Inspection Reports for
Majestic Care of Deming Park
3300 POPLAR ST, TERRE HAUTE, IN, 47803
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
15.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
262% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
100% occupied
Based on a April 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 15, 2026
Visit Reason
The inspection was conducted following a complaint and reportable incident involving alleged sexual abuse between two residents at the facility.
Complaint Details
The complaint involved an incident on 12/9/25 where Resident G was found sitting on Resident H's bed with pants down and Resident H's hands near Resident G's vaginal area. Both residents were interviewed and denied concerns. The facility initiated one-to-one supervision and conducted investigations including police involvement. Staff education on abuse and resident rights was completed.
Findings
The facility failed to protect a resident from sexual abuse by another resident. The incident was investigated, and corrective actions including one-to-one supervision, staff education, and ongoing monitoring were implemented. No charges were filed and no other inappropriate behaviors were reported.
Deficiencies (1)
F 0600: The facility failed to protect a resident from sexual abuse by another resident. The deficient practice was corrected prior to the survey with interventions including one-to-one supervision and staff education.
Report Facts
Staff educated on abuse and resident rights: 68
Residents interviewed denying inappropriate touching: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided interviews and statements regarding the incident and corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 12, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of resident-to-resident abuse to the Indiana Department of Health.
Complaint Details
The complaint investigation found that the facility did not notify the Indiana Department of Health within 2 hours of an alleged abuse incident involving Resident B and Resident C. The issue was corrected by 11/3/25 prior to the survey start. The facility implemented staff education, skin assessments, wound care plan audits, and ongoing monitoring.
Findings
The facility failed to report an allegation of resident-to-resident abuse in a timely manner for 2 of 4 residents reviewed. The deficient practice was corrected prior to the survey start date, and a systemic plan including staff education and monitoring was implemented.
Deficiencies (1)
F 0609: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. The facility failed to report an allegation of resident-to-resident abuse to the Indiana Department of Health within the required timeframe.
Report Facts
Residents reviewed for abuse: 4
Residents involved in abuse incident: 2
Date of incident: Oct 8, 2025
Date of correction: Nov 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding the abuse incident and reporting | |
| Interim Administrator | Submitted Facility Reported Incident form | |
| Former Administrator | Involved in delayed reporting of the abuse incident | |
| Director of Nursing | Provided current facility policy on abuse reporting |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 3, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where a confused resident at risk of elopement was able to leave the facility unsupervised, triggering an immediate jeopardy to resident health and safety.
Complaint Details
The complaint investigation was triggered by an incident on 10/11/25-10/12/25 when Resident B, a confused resident with traumatic brain injury and elopement risk, eloped from the facility undetected during the night shift. The facility alarm system failed to alert staff, and staff failed to perform required visual checks. The resident was found approximately 0.6 miles away with hypothermia and abnormal vital signs. Immediate jeopardy was declared on 10/30/25 and removed on 10/31/25 after corrective actions were implemented.
Findings
The facility failed to adequately supervise a resident with traumatic brain injury and elopement risk, resulting in the resident eloping from the facility undetected during the night shift. The WanderGuard alarm system failed to alert staff, and staff did not perform required visual checks. The resident was found outside with hypothermia and abnormal vital signs. Immediate jeopardy was identified but later removed after corrective actions, though noncompliance remained at a lower severity level.
Deficiencies (2)
F 0600: The facility failed to protect a resident from neglect by not visualizing the resident during the night shift, allowing the resident to elope undetected despite wearing a WanderGuard bracelet. The alarm system failed to alert staff, and the resident was found outside with hypothermia and abnormal vitals.
F 0689: The facility failed to provide adequate supervision and maintain a safe environment to prevent accidents, allowing a confused resident at risk of elopement to leave the facility undetected during the night shift. The WanderGuard alarm system and door locking mechanisms were insufficiently effective, and staff did not perform required resident checks every two hours.
Report Facts
Resident elopement distance: 0.6
Resident temperature: 95
Resident heart rate: 115
Resident blood pressure: 188111
Morse Fall Scale score: 65
Elopement risk assessment score: 3
Alarm door open duration: 74
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 25, 2025
Visit Reason
The inspection was conducted in response to Complaint IN00460327 regarding concerns about resident care and compliance with facility policies.
Complaint Details
This citation relates to Complaint IN00460327.
Findings
The facility failed to ensure call lights were kept within reach for one resident, did not provide showers according to resident preferences for three residents, and failed to provide nail care for one resident requiring assistance with activities of daily living.
