Inspection Report Summary
The most recent inspection on June 30, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mix of compliance and some deficiencies, primarily involving documentation accuracy, Life Safety Code issues such as sprinkler system maintenance, and occasional resident care concerns like following physician orders. Complaint investigations were mostly unsubstantiated, with one substantiated case in January 2025 related to incomplete wound care documentation. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility’s record shows some improvement in Life Safety Code compliance and resident care documentation since early 2025, following prior citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
112 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Date: Jun 30, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00461625.
Complaint Details
Complaint IN00461625 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations of Complaint IN00461625 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type Total: 112
Census Bed Type SNF/NF: 32
Census Bed Type SNF: 6
Census Bed Type NF: 74
Census Payor Type Medicare: 6
Census Payor Type Medicaid: 74
Census Payor Type Other: 32
Inspection Report
Life Safety
Census: 108
Capacity: 224
Deficiencies: 0
Date: May 6, 2025
Visit Reason
A Life Safety Code Pre Occupancy Survey was conducted for rooms 205-212 to verify compliance with 42 CFR 483.90(a) and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
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 one-story, fully sprinklered facility had appropriate fire alarm and smoke detection systems installed.
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 0
Date: Mar 3, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454275.
Complaint Details
Complaint IN00454275 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 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census: 108
Census Bed Type - SNF: 12
Census Bed Type - NF: 66
Census Bed Type - SNF/NF: 30
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 66
Census Payor Type - Other: 30
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 5, 2025
Visit Reason
Paper compliance review to the Investigation of Complaint IN00451705 completed on January 23, 2025.
Complaint Details
Complaint IN00451705 was investigated and found to be corrected.
Findings
Majestic Care of Bloomington was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 1
Date: Jan 23, 2025
Visit Reason
The visit was conducted as an investigation of Complaint IN00451705 regarding federal and state deficiencies related to resident records and documentation.
Complaint Details
Complaint IN00451705 was substantiated with federal and state deficiencies cited related to incomplete and inaccurate resident records documentation.
Findings
The facility failed to ensure resident records were complete and accurate for 3 of 3 residents reviewed (Residents B, C, and D), specifically lacking documentation of wound care treatments as ordered by physicians.
Deficiencies (1)
Failed to ensure resident records were complete and accurate for 3 of 3 residents reviewed for wound care documentation.
Report Facts
Census Bed Type - SNF/NF: 105
Census Bed Type - SNF: 9
Total Census: 114
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 69
Census Payor Type - Other: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Warren McCreery | Administrator | Signed the report |
| Director of Nursing | Interviewed regarding wound care documentation deficiencies | |
| Assistant Director of Nursing | Involved in auditing wound orders and documentation | |
| Unit Managers | Involved in auditing wound orders and documentation | |
| LPN 1 | Interviewed regarding wound care documentation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 23, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about incomplete and inaccurate resident medical record documentation at Majestic Care of Bloomington.
Complaint Details
This citation relates to Complaint IN00451705.
Findings
The facility failed to ensure complete and accurate documentation of wound care treatments for three residents (Resident B, Resident C, and Resident D). Multiple instances of missing treatment documentation were identified in the Treatment Administration Records (TAR) for wound care treatments ordered by physicians.
Deficiencies (1)
Failed to ensure resident records were complete and accurate for 3 of 3 residents reviewed for documentation of wound care treatments.
Report Facts
Residents affected: 3
Dates with missing documentation: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Indicated documentation for Residents B, C, and D treatments should have been completed during interviews on 1/23/25 |
| LPN 1 | Licensed Practical Nurse | Indicated documentation for wound care should have been completed in the medical record during interview on 1/23/25 |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 0
Date: Dec 26, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00448737 and IN00449682.
Complaint Details
Complaint IN00448737 - No deficiencies related to the allegations are cited. Complaint IN00449682 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00448737 and IN00449682 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: 114
Total Census: 117
Census Payor Type - Medicare: 14
Census Payor Type - Medicaid: 65
Census Payor Type - Other: 38
Inspection Report
Re-Inspection
Census: 121
Capacity: 224
Deficiencies: 0
Date: Dec 23, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted 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 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered with appropriate smoke detection systems and all resident-accessible areas were sprinklered except for two detached storage buildings.
