Inspection Reports for Majestic Care of Deming Park
3300 POPLAR ST, IN, 47803
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 15, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mixed record with several citations primarily involving emergency preparedness and life safety code compliance, as well as resident care issues such as safe transfer procedures and medication management. A substantiated complaint in August 2024 involved failure to ensure safe resident transfers, while a prior complaint investigation in March 2024 identified immediate jeopardy related to unsafe mechanical lifts and inadequate urinary catheter care, which resulted in resident harm and hospitalization. Most complaint investigations were unsubstantiated or found no deficiencies, and enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed many prior deficiencies, with recent inspections showing compliance and fewer citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
169% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
100% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 0
Apr 15, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452240.
Findings
No deficiencies related to the allegations in Complaint IN00452240 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00452240 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 11
Medicaid residents: 44
Other residents: 12
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 0
Oct 30, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00445217.
Findings
No deficiencies related to the allegations in Complaint IN00445217 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00445217 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 3
Medicaid residents: 50
Other residents: 7
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 1
Aug 20, 2024
Visit Reason
This visit was for the investigation of complaints IN00439953, IN00439730, and IN00439966. Deficiencies related to complaint IN00439730 were cited.
Findings
The facility failed to ensure a resident (Resident C) was transferred in a safe manner, specifically not using the required two-person assistance and pivot device during transfers, and issues with bed locking mechanisms were identified. Staff education and maintenance procedures were planned to address these issues.
Complaint Details
Complaint IN00439730 was substantiated with federal/state deficiencies cited. Complaints IN00439953 and IN00439966 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a resident was transferred in a safe manner with appropriate assistance and use of transfer devices. | SS=D |
Report Facts
Census: 63
Total Capacity: 63
Medicare Census: 8
Medicaid Census: 43
Other Payor Census: 12
Transfer Attempts: 69
2-person Transfers: 41
1-person Transfers: 3
Activity Did Not Occur: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Clevenger | HFA/ED | Signed the report as provider/supplier representative |
| CNA 3 | Interviewed regarding bed locking issues and transfer practices | |
| CNA 4 | Interviewed regarding bed locking issues and transfer practices | |
| Director of Nursing | DON | Provided information on resident transfer status and bed locking concerns |
| Maintenance Director | Interviewed about bed lock repairs and maintenance | |
| Certified Occupational Therapy Assistant | COTA 9 | Provided information on staff training for use of Pivot Disk |
| Administrator | ADM | Interviewed regarding staff transfer procedures and facility policies |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 20, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00439730 completed on August 20, 2024.
Findings
Majestic Care of Deming Park 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 IN00439730; paper compliance review found the facility in compliance.
Inspection Report
Re-Inspection
Census: 62
Capacity: 86
Deficiencies: 0
Aug 13, 2024
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 07/08/24.
Findings
At this PSR survey, Majestic Care of Deming Park was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Certified beds: 86
Census: 62
Inspection Report
Life Safety
Census: 62
Capacity: 86
Deficiencies: 18
Jul 8, 2024
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 multiple Life Safety Code requirements including emergency preparedness plan deficiencies, emergency lighting testing, fire alarm system maintenance, sprinkler system installation and maintenance, fire drills, fire door inspections, electrical system maintenance, and oxygen storage safety.
Severity Breakdown
SS=F: 9
SS=D: 4
SS=E: 3
SS=C: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to develop and maintain an emergency preparedness plan reviewed and updated at least annually. | SS=F |
| Failed to maintain an emergency preparedness plan based on a documented facility and community-based risk assessment utilizing an all-hazards approach. | SS=F |
| Failed to develop and implement emergency preparedness policies and procedures reviewed and updated at least annually. | SS=F |
| Failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated at least annually. | SS=F |
| Failed to conduct initial and ongoing emergency preparedness training for all staff and volunteers, including documentation and demonstration of staff knowledge. | SS=F |
| Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills. | SS=F |
| Failed to implement emergency power system inspection, testing, and maintenance requirements including monthly generator load testing and weekly visual inspections. | SS=F |
| Failed to ensure battery backup emergency lights were tested monthly and annually for 90 minutes with written records. | SS=D |
| Fire alarm control panel displayed incorrect time and date. | SS=C |
| Sprinkler head in Physical Therapy restroom had an annular space around it not covered by metallic escutcheon. | SS=D |
| Failed to maintain ceiling construction in 200 Hall linen room with missing ceiling tiles exposing attic space. | SS=D |
| Failed to maintain sprinkler system inspections and testing documentation including dry pipe sprinkler gauge inspections and control valve inspections. | SS=F |
| Sprinkler head in walk-in freezer had a bent deflector. | SS=F |
| Failed to ensure annual inspection and testing of at least one fire door assembly. | SS=D |
| Failed to ensure all non-hospital grade electrical receptacles at resident bed locations were tested annually. | SS=E |
| Failed to ensure weekly emergency generator visual inspection documentation was maintained for all weeks from July 2023 through July 2024. | SS=F |
| Used extension cords and multi-plug adapters in patient care vicinity, which is not permitted. | SS=E |
| Failed to ensure minimum distance of at least five feet separated combustible materials from oxygen storage equipment. | SS=D |
Report Facts
Certified beds: 86
Census: 62
Fire drills missing: 4
Battery backup lights: 3
Sprinkler heads with annular space: 1
Missing ceiling tiles: 6
Fire door assemblies inspected: 1
Non-hospital grade receptacles: 6
Weekly generator inspections missing: 16
Monthly generator load testing missing: 6
Extension cords observed: 3
Combustible boxes near oxygen cylinders: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Clevenger | Executive Director/HFA | Named in relation to findings and exit conference. |
| Maintenance Director | Named in relation to multiple findings and interviews. |
Inspection Report
Annual Inspection
Census: 59
Capacity: 59
Deficiencies: 7
Jun 7, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00432312 and IN00433238.