Deficiencies (3)
F 0558: The facility failed to ensure a resident's call light was kept within reach for 1 of 24 residents reviewed. Observations showed the call light was hanging off the bed and the resident was unsure how to call for assistance.
F 0561: The facility failed to honor resident self-determination by not providing showers according to preferences for 3 of 24 residents reviewed. Records showed discrepancies between scheduled showers and actual care provided.
F 0677: The facility failed to provide nail care for 1 of 24 residents reviewed who required assistance. Observations and records showed untrimmed fingernails with dark debris and lack of documentation of nail care refusals.
Report Facts
Residents reviewed: 24
Showers scheduled: 7
Showers received: 3
Showers refused: 2
Residents affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 7 | Licensed Practical Nurse | Interviewed regarding call light use and nail care |
| Administrator | Administrator | Interviewed regarding call light policy and resident bathing preferences |
| Director of Nursing | Director of Nursing | Interviewed regarding bathing orders and facility policies |
| Certified Nursing Assistant 5 | Certified Nursing Assistant | Interviewed about shower sheet documentation |
| Certified Nursing Assistant 6 | Certified Nursing Assistant | Interviewed about shower and bed bath documentation |
| Unit Manager 7 | Unit Manager | Interviewed about shower scheduling |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Jun 25, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to multiple resident care concerns including call light accessibility, shower preferences, nail care, medication errors, food safety, infection control, and infection preventionist designation.
Complaint Details
This citation relates to Complaint IN00460327. The complaint involved issues with call light accessibility, shower preferences, nail care, medication errors, food safety, infection control, and infection preventionist designation.
Findings
The facility was found deficient in ensuring call lights were kept within reach, resident shower preferences were honored, nail care was provided as needed, medication orders were accurately transcribed, medication labeling was compliant, food safety and sanitation standards were maintained, infection control procedures were followed, and a dedicated infection preventionist was designated.
Deficiencies (8)
F 0558: The facility failed to ensure a resident's call light was kept within reach for 1 of 24 residents reviewed.
F 0561: The facility failed to ensure showers were provided based on resident preferences for 3 of 24 residents reviewed.
F 0677: The facility failed to ensure nail care was provided for a resident requiring assistance with activities of daily living.
F 0756: The facility failed to ensure a physician's order was accurately transcribed from a pharmacy recommendation for 1 of 5 residents reviewed for unnecessary medications.
F 0761: The facility failed to ensure an insulin pen medication was labeled to indicate date opened during 1 of 2 medication cart observations.
F 0812: The facility failed to ensure a sanitary area for handwashing, dishwasher functionality was effectively checked, foods were covered when stored, and foods were discarded once past the best if used by date.
F 0880: The facility failed to ensure infection control procedures were followed to prevent possible contamination of work surfaces during glucometer use.
F 0882: The facility failed to ensure a dedicated Infection Preventionist was designated to oversee the infection prevention program.
Report Facts
Residents reviewed: 24
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents reviewed: 5
Dishwasher temperature: 121.4
Dishwasher chemical concentration: 50
Medication dosage error: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 7 | Licensed Practical Nurse | Named in call light and nail care findings |
| Administrator | Administrator | Provided policies and interviewed regarding call light, shower, nail care, medication, food safety, and infection control |
| Director of Nursing | Director of Nursing | Interviewed regarding call light, shower preferences, medication errors, infection control, and infection preventionist designation |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Observed medication cart and insulin pen labeling deficiency |
| Licensed Practical Nurse 8 | Licensed Practical Nurse | Observed glucometer use and infection control deficiency |
| Registered Nurse 11 | Registered Nurse | Designated Infection Preventionist who stepped down and assisted intermittently |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452240.
Complaint Details
Complaint IN00452240 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00452240 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 11
Medicaid residents: 44
Other residents: 12
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 0
Date: Oct 30, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00445217.
Complaint Details
Complaint IN00445217 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00445217 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 3
Medicaid residents: 50
Other residents: 7
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 20, 2024
Visit Reason
The inspection was conducted in response to complaint IN00439730 regarding the safe transfer of a resident within the nursing home.
Complaint Details
This citation relates to complaint IN00439730. The complaint involved unsafe transfer practices resulting in a resident fall.
Findings
The facility failed to ensure a resident was transferred safely, resulting in a fall involving both the resident and a CNA due to a bed that moved during transfer. Interviews and record reviews revealed inconsistent use of required transfer devices and staff not following transfer protocols.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents. A resident was transferred unsafely, causing a fall due to a bed moving during transfer and lack of proper use of transfer devices and staff assistance.
