiencies cited, while Complaint IN00419672 had no deficiencies related to the allegations.
Complaint Details
Complaint IN00419692 was substantiated with federal/state deficiencies cited at F689 and F921. Complaint IN00419672 was not substantiated with no deficiencies cited.
Findings
The facility was found deficient in providing adequate supervision to prevent accidents related to residents possessing electronic cigarettes without proper assessment or care plans. Additionally, the facility failed to maintain a clean and sanitary environment in three shower rooms, with issues such as soap scum buildup, yellow discoloration, and improper storage of personal care items.
Deficiencies (2)
Failed to provide supervision to prevent accidents for 3 residents possessing electronic cigarettes without assessment or care plans.
Failed to ensure a clean and sanitary environment in 3 shower rooms with soap scum buildup, yellow discoloration, and improper storage of personal items.
Report Facts
Residents reviewed for accident hazards: 3
Shower rooms observed with deficiencies: 3
Total census: 96
Total capacity: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christy Marlow | Executive Director | Signed the report and was involved in observations regarding electronic cigarette possession and shower room sanitation |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 0
Date: Oct 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00419213.
Complaint Details
Complaint IN00419213 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00419213 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 99
Census Bed Type - SNF/NF: 89
Census Bed Type - SNF: 10
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 74
Census Payor Type - Other: 15
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 0
Date: Sep 18, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00416005 and IN00417395.
Complaint Details
Complaint IN00416005 and Complaint IN00417395 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00416005 and IN00417395 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF: 9
Census Bed Type - SNF/NF: 87
Total Census: 96
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 72
Census Payor Type - Other: 15
Total Census Payor: 96
Inspection Report
Life Safety
Census: 98
Capacity: 190
Deficiencies: 0
Date: Aug 14, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 07/10/23 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, Majestic Care of Bedford was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is a two-story split level, fully sprinklered, with fire alarm and smoke detection systems, and battery operated smoke alarms in all resident sleeping rooms.
Report Facts
Facility capacity: 190
Census: 98
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 19, 2023
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey completed on June 12, 2023.
Findings
Majestic Care of Bedford was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 91
Capacity: 190
Deficiencies: 2
Date: Jul 10, 2023
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, specifically failing to maintain protection of a hot oil popcorn popper without self-closing doors affecting 20 residents, and one corridor door failing to close and latch properly affecting 2 residents.
Deficiencies (2)
Failed to maintain protection of 1 hot oil popcorn popper in Unit Five dining room; corridor doors to dining room lacked self-closing devices or hinges.
One corridor door to Resident Room 115 failed to close and latch positively into the door frame.
Report Facts
Certified beds: 190
Census: 91
Residents potentially affected: 20
Corridor doors inspected: 100
Residents potentially affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christy Marlow | Administrator | Named as Administrator present during survey and exit conference |
| Maintenance Director | Named role involved in confirming deficiencies and corrective actions |
Inspection Report
Annual Inspection
Census: 87
Capacity: 87
Deficiencies: 4
Date: Jun 12, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from June 6 to June 12, 2023.
Findings
The facility was found deficient in ensuring written notification of transfer/discharge and bed-hold policy was provided to residents and their representatives for 2 of 4 residents reviewed. Additionally, the facility failed to initiate timely treatment for a resident with limited range of motion and did not ensure timely completion of stat X-rays for a resident after a fall.
Deficiencies (4)
Failed to ensure written notification of transfer/discharge was given to resident and representative for 2 of 4 residents reviewed.
Failed to provide written notification of bed-hold policy to resident or representative for 2 of 4 residents reviewed for hospitalization.
Failed to initiate treatment and services to prevent further decline in range of motion for 1 of 4 residents reviewed for mobility.
Failed to ensure stat X-ray was completed in a timely manner for 1 of 2 residents reviewed for accidents.
Report Facts
Census: 87
Total Capacity: 87
Deficiencies cited: 4
Survey dates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christy Marlow | Administrator | Named in relation to findings and interviews regarding deficiencies |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Date: Apr 4, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00404839.
Complaint Details
Complaint IN00404839 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00404839 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF: 5
Census Bed Type - NF: 76
Total Census: 81
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 73
Census Payor Type - Other: 3
Inspection Report
Re-Inspection
Census: 81
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00401242 completed on February 16, 2023.
Complaint Details
Complaint IN00401242 - Corrected.
Findings
Garden Villa - Bedford was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00401242.
Report Facts
Census Bed Type: 81
SNF/NF beds: 74
SNF beds: 7
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 72
Census Payor Type - Other: 2
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Date: Mar 16, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00403516.
Complaint Details
Complaint IN00403516 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant federal and state regulations.
Report Facts
Census Bed Type Total: 84
Census Payor Type Total: 84
SNF/NF Beds: 74
SNF Beds: 10
Medicare Residents: 10
Medicaid Residents: 71
Other Payor Residents: 3
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 1
Date: Feb 16, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00401242, which was substantiated with related Federal/State deficiencies cited.
Complaint Details
Complaint IN00401242 was substantiated. The facility failed to immediately report verbal abuse involving CNA 1 yelling and cursing at Resident B and telling Resident C to 'shut the f*** up'. The abuse was reported late by RN 1 to the Administrator the next day.
Findings
The facility failed to immediately report verbal abuse to the administrator for 2 residents reviewed. The incident involved a CNA verbally abusing Resident B and Resident C, and the failure to timely report the abuse was confirmed.
Deficiencies (1)
Failure to immediately report verbal abuse to the administrator for 2 residents.
Report Facts
Census: 80
Total Capacity: 80
Residents potentially affected: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christy Fougerousse | Administrator | Administrator who received the late abuse report |
| RN 1 | Registered Nurse | Reported the verbal abuse incident to the Administrator late |
| CNA 1 | Certified Nursing Aide | Alleged perpetrator of verbal abuse to residents |
| DON | Director of Nursing | Interviewed regarding the abuse allegation and facility policy |
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