Inspection Reports for Majestic Care of Connersville
1029 E 5TH STREET, IN, 47331
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 30, 2025, found the facility in compliance with no deficiencies noted during a paper compliance review related to a complaint investigation. Earlier inspections showed a pattern of deficiencies primarily involving documentation and adherence to physician orders for medication administration, pest control issues related to a faulty kitchen door, and care planning including fall interventions and colostomy care. Several complaint investigations were substantiated with deficiencies cited, while many others were found unsubstantiated or corrected upon follow-up. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows some improvement in recent months, with the latest inspections indicating compliance after prior citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
257% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
May 30, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00458469 completed on May 7, 2025.
Findings
Majestic Care of Connersville 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 of the complaint investigation.
Complaint Details
Complaint IN00458469 was investigated and found to be corrected.
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 1
May 7, 2025
Visit Reason
This visit was conducted for the investigation of Complaints IN00458469 and IN00458841. Complaint IN00458469 resulted in a federal/state deficiency citation, while Complaint IN00458841 had no deficiencies cited.
Findings
The facility failed to ensure accurate documentation of a lack of bowel movements for Resident C, which contributed to not following physician's orders related to PRN administration of medications to encourage stooling. The facility's electronic medical record system did not properly alert nursing staff about the lack of bowel movements, and the medication administration did not follow the bowel protocol orders.
Complaint Details
Complaint IN00458469 was substantiated with a federal/state deficiency cited. Complaint IN00458841 was not substantiated with no deficiencies cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure accurate documentation of a lack of bowel movements and adherence to physician's orders for PRN medications to encourage stooling for Resident C. | SS=D |
Report Facts
Census: 79
Total Capacity: 79
Medicare Residents: 2
Medicaid Residents: 71
Other Payor Residents: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Elwell | HFA | Laboratory Director or Provider/Supplier Representative who signed the report |
| Director of Nursing | Interviewed regarding bowel movement documentation and facility policies |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Feb 7, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452219.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00452219 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 2
Medicaid census: 71
Other payor census: 6
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 0
Nov 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446231.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00446231 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 81
Total Capacity: 81
Medicare Census: 2
Medicaid Census: 67
Other Payor Census: 12
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 16, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00443547 completed on September 27, 2024.
Findings
Majestic Care of Connersville 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 of the complaint investigation.
Complaint Details
Investigation of Complaint IN00443547 completed on September 27, 2024; paper compliance review found the facility in compliance.
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 1
Sep 27, 2024
Visit Reason
This visit was for the investigation of multiple complaints (IN00444020, IN00443547, IN00443572, IN00442865, IN00442679, IN00442680, IN00442683, IN00442699, and IN00442719) at Majestic Care of Connersville.
Findings
The facility was found deficient in maintaining an effective pest control program due to a faulty kitchen door in the west building allowing rodents to enter, potentially affecting 42 residents. Multiple pest control reports documented ongoing rodent issues linked to the door not sealing properly and being propped open by staff.
Complaint Details
Complaint IN00443547 was substantiated with federal/state deficiencies cited at F-925 related to pest control. Other complaints investigated found no deficiencies related to the allegations.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain the entry door into the main kitchen resulting in rodents entering the west building kitchen, affecting 42 residents. | SS=E |
Report Facts
Residents in west building: 42
Total census: 76
Total capacity: 76
Medicare residents: 3
Medicaid residents: 64
Other payor residents: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Elwell | HFA | Signed as Laboratory Director's or Provider/Supplier Representative |
| Dietary Manager | Interviewed regarding pest control and kitchen door issues | |
| Dietary Manager in Training | Interviewed about staff propping open kitchen door | |
| Licensed Practical Nurse (LPN) 1 | Reported seeing a mouse in a resident's room | |
| Pest Control Technician | Provided ongoing pest control service and assessment | |
| Maintenance Director | Discussed attempts to fix the kitchen door and corrective actions |
Inspection Report
Follow-Up
Census: 81
Capacity: 166
Deficiencies: 0
Aug 27, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/14/24 was performed by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR Life Safety Code survey, Majestic Care of Connersville was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies, and 410 IAC 16.2. The facility was fully sprinkled with fire alarm systems and smoke detection in corridors and spaces open to the corridor.