Report Facts
Facility capacity: 224
Census: 121
Inspection Report
Life Safety
Census: 114
Capacity: 224
Deficiencies: 1
Date: Dec 3, 2024
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 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to failure to maintain automatic sprinkler systems according to NFPA 25 standards. Specific deficiencies included missing hydraulic nameplates and malfunctioning quick opening devices on sprinkler systems.
Deficiencies (1)
Failed to maintain automatic sprinkler systems in accordance with NFPA 25, including missing hydraulic nameplates and quick opening devices not passing tests due to 'Accelerator shut off'.
Report Facts
Certified beds: 224
Census: 114
Date of sprinkler inspection: Nov 13, 2024
Date of compliance accelerators replaced: Dec 11, 2024
Date of compliance name plates replaced: Dec 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Warren McCreery | Executive Director | Signed the report and involved in exit conference |
| Director of Plant Operations | Interviewed regarding sprinkler system deficiencies and maintenance |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 21, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Majestic Care of Bloomington 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: 112
Capacity: 112
Deficiencies: 3
Date: Nov 4, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00445671.
Complaint Details
Complaint IN00445671 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found to have deficiencies including failure to follow physician orders for respiratory care for one resident, failure to post the facility name on daily staffing sheets, and failure to secure a medication cart. The complaint investigation found no deficiencies related to the allegations.
Deficiencies (3)
Failed to ensure physician orders were followed for respiratory care for 1 of 2 residents reviewed (Resident 213).
Failed to ensure the posted daily staffing information sheet included the facility name for 5 of 5 daily staffing sheets reviewed.
Failed to ensure a medication cart on the 300 unit was locked for 1 of 8 medication carts observed.
Report Facts
Census Bed Type: 112
Census: 112
Medicare residents: 13
Medicaid residents: 62
Other payor residents: 37
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Warren McCreery | Executive Director | Signed the report and involved in QAPI meetings |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding Resident 213's oxygen order and care |
| RN 1 | Registered Nurse | Interviewed regarding medication cart security |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 4, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to respiratory care, nurse staffing information posting, and medication storage security at Majestic Care of Bloomington.
Findings
The facility failed to ensure physician orders were followed for respiratory care for one resident, did not include the facility name on posted daily nurse staffing sheets for five days, and failed to keep one of eight medication carts locked when unattended.
Deficiencies (3)
Failed to ensure physician orders were followed for respiratory care for 1 of 2 residents reviewed (Resident 213).
Failed to ensure the posted daily staffing information sheet included the facility name for 5 of 5 daily staffing sheets reviewed.
Failed to ensure a medication cart on the 300 unit was locked for 1 of 8 medication carts observed.
Report Facts
Medication carts observed: 8
Daily staffing sheets reviewed: 5
Residents reviewed for respiratory care: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Interviewed regarding Resident 213's oxygen order and oxygen concentrator settings | |
| RN 1 | Interviewed regarding medication cart locking procedures | |
| Administrator | Provided facility policies and interviewed regarding staffing sheets and policy awareness | |
| Director of Nursing | Provided Facility Drug Product Storage Requirements policy |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Date: Sep 11, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00442159 and IN00442984 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaints IN00442159 and IN00442984 were investigated with no deficiencies found related to the allegations.
Findings
No deficiencies related to the allegations in Complaints IN00442159 and IN00442984 were cited. The facility was found to be in compliance with relevant regulations including 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type: 109
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 76
Census Payor Type - Other: 28
Inspection Report
Deficiencies: 0
Date: Sep 11, 2024
Visit Reason
The inspection was conducted as a standard survey of Majestic Care of Bloomington to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Date: Aug 22, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00440014 and IN00441184 at Majestic Care of Bloomington.