Findings
The facility was found deficient in multiple areas including resident self-determination regarding shower preferences, catheter care, respiratory care including nebulizer treatments and oxygen administration, dialysis meal provision and fistula assessment, medication administration errors with inhalers, medication storage and labeling, and food safety practices related to temperature logs and expired food disposal.
Complaint Details
Complaint IN00432312 and IN00433238 were investigated with no deficiencies related to the allegations cited.
Severity Breakdown
Level E: 3
Level D: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Lack of documentation and provision of showers according to resident preferences for 3 of 24 residents reviewed. | Level E |
| Failure to ensure indwelling urinary catheter bag and tubing were prevented from contact with the floor and catheter care was documented for 2 residents. | Level D |
| Failure to complete respiratory assessment prior to nebulizer treatment, improper storage of respiratory equipment, and lack of physician order for oxygen for 1 resident. | Level E |
| Failure to provide meals missed while at dialysis and lack of documentation of dialysis fistula assessment for 1 resident. | Level D |
| Medication administration errors during inhaled medication pass for 2 residents, including failure to rinse and spit after inhaler use and improper timing between medications. | Level D |
| Failure to properly label medications and dispose of expired medications in medication storage rooms. | Level D |
| Failure to ensure refrigerator temperature logs were up to date and outdated food was discarded in kitchen. | Level E |
Report Facts
Survey dates: 5
Census: 59
Medication error rate: 11.54
Residents reviewed for shower preferences: 24
Residents reviewed for catheter care: 2
Residents reviewed for respiratory care: 3
Residents reviewed for dialysis: 1
Medication storage rooms reviewed: 2
Missing temperature log days: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela J. Clevenger | Executive Director/HFA | Signed report |
| Unit Manager 14 | Interviewed regarding shower documentation and catheter care | |
| Registered Nurse 13 | RN | Observed administering nebulizer and inhaled medications |
| Licensed Practical Nurse 11 | LPN | Interviewed regarding medication administration and Aplisol vial |
| Assistant Director of Nursing | ADON | Provided medication and catheter care policies |
| Dietary Manager | Interviewed regarding dialysis meal provision and kitchen temperature logs | |
| Infection Preventionist | IP | Interviewed regarding catheter care and respiratory equipment |
| Nurse Practitioner | NP | Interviewed regarding oxygen orders |
| Director of Nursing Services | DNS | Provided policies and interviewed regarding dialysis and medication storage |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 7, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on June 7, 2024.
Findings
Majestic Care of Deming Park 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
Re-Inspection
Census: 59
Capacity: 59
Deficiencies: 0
Apr 5, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00429213 and IN00429806 completed on March 8, 2024.
Findings
Majestic Care of Deming Park 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 Complaints IN00429213 and IN00429806. Both complaints were corrected.
Complaint Details
This visit was related to complaints IN00429213 and IN00429806. Both complaints were corrected.
Report Facts
Census SNF/NF beds: 59
Census Medicare residents: 5
Census Medicaid residents: 44
Census Other residents: 10
Inspection Report
Complaint Investigation
Census: 58
Capacity: 58
Deficiencies: 0
Apr 1, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00430869, IN00430659, and IN00430663.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00430869, IN00430659, and IN00430663 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 58
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 37
Census Payor Type - Other: 14
Total Census: 58
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Mar 5, 2024
Visit Reason
The visit was conducted for the investigation of complaints IN00429213 and IN00429806, resulting in a Partially Extended Survey due to Substandard Quality of Care with Immediate Jeopardy.