Report Facts
Documented transfer attempts: 69
Date of MDS assessment: Jul 22, 2024
Date of care plan: Dec 31, 2023
Date of fall incident: Jul 25, 2024
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 1
Date: Aug 20, 2024
Visit Reason
This visit was for the investigation of complaints IN00439953, IN00439730, and IN00439966. Deficiencies related to complaint IN00439730 were cited.
Complaint Details
Complaint IN00439730 was substantiated with federal/state deficiencies cited. Complaints IN00439953 and IN00439966 had no deficiencies related to the allegations.
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.
Deficiencies (1)
Failed to ensure a resident was transferred in a safe manner with appropriate assistance and use of transfer devices.
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
Date: Aug 20, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00439730 completed on August 20, 2024.
Complaint Details
Investigation of Complaint IN00439730; paper compliance review found the facility in compliance.
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.
Inspection Report
Re-Inspection
Census: 62
Capacity: 86
Deficiencies: 0
Date: 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
Date: 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.
Deficiencies (18)
Failed to develop and maintain an emergency preparedness plan reviewed and updated at least annually.
Failed to maintain an emergency preparedness plan based on a documented facility and community-based risk assessment utilizing an all-hazards approach.
Failed to develop and implement emergency preparedness policies and procedures reviewed and updated at least annually.
Failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated at least annually.
Failed to conduct initial and ongoing emergency preparedness training for all staff and volunteers, including documentation and demonstration of staff knowledge.
Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills.
Failed to implement emergency power system inspection, testing, and maintenance requirements including monthly generator load testing and weekly visual inspections.
Failed to ensure battery backup emergency lights were tested monthly and annually for 90 minutes with written records.
Fire alarm control panel displayed incorrect time and date.
Sprinkler head in Physical Therapy restroom had an annular space around it not covered by metallic escutcheon.
Failed to maintain ceiling construction in 200 Hall linen room with missing ceiling tiles exposing attic space.
Failed to maintain sprinkler system inspections and testing documentation including dry pipe sprinkler gauge inspections and control valve inspections.
Sprinkler head in walk-in freezer had a bent deflector.
Failed to ensure annual inspection and testing of at least one fire door assembly.
Failed to ensure all non-hospital grade electrical receptacles at resident bed locations were tested annually.
Failed to ensure weekly emergency generator visual inspection documentation was maintained for all weeks from July 2023 through July 2024.
Used extension cords and multi-plug adapters in patient care vicinity, which is not permitted.
Failed to ensure minimum distance of at least five feet separated combustible materials from oxygen storage equipment.
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
Complaint Investigation
Deficiencies: 7
Date: Jun 7, 2024
Visit Reason
The inspection was conducted based on complaints and concerns regarding resident care, including shower provision, catheter care, respiratory care, dialysis services, medication administration, medication storage, and food safety.
Complaint Details
The visit was complaint-related, triggered by resident and family concerns about shower provision, catheter care, respiratory care, dialysis services, medication errors, medication storage, and food safety. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in honoring resident shower preferences, catheter care and documentation, respiratory assessments and equipment storage, dialysis care and documentation, medication administration errors, expired and unlabeled medications, and food safety practices including temperature logs and expired food handling.
Deficiencies (7)
F 0561: The facility lacked documentation of showers being provided according to resident preferences for 3 of 24 residents reviewed. Shower sheets lacked documentation of showers or refusals for Residents 57, 14, and 11.
F 0690: The facility failed to prevent indwelling urinary catheter bags and tubing from contacting the floor for Resident 56 and failed to document catheter care for Residents 56 and 41 on multiple occasions.
F 0695: The facility failed to complete respiratory assessments prior to nebulizer treatments for Resident 8, failed to ensure proper storage and dating of respiratory equipment for Residents 8, 14, and 54, and failed to obtain a physician order for oxygen administration for Resident 14.
F 0698: The facility failed to provide meals missed during dialysis for Resident 27 and failed to document assessments of the resident's dialysis AV fistula on multiple shifts.
F 0759: The facility failed to ensure proper administration of inhaled medications for Residents 8 and 13, including failure to wait between medications and failure to rinse and spit after corticosteroid inhalers.
F 0761: The facility failed to ensure medications were properly labeled and failed to dispose of expired medications, including an undated opened vial of Aplisol and an expired COVID vaccine for Resident 43.
F 0812: The facility failed to ensure refrigerator temperatures were properly logged and failed to discard expired food, including milk and hard-boiled eggs past their use-by dates.