Complaint Details
Investigation of Complaints IN00440014 and IN00441184 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in Complaints IN00440014 and IN00441184 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type: 112
Census Bed Type - SNF: 12
Census Bed Type - SNF/NF: 100
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 64
Census Payor Type - Other: 36
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 0
Date: Jul 22, 2024
Visit Reason
This visit was conducted to investigate Complaints IN00438509 and IN00438454 at Majestic Care of Bloomington.
Complaint Details
Investigation of Complaints IN00438509 and IN00438454 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in Complaints IN00438509 and IN00438454 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 113
Census Bed Type - SNF: 13
Census Bed Type - SNF/NF: 100
Census Payor Type - Medicare: 13
Census Payor Type - Medicaid: 83
Census Payor Type - Other: 17
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Date: Jun 27, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00436576 and IN00436596.
Complaint Details
Complaint IN00436576 - No deficiencies related to the allegations are cited. Complaint IN00436596 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00436576 and IN00436596 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF: 10
Census Bed Type - SNF/NF: 101
Total Census: 111
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 82
Census Payor Type - Other: 19
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 0
Date: May 23, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00434568 and IN00434796.
Complaint Details
Complaint IN00434568 and IN00434796 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00434568 and IN00434796 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type Total: 108
Census Payor Type Total: 108
SNF/NF Beds: 30
SNF Beds: 9
NF Beds: 69
Medicare Residents: 9
Medicaid Residents: 69
Other Payor Residents: 30
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00431688 and IN00432212.
Complaint Details
Investigation of Complaints IN00431688 and IN00432212 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00431688 and IN00432212 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type Total: 110
Census Payor Type Total: 110
SNF/NF Beds: 36
SNF Beds: 4
NF Beds: 70
Medicare Residents: 4
Medicaid Residents: 70
Other Payor Residents: 36
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Date: Feb 21, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00428032 and IN00428661.
Complaint Details
Investigation of Complaints IN00428032 and IN00428661 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00428032 and IN00428661 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type Total: 107
Census Payor Type Total: 107
SNF/NF Beds: 22
SNF Beds: 9
NF Beds: 76
Medicare Residents: 9
Medicaid Residents: 76
Other Residents: 22
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Date: Feb 7, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00426981, IN00427084, and IN00427122.
Complaint Details
Complaints IN00426981, IN00427084, and IN00427122 were investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 109
Census Bed Type: 15
Census Bed Type: 72
Census Bed Type: 22
Census Payor Type: 15
Census Payor Type: 72
Census Payor Type: 22
Inspection Report
Life Safety
Census: 107
Capacity: 224
Deficiencies: 0
Date: Feb 6, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with the Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered with appropriate smoke detection systems in resident sleeping rooms and corridors.
Report Facts
Facility capacity: 224
Census: 107
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 0
Date: Jan 22, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00424027 and IN00425764.
Complaint Details
Complaint IN00424027 - No deficiencies related to the allegations are cited. Complaint IN00425764 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in Complaints IN00424027 and IN00425764 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF beds: 11
Census SNF/NF beds: 99
Total census: 110
Medicare census: 11
Medicaid census: 64
Other payor census: 35
Total payor census: 110
Inspection Report
Life Safety
Census: 104
Capacity: 224
Deficiencies: 3
Date: Jan 8, 2024
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 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included exposed wood studs with unknown flame spread rating in a former senior flex area, corridor doors propped open impeding smoke resistance, and improper use of extension cords and power strips in patient care areas.
Deficiencies (3)
Failed to ensure 1 of 1 senior flex area was provided with a complete interior finish with a flame spread rating of Class A or Class B for a sprinklered facility; exposed wood studs were observed.
Failed to ensure 1 of 1 corridor medical records door and 1 of 1 corridor scheduling office door were provided with means suitable for keeping the door closed, had no impediment to closing, latching and would resist passage of smoke; doors were propped open with wedges.
Failed to ensure 1 of 1 extension cords including power strips were not used as a substitute for fixed wiring; power strip used for both medical and personal devices in resident room 321.