Findings
The facility failed to follow safe mechanical lift transfer procedures for one resident, leaving the resident unattended in a lift pad. Additionally, the facility failed to properly assess and treat a resident's urinary catheter complications and follow-up on continued hematuria, resulting in immediate jeopardy and the resident's subsequent hospitalization and death.
Complaint Details
Complaint IN00429213 related to failure to provide adequate supervision and accident hazard prevention. Complaint IN00429806 related to failure to properly assess and treat urinary catheter complications and follow-up on hematuria, resulting in immediate jeopardy and resident death.
Severity Breakdown
SS=D: 1
SS=J: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow policy and procedure for safe mechanical lift transfer for 1 of 2 residents observed for transfers (Resident K). | SS=D |
| Failure to assess and treat a resident's urinary catheter and follow-up on continued hematuria resulting in immediate jeopardy (Resident B). | SS=J |
Report Facts
Survey dates: March 5, 6, 7, and 8, 2024
Census Bed Type: 61
Resident count: 1
Resident count: 5
Plan of Correction Completion Date: March 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Observed and assisted with mechanical lift transfer of Resident K; acknowledged resident was left unattended in lift pad. |
| CNA 5 | Certified Nurse Aide | Left Resident K unattended in mechanical lift pad during transfer. |
| Therapist 3 | Occupational Therapist | Assisted with mechanical lift transfer of Resident K; confirmed two-person assist policy. |
| DNS | Director of Nursing Services | Provided information on mechanical lift policy and urinary catheter care policies; acknowledged delayed notification of Resident B's condition. |
| LPN 13 | Licensed Practical Nurse | Provided care to Resident B; did not notify physician of condition changes; arranged hospital transfer after family consultation. |
| NP 17 | Nurse Practitioner | Saw Resident B on 2/27/24; documented hematuria and catheter issues; advised on hospital transfer. |
| Urologist 18 | Urologist | Saw Resident B twice for catheter changes; stated Resident B was not his patient and had limited involvement. |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 56
Deficiencies: 0
Dec 6, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00418075 and IN00419225.
Findings
No deficiencies related to the allegations in complaints IN00418075 and IN00419225 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00418075 and IN00419225 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 56
Census total residents: 56
Census Medicare residents: 7
Census Medicaid residents: 39
Census other payor residents: 10
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 0
Jun 22, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00410304 and was conducted in conjunction with a Post Survey Revisit to the Recertification and State Licensure Survey completed on April 6, 2023.
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.
Complaint Details
Complaint IN00410304 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 51
Census Payor Type Medicare: 7
Census Payor Type Medicaid: 30
Census Payor Type Other: 14
Inspection Report
Re-Inspection
Census: 50
Capacity: 50
Deficiencies: 0
Jun 22, 2023
Visit Reason
This visit was for a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on April 6, 2023, and was conducted in conjunction with the Investigation of Complaint IN00410304.
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 PSR to the Recertification and State Licensure Survey.
Complaint Details
Complaint IN00410304 was investigated and no deficiencies related to the allegations were cited.
Report Facts
Census: 50
Total Capacity: 50
Medicare Census: 7
Medicaid Census: 29
Other Payor Census: 14
Inspection Report
Re-Inspection
Census: 50
Capacity: 86
Deficiencies: 0
Jun 22, 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 05/01/23.
Findings
At this PSR survey, Majestic Care of Deming Park was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Life Safety
Census: 47
Capacity: 86
Deficiencies: 10
May 1, 2023
Visit Reason
An Emergency Preparedness and Life Safety Code survey was conducted to assess compliance with Medicare and Medicaid participation requirements, including emergency preparedness exercises, generator testing, fire safety, and facility maintenance.
Findings
The facility was found not in compliance with emergency preparedness exercise requirements, generator testing and maintenance, emergency lighting, fire alarm system testing and documentation, sprinkler system inspections, portable fire extinguisher accessibility and inspections, fire drills documentation, hazardous area door self-closing mechanisms, and oxygen cylinder storage safety.