Report Facts
Medication administration errors: 3
Dialysis frequency: 3
Dates missing temperature logs: 2
Expired medication date: Mar 27, 2024
Inspection Report
Annual Inspection
Census: 59
Capacity: 59
Deficiencies: 7
Date: Jun 7, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00432312 and IN00433238.
Complaint Details
Complaint IN00432312 and IN00433238 were investigated with no deficiencies related to the allegations cited.
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.
Deficiencies (7)
Lack of documentation and provision of showers according to resident preferences for 3 of 24 residents reviewed.
Failure to ensure indwelling urinary catheter bag and tubing were prevented from contact with the floor and catheter care was documented for 2 residents.
Failure to complete respiratory assessment prior to nebulizer treatment, improper storage of respiratory equipment, and lack of physician order for oxygen for 1 resident.
Failure to provide meals missed while at dialysis and lack of documentation of dialysis fistula assessment for 1 resident.
Medication administration errors during inhaled medication pass for 2 residents, including failure to rinse and spit after inhaler use and improper timing between medications.
Failure to properly label medications and dispose of expired medications in medication storage rooms.
Failure to ensure refrigerator temperature logs were up to date and outdated food was discarded in kitchen.
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
Date: 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
Date: 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.
Complaint Details
This visit was related to complaints IN00429213 and IN00429806. Both complaints were corrected.
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.
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
Date: Apr 1, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00430869, IN00430659, and IN00430663.
Complaint Details
Complaints IN00430869, IN00430659, and IN00430663 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 applicable regulations.
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
Deficiencies: 2
Date: Mar 8, 2024
Visit Reason
The inspection was conducted in response to complaints regarding unsafe mechanical lift transfers and inadequate catheter care resulting in resident harm.
Complaint Details
This citation relates to Complaint IN00429213 for mechanical lift transfer issues and Complaint IN00429806 for catheter care and urinary tract infection issues. Immediate jeopardy was identified related to catheter care and was later removed after corrective actions.
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, resulting in immediate jeopardy and the resident's subsequent hospitalization and death.
Deficiencies (2)
F 0689: The facility failed to follow policy and procedure for safe mechanical lift transfer for 1 of 2 residents observed, leaving the resident unattended in the lift pad for approximately 15 minutes without a second staff member present.
F 0690: The facility failed to assess and treat a resident's urinary catheter complications, including failure to notify the physician timely and lack of follow-up with a urologist, resulting in immediate jeopardy to resident health and safety.
Report Facts
Duration resident left unattended in lift pad: 15
Urinary output measurements: 2300
Urinary output measurements: 200
Number of residents reviewed for change in condition: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Observed Resident K unattended in mechanical lift pad and assisted with transfer |
| Therapist 3 | Occupational Therapist | Assisted with mechanical lift transfer of Resident K and confirmed two-person assist policy |
| Director of Nursing Services | Director of Nursing | Provided information on mechanical lift policy and change of condition procedures |
| LPN 13 | Licensed Practical Nurse | Provided care to Resident B, assessed condition, and arranged hospital transfer |
| Certified Nurse Aide 12 | Certified Nurse Aide | Reported use of two-person mechanical lift transfers and catheter care practices |
| Certified Nurse Aide 11 | Certified Nurse Aide | Described catheter care procedures for Resident B |
| NP | Nurse Practitioner | Provided medical orders and assessments for Resident B's hematuria and catheter issues |
| Urologist 18 | Urologist | Saw Resident B twice for catheter changes but was not primary physician |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Date: 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.
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.
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.
Deficiencies (2)
Failure to follow policy and procedure for safe mechanical lift transfer for 1 of 2 residents observed for transfers (Resident K).
Failure to assess and treat a resident's urinary catheter and follow-up on continued hematuria resulting in immediate jeopardy (Resident B).
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
Date: Dec 6, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00418075 and IN00419225.
Complaint Details
Investigation of Complaints IN00418075 and IN00419225 found no deficiencies related to the allegations.
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.
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
Date: 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.
Complaint Details
Complaint IN00410304 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 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
Date: 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.
Complaint Details
Complaint IN00410304 was investigated and no deficiencies related to the allegations were cited.
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.
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
Date: 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
Date: 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.
Deficiencies (10)
Failed to conduct emergency preparedness exercises at least twice per year including unannounced staff drills.
Failed to implement emergency power system inspection, testing, and maintenance requirements; weekly generator testing documentation missing prior to 03/06/23.
Battery powered emergency lights not maintained; 2 of 3 failed to function and no monthly or annual testing documentation.
Hazardous area corridor doors (storage rooms) lacked self-closing devices.