Inspection Report
Life Safety
Census: 81
Capacity: 166
Deficiencies: 4
Aug 14, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 Life Safety Code requirements.
Findings
The facility was found not in compliance with Life Safety Code requirements due to deficiencies including hazardous area doors lacking self-closing devices, a smoke detector improperly located near an air supply, obstructed combustion air intake in the laundry room, and improper use of a power strip for high current equipment.
Severity Breakdown
SS=E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| The corridor doors to hazardous storage rooms (e.g., Resident Rooms #308, #806, #807) were not equipped with self-closing devices, potentially affecting residents in smoke compartments. | SS=E |
| A smoke detector was located within 3 feet of an air supply vent, which could prevent proper operation of the detector, affecting 10 residents in one smoke compartment. | SS=E |
| The laundry room's fuel-fired dryers had obstructed outside air vents due to a container of towels, restricting combustion air intake and potentially creating a carbon monoxide hazard for staff. | SS=E |
| A power strip was used to power a room air conditioner (high current draw equipment) in the IT computer room, which is not permitted as a substitute for fixed wiring. | SS=E |
Report Facts
Certified beds: 166
Census: 81
Hazardous rooms with deficient doors: 3
Residents potentially affected by smoke detector issue: 10
Fuel-fired dryers in laundry room: 2
Hazardous rooms with deficient doors in second building: 2
Residents potentially affected by hazardous doors: 6
Inspection Report
Annual Inspection
Census: 83
Capacity: 83
Deficiencies: 9
Jul 29, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00436424, IN00436425, and IN00436426.
Findings
The facility was found deficient in multiple areas including hydration, homelike environment, activities, medication administration, compression stocking use, urinary catheter care, pain management, radiology follow-up, dental services, and documentation of treatments and feeding. Several residents were assessed and corrective actions were implemented with ongoing monitoring plans.
Complaint Details
This visit included the investigation of Complaints IN00436424, IN00436425, and IN00436426. No deficiencies related to the allegations were cited for any of these complaints.
Severity Breakdown
SS=D: 7
SS=E: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to provide fresh fluids and keep fluids within reach for 3 residents. | SS=D |
| Failed to provide a homelike environment for 5 residents. | SS=E |
| Failed to provide in-room self-initiated activities for 1 resident. | SS=D |
| Failed to administer medications as ordered, notify physician of weight gain, clarify medication orders, ensure compression stockings were in place, and follow-up on gastrostomy tube removal for multiple residents. | SS=E |
| Failed to ensure urinary catheter drainage bag and tubing remained free of contact with the floor for 1 resident. | SS=D |
| Failed to routinely assess pain and administer narcotic pain medication for 1 resident. | SS=D |
| Failed to timely follow-up on scheduling a CT scan appointment for 1 resident. | SS=D |
| Failed to ensure a resident was seen for routine dental services. | SS=D |
| Failed to document treatments completed or refused and enteral feeding administered or refused for 1 resident. | SS=D |
Report Facts
Census: 83
Total Capacity: 83
Medicare Census: 2
Medicaid Census: 64
Other Payor Census: 17
Missed doses of tramadol: 4
Weight gain: 7.8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Elwell | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report. |
Inspection Report
Renewal
Deficiencies: 0
Jul 29, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on July 29, 2024.
Findings
Majestic Care of Connersville 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 to the Recertification and State Licensure Survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 27, 2024
Visit Reason
Paper compliance review to the Investigation of Complaints IN00434936, IN00435056, IN00434861, and IN00434793 completed on May 24, 2024.
Findings
Majestic Care of Connersville was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Complaint Investigation.
Complaint Details
Paper compliance review related to multiple complaint investigations completed on May 24, 2024.