Report Facts
Certified beds: 224
Census: 104
Residents affected: 15
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Warren McCreery | Executive Director | Named in relation to review of findings at exit conference |
| Director of Plant Operations | Interviewed and involved in observations related to deficiencies |
Inspection Report
Annual Inspection
Census: 107
Capacity: 107
Deficiencies: 0
Date: Dec 4, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey and included the Investigation of Complaint IN00421478.
Complaint Details
Complaint IN00421478 was investigated and no deficiencies related to the allegations were cited.
Findings
Majestic Care of Bloomington was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Recertification and State Licensure Survey and the Investigation of Complaint IN00421478. No deficiencies related to the complaint allegations were cited.
Report Facts
Medicare census: 14
Medicaid census: 65
Other payor census: 28
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 4, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Majestic Care of Bloomington.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 0
Date: Nov 6, 2023
Visit Reason
This visit was conducted to investigate complaints IN00420905, IN00420650, and IN00420063 at Majestic Care of Bloomington.
Complaint Details
Complaints IN00420905, IN00420650, and IN00420063 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF: 12
Census Bed Type - NF: 79
Census Bed Type - SNF/NF: 19
Total Census: 110
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 79
Census Payor Type - Other: 19
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 0
Date: Oct 10, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418939.
Complaint Details
Complaint IN00418939 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 regulations.
Report Facts
Census Bed Type - NF: 71
Census Bed Type - SNF: 8
Census Bed Type - SNF/NF: 24
Total Census: 103
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 71
Census Payor Type - Other: 24
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 0
Date: Sep 25, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416968.
Complaint Details
Complaint IN00416968 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 Bed Type - SNF: 9
Census Bed Type - SNF/NF: 95
Total Census: 104
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 86
Census Payor Type - Other: 9
Inspection Report
Complaint Investigation
Census: 105
Capacity: 105
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00414843.
Complaint Details
Investigation of Complaint IN00414843 found 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 Bed Type - SNF/NF: 93
Census Bed Type - SNF: 12
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 82
Census Payor Type - Other: 11
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 0
Date: Jul 28, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413499.
Complaint Details
Complaint IN00413499 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00413499 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF: 11
Census Bed Type - SNF/NF: 90
Total Census: 101
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 77
Census Payor Type - Other: 13
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Date: Jul 2, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00411200, IN00411510, and IN00411741.
Complaint Details
Complaints IN00411200, IN00411510, and IN00411741 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00411200, IN00411510, and IN00411741 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 98
Census Bed Type - SNF/NF: 80
Census Bed Type - SNF: 18
Census Payor Type - Medicare: 18
Census Payor Type - Medicaid: 64
Census Payor Type - Other: 16
Inspection Report
Follow-Up
Census: 84
Capacity: 224
Deficiencies: 0
Date: Mar 20, 2023
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 02/02/23.
Findings
At this PSR survey, Garden Villa-Bloomington 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 with appropriate fire alarm and smoke detection systems in place.
Report Facts
Certified beds: 224
Census: 84
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 22, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Garden Villa - Bloomington 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
Routine
Census: 87
Capacity: 224
Deficiencies: 10
Date: Feb 2, 2023
Visit Reason
Routine Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency preparedness, egress door locking, cooking facilities, fire alarm system installation, sprinkler system maintenance, smoke barrier integrity, HVAC fire damper inspection, and soiled linen/trash container management.
Deficiencies (10)
Emergency preparedness policies did not include a system to preserve resident medical documentation during an emergency.
Failed to develop and maintain an emergency preparedness training and testing program based on the emergency plan.
Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills.
Means of egress through 3 of 13 exit doors were not readily accessible without a key or tool and lacked posted instructions.
Cook tops in the dining room were not shut off at the switch when not in use; fryer was not under hood extinguishing system.
Fire alarm system smoke detector located within 3 feet of an air return vent where airflow prevents proper operation.
Failed to provide written documentation of sprinkler system inspection and testing for 1 of 4 quarters.
Open attic access panel above suspended ceiling tiles by resident room 503 exposed the attic, compromising smoke barrier.