Fire alarm system annual inspection documentation incomplete; no documentation of semi-annual visual inspections; smoke detector sensitivity testing not documented for past 24 months.
Sprinkler system inspection documentation missing for 2 of 4 quarters.
Portable fire extinguisher obstructed and monthly inspections not documented.
Fire drills documentation incomplete for multiple shifts and quarters; missing verification of fire alarm signal transmission.
Generator monthly load testing records incomplete; weekly generator testing documentation missing for 44 of 52 weeks.
Oxygen cylinders not properly secured from falling in storage room.
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
Deficiencies: 6
Date: Apr 6, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home operations, including resident care, safety, medication management, and food service.
Findings
The facility was found to have multiple deficiencies including unsafe hot water temperatures in resident rooms, incomplete and inaccurate care plans for residents, failure to conduct timely care plan meetings, unsafe hot water temperatures causing burn risks, improper medication storage with expired insulin vials and pens, and inadequate food safety practices including missing refrigerator/freezer temperature logs and improper food handling.
Deficiencies (6)
F 0584: The facility failed to ensure comfortable hot water temperatures for 18 of 45 rooms reviewed, with some rooms measuring as low as 85 degrees Fahrenheit.
F 0655: The facility failed to develop a baseline care plan within 48 hours of admission for 1 of 3 new residents, including missing dementia care plan and inaccurate hospice and dialysis services documentation.
F 0657: The facility failed to conduct care plan meetings timely for 1 of 16 residents reviewed, with no documentation of care plan meetings for Resident 27.
F 0689: The facility failed to maintain safe hot water temperatures, with bathroom sinks for 3 residents measuring between 122 and 133 degrees Fahrenheit, posing burn risks.
F 0761: The facility failed to ensure opened insulin vials and an insulin pen were not stored past their expiration date on 2 medication carts reviewed.
F 0812: The facility failed to obtain refrigerator and freezer temperatures for 7 out of 7 logs observed and failed to ensure proper food handling during a dining observation.
Report Facts
Rooms with hot water temperature issues: 18
Residents reviewed for care plan timing: 16
Residents reviewed for accident hazards: 3
Medication carts reviewed: 2
Refrigerator/freezer logs missing temperatures: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator (ADM) | Interviewed regarding hot water temperature issues and maintenance | |
| Maintenance Director | Provided hot water temperature logs and facility policies | |
| Regional Director of Facilities | Interviewed about water temperature issues | |
| Certified Nursing Assistant (CNA) 14 | Interviewed about water temperature delays in resident rooms | |
| Licensed Practical Nurse (LPN) 15 | Interviewed about water temperature issues | |
| Social Services Director (SSD) | Interviewed about care plan documentation and meetings | |
| Director of Nursing (DON) | Provided facility policies and care plan information | |
| Licensed Practical Nurse (LPN) 18 | Interviewed about expired insulin storage | |
| Licensed Practical Nurse (LPN) 19 | Interviewed about insulin pen expiration | |
| Regional Nurse Consultant | Provided medication administration expiration policy | |
| Dietary Manager (DM) | Interviewed about food temperature logs and food handling | |
| Licensed Practical Nurse (LPN) 7 | Observed handling food with bare hands during dining |
Inspection Report
Annual Inspection
Census: 47
Capacity: 47
Deficiencies: 7
Date: 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.
Deficiencies (7)
Failed to ensure comfortable hot water temperatures for 18 of 45 rooms reviewed.
Failed to ensure accuracy of Minimum Data Set (MDS) assessment for 1 of 16 residents reviewed.
Failed to ensure baseline care plan was developed and accurate for 1 of 3 new admission residents.
Failed to ensure care plan meetings were conducted timely for 1 of 16 residents reviewed.
Failed to ensure hot water temperatures were maintained within safe range for 3 of 3 residents reviewed for accidents.
Failed to ensure opened insulin vials and insulin pen were not stored past expiration date and properly labeled.
Failed to obtain refrigerator and freezer temperatures for 7 out of 7 logs and failed to ensure proper food handling during dining observation.
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
Date: Sep 22, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00390047.
Complaint Details
Complaint IN00390047 - Unsubstantiated due to lack of evidence.
Findings
Complaint IN00390047 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
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
Date: Aug 2, 2022
Visit Reason
This visit was for the investigation of Complaint IN00383016.
Complaint Details
Complaint IN00383016 was unsubstantiated due to lack of evidence.
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.
Report Facts
Census: 44
Total Capacity: 44
Medicare Census: 3
Medicaid Census: 23
Other Payor Census: 18
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