Inspection Report
Complaint Investigation
Census: 91
Capacity: 91
Deficiencies: 5
May 21, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints against Majestic Care of Connersville, including allegations related to colostomy care, respiratory care, falls, and care planning.
Findings
The facility was found deficient in several areas including failure to provide dignified colostomy care for one resident, failure to develop a care plan for a resident refusing pulse oximeter use, failure to conduct root cause analysis and implement fall interventions after falls, failure to provide colostomy care consistent with professional standards, and failure to ensure continuous pulse oximeter use for ventilator residents. Corrective actions and education plans were implemented.
Complaint Details
This inspection was triggered by multiple complaints (IN00435184, IN00434936, IN00435056, IN00434946, IN00434861, IN00434805, IN00434793, IN00434801, IN00434811, IN00434481, IN00434106). Deficiencies were substantiated related to complaints IN00434936, IN00435056, IN00434861, and IN00434793. Several complaints had no deficiencies related to allegations.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide colostomy care in a manner to promote dignity for 1 of 3 residents reviewed for colostomy care (Resident G). | SS=D |
| Failed to develop a plan of care for a resident who refused to wear a pulse oximeter for 1 of 3 residents reviewed for respiratory care (Resident J). | SS=D |
| Failed to ensure interdisciplinary team review of post fall event including root cause analysis and implementation of fall interventions for 1 of 3 residents reviewed for accidents (Resident B). | SS=D |
| Failed to provide colostomy services consistent with professional standards for 1 of 3 residents reviewed for colostomy care (Resident G). | SS=D |
| Failed to ensure continuous pulse oximeter use as ordered and failed to notify physician of refusals for 2 of 3 residents reviewed for respiratory care (Resident C and Resident J). | SS=D |
Report Facts
Census: 91
Total Capacity: 91
Medicare Census: 6
Medicaid Census: 65
Other Payor Census: 20
Survey Dates: 2024-05-21 to 2024-05-24
Audit Frequency: 3
Audit Frequency: 3
Audit Frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Elwell | Executive Director | Signed report and involved in corrective action planning |
| CNA 7 | Named in colostomy care deficiency for placing trash bag over resident's stoma | |
| RN 5 | Reported issues with colostomy bags leaking and communicated with Executive Director and Director of Nursing | |
| Director of Nursing Services | DNS | Responsible for care plan implementation and education related to deficiencies |
| Respiratory Therapist 1 | Cared for residents refusing pulse oximeter and reported issues | |
| Respiratory Therapist 8 | Educated on respiratory supplies location and involved in audits | |
| Medical Director | Provided expectations for continuous pulse oximeter use |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 94
Deficiencies: 0
Apr 22, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00431880.
Findings
No deficiencies related to the allegations in Complaint IN00431880 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00431880 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 94
Census Payor Type Medicare: 5
Census Payor Type Medicaid: 72
Census Payor Type Other: 17
Inspection Report
Life Safety
Census: 93
Capacity: 166
Deficiencies: 0
Apr 2, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 02/22/24 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR Life Safety Code survey, Majestic Care of Connersville was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies, and 410 IAC 16.2. The facility was fully sprinkled with fire alarm systems and smoke detection in corridors and spaces open to corridors.
Inspection Report
Complaint Investigation
Census: 93
Capacity: 93
Deficiencies: 0
Mar 27, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00430793 and IN00430883.
Findings
No deficiencies related to the allegations in Complaints IN00430793 and IN00430883 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00430793 and IN00430883 found no deficiencies related to the allegations.
Report Facts
Census: 93
Total Capacity: 93
Medicare Census: 5
Medicaid Census: 77
Other Payor Census: 11
Inspection Report
Renewal
Deficiencies: 0
Mar 19, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Recertification and State Licensure of the facility.
Findings
Majestic Care of Connersville was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding paper compliance for Recertification and State Licensure.