Severity Breakdown
SS=C: 1
SS=D: 2
SS=E: 1
SS=F: 6
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to conduct emergency preparedness exercises at least twice per year including unannounced staff drills. | SS=C |
| Failed to implement emergency power system inspection, testing, and maintenance requirements; weekly generator testing documentation missing prior to 03/06/23. | SS=F |
| Battery powered emergency lights not maintained; 2 of 3 failed to function and no monthly or annual testing documentation. | SS=D |
| Hazardous area corridor doors (storage rooms) lacked self-closing devices. | SS=E |
| Fire alarm system annual inspection documentation incomplete; no documentation of semi-annual visual inspections; smoke detector sensitivity testing not documented for past 24 months. | SS=F |
| Sprinkler system inspection documentation missing for 2 of 4 quarters. | SS=F |
| Portable fire extinguisher obstructed and monthly inspections not documented. | SS=F |
| Fire drills documentation incomplete for multiple shifts and quarters; missing verification of fire alarm signal transmission. | SS=F |
| Generator monthly load testing records incomplete; weekly generator testing documentation missing for 44 of 52 weeks. | SS=F |
| Oxygen cylinders not properly secured from falling in storage room. | SS=D |
Report Facts
Certified beds: 86
Census: 47
Deficiencies cited: 10
Fire extinguishers inspected: 20
Oxygen cylinders: 47
Battery powered emergency lights: 3
Fire drills missing documentation: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Clevenger | Maintenance Director | Named in relation to findings on emergency preparedness exercises, generator testing, emergency lighting, fire alarm system, sprinkler system, fire drills, and oxygen cylinder storage |
| Unknown Executive Director | Executive Director | Mentioned in exit conferences and plan of correction discussions |
Inspection Report
Annual Inspection
Census: 47
Capacity: 47
Deficiencies: 7
Apr 6, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 31 to April 6, 2023.
Findings
The facility was found deficient in several areas including unsafe hot water temperatures in multiple resident rooms, inaccurate Minimum Data Set (MDS) assessments, incomplete baseline care plans, failure to conduct timely care plan meetings, unsafe hot water temperatures posing accident hazards, improper labeling and storage of insulin medications, and inadequate food safety practices including incomplete temperature logs and improper food handling.
Severity Breakdown
SS=E: 2
SS=A: 1
SS=D: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure comfortable hot water temperatures for 18 of 45 rooms reviewed. | SS=E |
| Failed to ensure accuracy of Minimum Data Set (MDS) assessment for 1 of 16 residents reviewed. | SS=A |
| Failed to ensure baseline care plan was developed and accurate for 1 of 3 new admission residents. | SS=D |
| Failed to ensure care plan meetings were conducted timely for 1 of 16 residents reviewed. | SS=D |
| Failed to ensure hot water temperatures were maintained within safe range for 3 of 3 residents reviewed for accidents. | SS=E |
| Failed to ensure opened insulin vials and insulin pen were not stored past expiration date and properly labeled. | SS=D |
| Failed to obtain refrigerator and freezer temperatures for 7 out of 7 logs and failed to ensure proper food handling during dining observation. | SS=D |
Report Facts
Residents affected by hot water temperature deficiency: 18
Total census: 47
Total capacity: 47
Number of MDS assessments reviewed: 16
Number of new admission care plans reviewed: 3
Number of residents reviewed for care plan meetings: 16
Number of residents reviewed for accident hazards: 3
Number of medication carts reviewed: 2
Number of refrigerator/freezer logs missing temperatures: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Clevenger | Executive Director | Signed the report and involved in facility administration. |
| LPN 18 | Licensed Practical Nurse | Provided information about insulin vial and pen expiration and labeling. |
| LPN 19 | Licensed Practical Nurse | Provided information about insulin pen expiration date. |
| Maintenance Director | Performed water temperature checks and educated on safe water temperatures. | |
| Administrator | Administrator (ADM) | Interviewed about water temperature issues and maintenance actions. |
| Social Services Director | Social Services Director (SSD) | Interviewed about care plan meetings and resident involvement. |
| Dietary Manager | Dietary Manager (DM) | Interviewed about refrigerator/freezer temperature logs and food handling. |
| LPN 7 | Licensed Practical Nurse | Observed improperly handling food with bare hands during dining service. |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 42
Deficiencies: 0
Sep 22, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00390047.
Findings
Complaint IN00390047 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00390047 - Unsubstantiated due to lack of evidence.
Report Facts
Census: 42
Total Capacity: 42
Medicare Residents: 6
Medicaid Residents: 21
Other Payor Residents: 15
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 0
Aug 2, 2022
Visit Reason
This visit was for the investigation of Complaint IN00383016.
Findings
The complaint IN00383016 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.
Complaint Details
Complaint IN00383016 was unsubstantiated due to lack of evidence.
Report Facts
Census: 44
Total Capacity: 44
Medicare Census: 3
Medicaid Census: 23
Other Payor Census: 18
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