Failed to ensure all fire dampers were inspected and maintained within the most recent four year period with itemized documentation.
Unattended 55 gallon soiled linen/trash barrel outside soiled utility room exceeded allowed capacity and was not stored properly.
Report Facts
Facility certified beds: 224
Census: 87
Exit doors with locking issues: 3
Soiled linen/trash barrel capacity: 55
Sprinkler system inspection quarters missing: 1
Attic access panel size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Patterson | Director of Nursing | Named in relation to emergency preparedness findings and exit conference. |
| Director of Plant Operations | Interviewed and observed regarding emergency preparedness, egress doors, fire alarm, sprinkler system, smoke barrier, HVAC, and soiled linen findings. | |
| Administrator | Participated in interviews and exit conference related to multiple findings. |
Inspection Report
Renewal
Census: 91
Capacity: 91
Deficiencies: 2
Date: Jan 31, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over multiple days in January 2023.
Findings
The facility was found deficient in providing adequate repositioning to prevent moisture acquired skin damage for one resident and failed to apply a hand splint for a resident with limited range of motion. Corrective actions and monitoring plans were implemented for these deficiencies.
Deficiencies (2)
Failed to provide repositioning to prevent moisture acquired skin damage for 1 of 6 residents reviewed for pressure sores (Resident 72).
Failed to apply a hand splint on a resident with an assessed limited range of motion for 1 of 5 residents reviewed for mobility (Resident 24).
Report Facts
Census Bed Type - SNF/NF: 80
Census Bed Type - SNF: 11
Total Census: 91
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 68
Census Payor Type - Other: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Patterson | Director of Nursing | Named in relation to findings and interviews regarding repositioning and splint application |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 31, 2023
Visit Reason
The inspection was conducted to assess compliance with care standards related to pressure sore prevention and mobility care for residents at Majestic Care of Bloomington.
Findings
The facility failed to provide adequate repositioning to prevent moisture acquired skin damage for one resident and failed to apply a prescribed hand splint for another resident with limited range of motion. Both deficiencies were associated with minimal harm or potential for actual harm and affected a few residents.
Deficiencies (2)
Failed to provide repositioning to prevent moisture acquired skin damage for 1 of 6 residents reviewed for pressure sores (Resident 72).
Failed to apply a hand splint on a resident with an assessed limited range of motion for 1 of 5 residents reviewed for mobility (Resident 24).
Report Facts
Residents reviewed for pressure sores: 6
Residents reviewed for mobility: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Indicated Resident 72 was occasionally resistant to care and repositioning. |
| Director of Nursing | Director of Nursing | Indicated Resident 72 had moisture acquired skin damage and was frequently resistant to hands on care; also indicated the facility did not have a nursing restorative program and Resident 24 was one of the few residents who wore their splints. |
| Certified Nurse Aide 1 | Certified Nurse Aide | Indicated Resident 72 was to be repositioned every 2 hours if possible, but sometimes missed on busy shifts. |
| Qualified Medication Aide 1 | Qualified Medication Aide | Indicated Resident 24 wore a splint to his left hand and would inform nurse if splint was removed. |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Indicated Resident 24 wore a splint and refusals would be documented. |
| Administrator | Administrator | Provided facility policy on Nurse Aide Qualifications and Training Requirements. |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Date: Dec 6, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00390775.
Complaint Details
Complaint IN00390775 was investigated and determined to be unsubstantiated due to lack of evidence.
Findings
The complaint IN00390775 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 71
Census Bed Type - SNF: 19
Census Total: 90
Census Payor Type - Medicare: 19
Census Payor Type - Medicaid: 60
Census Payor Type - Other: 11
Census Payor Type - Total: 90
Inspection Report
Complaint Investigation
Census: 84
Capacity: 84
Deficiencies: 0
Date: Aug 30, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00382743.
Complaint Details
Complaint IN00382743 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The complaint IN00382743 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census: 84
Total Capacity: 84
Medicare Census: 6
Medicaid Census: 68
Other Payor Census: 10
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