Inspection Report
Life Safety
Census: 90
Capacity: 166
Deficiencies: 3
Feb 22, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of the NFPA 101 Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements, specifically related to corridor doors that failed to latch positively and exit discharge surfaces that were not level and free of obstructions, creating potential safety hazards.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 2 of over 50 corridor doors had no impediment to closing and latching into the door frame and would resist the passage of smoke, affecting 6 staff and 4 residents. | SS=E |
| Failed to ensure 1 of over 8 exit discharges had a level walking surface, free of obstructions, and constructed of hard packed all-weather travel surface, affecting 12 residents and staff. | SS=E |
| Failed to ensure 2 corridor doors in the West Building latched positively into their respective door frames. | SS=E |
Report Facts
Certified beds: 166
Census: 90
Corridor doors inspected: 50
Exit discharges inspected: 8
Affected residents and staff: 10
Affected residents and staff: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Benjamin Meier | Executive Director | Named as Executive Director present during observations and exit conference |
| Maintenance Director | Named as involved in findings and corrective actions related to door latching and exit discharge | |
| Regional Facilities Support Representative | Present during observations and exit conference |
Inspection Report
Annual Inspection
Census: 92
Capacity: 92
Deficiencies: 7
Feb 12, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00423921, IN00427027, and IN00427373.
Findings
The facility was found deficient in several areas including failure to develop comprehensive care plans for blood pressure medications, failure to ensure resident participation in care plan meetings, inadequate ADL care for facial hair grooming, medication administration errors, missing fall prevention interventions, improper labeling and storage of medications, and inaccurate weekly nursing summary assessments.
Complaint Details
This visit included the investigation of Complaints IN00423921, IN00427027, and IN00427373. No deficiencies related to the allegations were cited for any of these complaints.
Severity Breakdown
SS=D: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to develop a care plan for blood pressure medications for a resident with hypertensive heart disease. | SS=D |
| Failed to ensure resident and representative participation in care plan meetings. | SS=D |
| Failed to ensure dependent resident had facial hair groomed to their preferences. | SS=D |
| Failed to administer pain medication according to physician's orders for a resident. | SS=D |
| Failed to ensure fall interventions of nonskid strips were in place for a resident. | SS=D |
| Failed to ensure each medication in the medication cart was appropriately labeled, including directions for use. | SS=D |
| Failed to ensure Weekly Nursing Summary Assessment accuracy for a resident. | SS=D |
Report Facts
Census: 92
Total Capacity: 92
Medication administration error: 162.5
Survey dates: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Benjamin Meier | Executive Director | Signed the inspection report |
| Director of Nurses | Interviewed regarding care plan development, medication administration, and policies | |
| Unit Manager 3 | Interviewed regarding ADL care for Resident 28 | |
| Social Services Designee | Discussed regarding care plan meeting participation and documentation | |
| LPN 3 | Observed medication cart and discussed insulin pen labeling | |
| QMA 4 | Observed medication pass with administration error |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 91
Deficiencies: 0
Dec 7, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00423440.
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 regards to the Investigation of Complaint IN00423440.
Complaint Details
Complaint IN00423440 - No deficiencies related to the allegations are cited.
Report Facts
Census: 91
Total Capacity: 91
Medicare Census: 5
Medicaid Census: 68
Other Payor Census: 18
Inspection Report
Complaint Investigation
Census: 95
Capacity: 95
Deficiencies: 0
Nov 15, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00418009 and IN00420486 at Majestic Care of Connersville.
Findings
No deficiencies related to the allegations in complaints IN00418009 and IN00420486 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00418009 and IN00420486 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Census: 95
Total Capacity: 95
Medicare Census: 5
Medicaid Census: 63
Other Payor Census: 27
Inspection Report
Follow-Up
Census: 96
Capacity: 166
Deficiencies: 0
Oct 13, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 09/07/23.
Findings
At this Post Survey Revisit, Majestic Care of Connersville was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements including 42 CFR 483.73 and 42 CFR 483.90(a). The facility was fully sprinkled with fire alarm systems and smoke detection in corridors and spaces open to the corridor.
Report Facts
Certified beds: 166
Census: 96
Inspection Report
Re-Inspection
Census: 93
Capacity: 93
Deficiencies: 0
Oct 5, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on August 24, 2023, including PSRs to the Investigations of Complaints IN00407259, IN00414446, and IN00415628.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Recertification and State Licensure Survey and the complaint investigations. All cited complaints were corrected.
Complaint Details
This visit included PSRs to the Investigations of Complaint IN00407259, IN00414446, and IN00415628. All complaints were corrected.
Report Facts
Census SNF/NF: 93
Total licensed capacity: 93
Medicare census: 7
Medicaid census: 78
Other census: 8
Inspection Report
Re-Inspection
Census: 93
Capacity: 93
Deficiencies: 0
Oct 5, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00415628 completed on August 24, 2023, conducted in conjunction with the PSR to the Recertification and State Licensure Survey and PSRs to Complaints IN00407259 and IN00414446.
Findings
The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Investigation of Complaint IN00415628. All three complaints referenced were corrected.
Complaint Details
Complaint IN00415628, IN00407259, and IN00414446 were investigated and found to be corrected.
Report Facts
Census Bed Type: 93
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 78
Census Payor Type - Other: 8
Inspection Report
Life Safety
Census: 96
Capacity: 166
Deficiencies: 15
Sep 7, 2023
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 NFPA 101 Life Safety Code. Deficiencies included issues with exit discharge surfaces, hazardous area door self-closures, corridor door latching, smoke barrier integrity, fire door inspections, means of egress obstructions, delayed egress door signage and operation, alcohol-based hand sanitizer placement, fire alarm and sprinkler system policies, portable fire extinguisher signage, electrical outlet covers, fire drills, and electrical equipment power cords.
Severity Breakdown
SS=E: 12
SS=C: 2
SS=F: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Exit discharge surfaces were not level, free of obstructions, or hard packed all-weather travel surfaces at three exits leading to a courtyard. | SS=E |
| Hazardous area door (300 Hall Mechanical Room) lacked a properly working self-closing device. | SS=E |
| Corridor doors in the East and West Buildings failed to latch positively into their frames and resist passage of smoke. | SS=E |
| Smoke barrier walls in the 300 hall had holes allowing passage of smoke. | SS=E |
| Annual inspection and testing documentation for East Building fire door assemblies was incomplete or undated. | SS=E |
| Corridor means of egress were obstructed by carts without wheels. | SS=E |
| Delayed egress doors lacked required signage and some exit doors had incorrect posted codes that did not release locks. | SS=E |
| Alcohol-based hand sanitizer dispensers were installed directly above electrical outlets. | SS=E |
| Fire alarm system out-of-service policy did not include required Indiana State Department of Health Gateway link notification method. | SS=C |
| Sprinkler system lacked two spare sprinklers of every type represented in the facility. | SS=E |
| Sprinkler system out-of-service policy did not include required Indiana State Department of Health Gateway link notification method. | SS=C |
| Portable K Class fire extinguisher in West Building kitchen lacked signage stating the fixed fire protection system must be actuated prior to use. | SS=E |
| Electrical outlet cover in dining hall was broken and did not completely cover the receptacle. | SS=E |
| Fire drills were not conducted on each shift for one quarter (Third Shift First Quarter 2023 drill missing). | SS=F |
| Power strip was used to power high current draw equipment (dorm style refrigerator) instead of direct electrical receptacle. | SS=E |
Report Facts
Certified beds: 166
Census: 96
Deficiencies cited: 15
Fire drills missing: 1
Spare sprinklers: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed and acknowledged findings during survey | |
| Maintenance Director | Interviewed and acknowledged findings during survey |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 93
Deficiencies: 11
Aug 24, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaints IN00407259, IN00414292, IN00414446, and IN00415628.
Findings
The facility was found deficient in multiple areas including resident dignity, honoring advance directives, maintaining a homelike environment, providing appropriate activities, pressure ulcer care, mobility interventions, fall prevention, nutrition monitoring, respiratory care, food safety, and staff licensure compliance.
Complaint Details
Complaints IN00407259, IN00414446, and IN00415628 were substantiated with federal/state deficiencies cited. Complaint IN00414292 was not substantiated due to lack of evidence.
Severity Breakdown
SS=D: 9
SS=E: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Facility failed to ensure dignified environment; staff member was observed cursing near resident rooms. | SS=D |
| Facility failed to honor Resident 14's advance directive for code status. | SS=D |
| Facility failed to ensure a homelike environment due to strong urine odor near Resident G's room. | SS=D |
| Facility failed to ensure activity interventions were available and in use for 3 residents. | SS=D |
| Facility failed to ensure pressure ulcers were assessed on admission, treatments initiated timely, and wound care provider recommendations followed for 2 residents. | SS=D |
| Facility failed to ensure a carrot device was present and care plan reflected utilization of a boot for Resident 82. | SS=D |
| Facility failed to implement fall interventions for Resident K after a fall. | SS=D |
| Facility failed to reweigh Resident 80 after significant weight loss, notify family and physician, and follow up in nutrition risk meeting. | SS=D |
| Facility failed to follow physician order for oxygen therapy and oxygen saturation levels for Resident 44. | SS=D |
| Facility failed to have chlorine sanitizer in dishwasher, cleaning bucket, and third compartment sink. | SS=E |
| Facility allowed a Certified Nursing Assistant (CNA 15) to work with an expired certification. | — |
Report Facts
Census SNF/NF: 93
Total Capacity: 93
Medicaid Census: 70
Other Payor Census: 23
Weight Loss Percentage: 7.98
Weight Loss Percentage: 9.6
CNA 15 Days Worked with Expired Certification: 19
Dishwasher Sanitizer Minimum Chlorine PPM: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mandi Paul | RNC | Signed the report |
| LPN 14 | Licensed Practical Nurse | Involved in CPR initiation for Resident 14 |
| UM 6 | Unit Manager | Observed cursing near resident rooms |
| DON | Director of Nursing | Provided policies and interviews related to multiple deficiencies |
| CNA 5 | Certified Nursing Assistant | Interviewed regarding residents' activity and TV usage |
| CNA 8 | Certified Nursing Assistant | Interviewed regarding fall prevention for Resident K |
| Human Resource Manager | HRM | Responsible for licensure compliance |
| Dietary Manager | DM | Provided kitchen sanitation information |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 93
Deficiencies: 1
Aug 24, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00415628, in conjunction with a Recertification and State Licensure Survey and investigations of Complaints IN00407259, IN00414292, and IN00414446.
Findings
The facility was found to have federal/state deficiencies related to complaints IN00415628, IN00407259, and IN00414446, with no deficiency found for complaint IN00414292. Specifically, the facility failed to implement fall interventions for Resident K, a high fall risk resident, following a fall incident.
Complaint Details
Complaint IN00415628 was substantiated with federal/state deficiencies cited at F689 related to fall interventions. Complaints IN00407259 and IN00414446 also had deficiencies cited. Complaint IN00414292 was not substantiated due to lack of evidence.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to implement fall interventions for Resident K, a high fall risk resident, after a fall incident. | SS=D |
Report Facts
Census: 93
Total Capacity: 93
Medicaid Census: 70
Other Payor Census: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Benjamin Meier | Executive Director | Signed the report |
| DON/Designee | Named in corrective actions and interviews related to fall intervention deficiency | |
| CNA 8 | Interviewed regarding fall intervention for Resident K |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 99
Deficiencies: 0
Jun 29, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00411751.
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 Investigation of Complaint IN00411751.
Complaint Details
Complaint IN00411751 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 99
Total Capacity: 99
Medicare Census: 3
Medicaid Census: 70
Other Payor Census: 26
Inspection Report
Complaint Investigation
Deficiencies: 0
May 30, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00403929 and IN00405361 dated April 12, 2023.
Findings
Majestic Care of Connersville was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding paper compliance to the complaint investigation.
Complaint Details
The visit was complaint-related for complaints IN00403929 and IN00405361. The facility was found to be in compliance with no deficiencies noted.
Inspection Report
Complaint Investigation
Census: 96
Capacity: 96
Deficiencies: 2
Apr 12, 2023
Visit Reason
This visit was for the investigation of complaints IN00403929, IN00405361, and IN00405440 at Majestic Care of Connersville.
Findings
The facility was found deficient in providing adequate activities programming for the advanced memory care unit affecting 18 residents, and failed to maintain a clean, safe, and home-like environment in the dining room and resident rooms on the AMCU.
Complaint Details
Complaint IN00403929 had a federal/state deficiency cited at F921. Complaint IN00405361 had federal/state deficiencies cited at F679 and F921. Complaint IN00405440 had no deficiencies related to the allegations cited.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide activities programming for the facility's advanced memory care unit affecting all 18 residents. | SS=E |
| Failed to ensure the dining room floor was free from spills and food for 7 of 7 residents and a resident's bedroom floor was not clean for 8 of 18 residents on the AMCU. | SS=E |
Report Facts
Residents affected by activities deficiency: 18
Residents affected by environment deficiency: 7
Residents affected by environment deficiency: 8
Total census: 96
Total capacity: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mandi Paul | RNC | Laboratory Director's or Provider/Supplier Representative's signature on report. |
| Resident B | Named in relation to activities deficiency and environmental deficiency findings. | |
| Resident D | Named in relation to activities deficiency findings. | |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding staffing and activities. |
| CNA 4 | Certified Nursing Assistant | Interviewed regarding dining room conditions and floor stickiness. |
| LPN 5 | Licensed Practical Nurse | Interviewed regarding lunch meal service. |
| Housekeeper 6 | Housekeeper | Observed cleaning Resident B's room floor. |
| Activity Director | Interviewed regarding activities programming and staffing. | |
| Memory Care Unit (MCU) Facilitator | Interviewed regarding activities staffing and programming. |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 102
Deficiencies: 1
Mar 13, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00402708, IN00402727, and IN00403638 regarding allegations of abuse at Majestic Care of Connersville.
Findings
The facility failed to follow policies and procedures related to the timely reporting of an allegation of verbal and physical abuse and failed to notify the family of one resident (Resident C) in a timely manner. The abuse allegation was not substantiated, but deficiencies were cited related to abuse prevention and reporting.
Complaint Details
Complaint IN00402727 had federal/state deficiencies related to the allegations cited at F607 and F609. Complaints IN00402708 and IN00403638 had no deficiencies related to the allegations. The investigation involved allegations of verbal and physical abuse by QMA 3 towards Resident C. The facility was unable to substantiate the abuse allegation. CNA 2 failed to report the abuse allegation timely and in a clear manner and was suspended. The family of Resident C was notified of the abuse allegation on or around 1/24/23 by the Memory Care Facilitator, which was delayed.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to follow policies and procedures related to timely reporting of an allegation of verbal and physical abuse and failed to notify the family of Resident C in a timely manner. | SS=D |
Report Facts
Census: 102
Total Capacity: 102
Medicare Census: 7
Medicaid Census: 74
Other Payor Census: 21
Survey Dates: 3
Suspension Date CNA 2: Jan 20, 2023
Return to Work Date CNA 2: Jan 26, 2023
Suspension Date QMA 3: Jan 19, 2023
Termination Date QMA 3: Jan 25, 2023
Plan of Correction Completion Date: Apr 5, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mandi Paul | Regional Nurse Consultant | Signed the report |
| CNA 2 | Named in failure to timely report abuse allegation and related findings | |
| QMA 3 | Named in abuse allegation and related findings | |
| Administrator (ADM) | Facility Administrator involved in abuse investigation and interviews | |
| Assistant Director of Nursing (ADON) | Involved in abuse investigation and interviews | |
| Administrator-in-Training (AIT) | Received texts related to abuse concerns | |
| Memory Care Unit Facilitator | Involved in family notification and abuse investigation | |
| Vice President of Operations (Corporate VP) | Involved in abuse investigation and family communication | |
| Director of Nursing | Provided abuse prevention policy | |
| Corporate Social Services staff | Involved in abuse investigation and interviews |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 13, 2023
Visit Reason
The document addresses paper compliance related to the investigation of a complaint (IN00402727) conducted on March 13, 2023.
Findings
Majestic Care of Connersville was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding paper compliance to the complaint investigation.
Complaint Details
Complaint IN00402727 was investigated with findings indicating compliance; no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 103
Capacity: 103
Deficiencies: 0
Feb 10, 2023
Visit Reason
This visit was conducted for the Investigation of Complaint IN00401391 and included a COVID-19 Focused Infection Control Survey.
Findings
The complaint IN00401391 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant federal and state regulations regarding the complaint and infection control.
Complaint Details
Complaint IN00401391 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census: 103
Total Capacity: 103
Medicare Census: 9
Medicaid Census: 71
Other Payor Census: 15
Inspection Report
Complaint Investigation
Census: 102
Capacity: 102
Deficiencies: 0
Feb 1, 2023
Visit Reason
This visit was conducted for the investigation of four complaints: IN00385032, IN00387546, IN00388918, and IN00393721.
Findings
Three complaints were substantiated but no deficiencies related to the allegations were cited. One complaint was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Complaint IN00385032 - Substantiated with no deficiencies cited. Complaint IN00387546 - Substantiated with no deficiencies cited. Complaint IN00388918 - Substantiated with no deficiencies cited. Complaint IN00393721 - Unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type: 102
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 69
Census Payor Type - Other: 23
Inspection Report
Complaint Investigation
Census: 98
Capacity: 98
Deficiencies: 0
Nov 9, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00393460.
Findings
Complaint IN00393460 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00393460 - Substantiated. No deficiencies related to the allegations are cited.
Report Facts
Census SNF/NF: 98
Total Capacity: 98
Census Payor Type Medicare: 6
Census Payor Type Medicaid: 64
Census Payor Type Other: 28
Inspection Report
Complaint Investigation
Census: 97
Capacity: 97
Deficiencies: 0
Oct 19, 2022
Visit Reason
This visit was conducted for the investigation of two complaints, IN00392017 and IN00392564.
Findings
Both complaints were substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant federal and state regulations regarding the complaints.
Complaint Details
Complaint IN00392017 - Substantiated with no deficiencies cited. Complaint IN00392564 - Substantiated with no deficiencies cited.
Report Facts
Census: 97
Total Capacity: 97
Medicare Census: 6
Medicaid Census: 65
Other Payor Census: 26
Inspection Report
Follow-Up
Census: 100
Capacity: 166
Deficiencies: 0
Aug 30, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 07/18/22.
Findings
At this PSR Emergency Preparedness survey, Majestic Care of Connersville was found in compliance with Emergency Preparedness Requirements. At the PSR Life Safety Code survey, 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.
Report Facts
Certified beds: 166
Census: 100
Inspection Report
Follow-Up
Census: 96
Capacity: 96
Deficiencies: 0
Jul 28, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on June 22, 2022, including a PSR to the Investigation of Complaints IN00383344, IN00382808, IN00382041, and IN00382043.
Findings
Majestic Care of Connersville 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 Recertification and State Licensure Survey and the PSR to the Investigation of the listed complaints.
Complaint Details
Complaints IN00383344, IN00382808, IN00382041, and IN00382043 were investigated and found to be corrected.
Report Facts
Census SNF/NF: 96
Total licensed capacity: 96
Census Payor Type Medicare: 22
Census Payor Type Medicaid: 53
Census Payor Type Other: 21
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