Inspection Report Summary
The most recent inspection on June 26, 2025, found no deficiencies related to the complaint investigated. Earlier inspections generally showed compliance with regulations, though several prior complaint investigations substantiated deficiencies related to medication administration errors, resident abuse, and failure to ensure trauma-informed care. Main themes of deficiencies included medication errors involving double dosing of Clozaril, incidents of resident abuse, and issues with staff communication and care documentation. Substantiated complaints involved medication errors that led to hospitalization and death, as well as abuse incidents resulting in staff suspension or termination; fines or license actions were not listed in the available reports. The facility’s record shows improvement over time, with recent inspections consistently finding no deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 0
Date: Jun 26, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00461486.
Complaint Details
Complaint IN00461486 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with relevant federal and state regulations.
Report Facts
Census: 69
Total Capacity: 69
Medicaid Census: 60
Other Payor Census: 9
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Date: Apr 28, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00457376 and IN00457800.
Complaint Details
Investigation of Complaints IN00457376 and IN00457800 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00457376 and IN00457800 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 68
Census Payor Type - Medicaid: 64
Census Payor Type - Other: 4
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 0
Date: Apr 1, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00455843.
Complaint Details
Complaint IN00455843 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 70
Census Payor Type Medicaid: 68
Census Payor Type Other: 2
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 0
Date: Jan 27, 2025
Visit Reason
This visit was conducted for the investigation of complaint IN00450325.
Complaint Details
Complaint IN00450325 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaint IN00450325 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 70
Total Capacity: 70
Medicaid Census: 68
Other Payor Census: 2
Inspection Report
Census: 69
Capacity: 70
Deficiencies: 0
Date: Jan 16, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
At the Emergency Preparedness survey, the facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the Life Safety Code survey, the facility was found in compliance with Requirements for Participation in Medicare/Medicaid and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Report Facts
Facility capacity: 70
Census: 69
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
The inspection was conducted as an annual survey of Majestic Care of Fort Wayne to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Renewal
Census: 69
Capacity: 69
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey and included the Investigation of Complaint IN00449514.
Complaint Details
Complaint IN00449514 was investigated and no deficiencies related to the allegations were cited.
Findings
Majestic Care of Fort Wayne was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Recertification and State Licensure Survey and the Investigation of Complaint IN00449514. No deficiencies related to the complaint allegations were cited.
Report Facts
Census SNF/NF: 69
Total licensed capacity: 69
Medicaid census: 63
Other payor census: 6
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Date: Dec 4, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00447649 and IN00448085 at Majestic Care of Fort Wayne.
Complaint Details
Investigation of complaints IN00447649 and IN00448085 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00447649 and IN00448085 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 68
Total Capacity: 68
Medicaid Census: 65
Other Payor Census: 3
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 0
Date: Oct 4, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00444017.
Complaint Details
Complaint IN00444017 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 66
Census Payor Type - Medicaid: 62
Census Payor Type - Other: 4
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00440726, IN00440928, and IN00441316.
Complaint Details
Complaint IN00440726, IN00440928, and IN00441316 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with relevant federal and state regulations regarding the complaints investigated.
Report Facts
Census: 66
Total Capacity: 66
Medicaid Census: 59
Other Payor Census: 7
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 5, 2024
Visit Reason
The inspection was conducted in response to an anonymous complaint alleging that Resident K was administered a double dose of medication, which was alleged to have contributed to his death.
Complaint Details
The visit was complaint-related based on an anonymous complaint to the Indiana Department of Health regarding a medication error involving Resident K. The complaint was substantiated as the facility confirmed the medication error and resultant harm.
Findings
The facility failed to ensure that Resident K was free from a significant medication error, resulting in a change of condition and hospitalization. Resident K was erroneously given two doses of Clozaril 150 mg within an hour, leading to lethargy, hospitalization, and subsequent cardiac/respiratory arrest. The facility corrected the deficient practice by in-servicing staff and reviewing medication administration procedures.
Deficiencies (1)
Failed to ensure residents are free from significant medication errors, resulting in actual harm to Resident K due to a double dose of Clozaril.
Report Facts
Medication doses administered: 2
Vital sign monitoring frequency: 2
Duration of medication pass observation monitoring: 6
Number of residents reviewed for medication error: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided timeline of medication administration error. |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner (NP) | Notified of medication error and provided monitoring recommendations. |
| Psychiatrist | Psychiatrist | Interviewed regarding medication error and resident condition. |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 1
Date: Jul 5, 2024
Visit Reason
The visit was conducted as an investigation of Complaint IN00437523 regarding allegations of a significant medication error involving Resident K.
Complaint Details
Complaint IN00437523 was substantiated with a federal/state deficiency cited at F760 related to the medication error that contributed to Resident K's hospitalization and death.
Findings
The facility failed to ensure one of three residents reviewed was free from a significant medication error, specifically Resident K who was erroneously given a double dose of Clozaril within an hour, resulting in a change of condition, hospitalization, and subsequent death.
Deficiencies (1)
Facility failed to ensure Resident K was free from a significant medication error involving administration of a double dose of Clozaril.
Report Facts
Census: 69
Total Capacity: 69
Medication doses given: 2
Vital sign monitoring frequency: 2
Vital sign monitoring frequency: 4
Rounds of epinephrine: 4
Completion monitoring period: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided timeline of medication administration error on 7/5/24 |
| Psychiatrist | Psychiatrist | Interviewed on 7/5/24 regarding medication error and treatment recommendations |
| Psychiatric Nurse Practitioner | Nurse Practitioner | Notified of medication error, communicated with psychiatrist, and provided monitoring recommendations |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 1
Date: Jun 21, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00436120 regarding medication administration errors at the facility.
Complaint Details
Complaint IN00436120 was substantiated with federal/state deficiency cited at F758 related to medication administration errors.
Findings
The facility failed to ensure safe medication administration resulting in a medication error for one resident (Resident E), who was given a double dose of Clozaril 150 mg within a short time frame. The facility implemented a plan of correction including staff re-education and audits to prevent recurrence.
Deficiencies (1)
Failure to ensure safe medication administration resulting in a medication error where Resident E was given a second dose of Clozaril 150 mg shortly after the first dose.
Report Facts
Census: 68
Total Capacity: 68
Medication Dose: 150
Medication Dose: 100
Medication Dose: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 5 | LPN | Interviewed regarding medication administration instructions given to QMA trainee |
| Qualified Medication Aide 4 | QMA | Administered medication and involved in the medication error incident |
| Director of Nursing | DON | Provided orders and communicated with staff regarding medication administration and monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 21, 2024
Visit Reason
The inspection was conducted due to a complaint investigation related to a medication error involving Resident E at Majestic Care of Fort Wayne.
Complaint Details
This citation is related to Complaint IN00436120.
Findings
The facility failed to ensure safe medication administration, resulting in Resident E receiving a double dose of Clozaril 150 mg within a short time frame. The error was self-reported and involved issues with medication order entry and documentation.
Deficiencies (2)
Failure to implement gradual dose reductions and non-pharmacological interventions prior to continuing psychotropic medication; PRN orders for psychotropic medications were not limited as required.
Medication error resulting in Resident E receiving a second dose of Clozaril 150 mg due to the first dose not being signed out.
Report Facts
Medication dose: 150
Date of survey completion: Jun 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 5 | Licensed Practical Nurse | Interviewed regarding medication administration to Resident E |
| Qualified Medication Aide 4 | Qualified Medication Aide | Interviewed regarding administration and documentation of Clozaril to Resident E |
| Director of Nursing | Director of Nursing | Provided information about medication order entry and monitoring after medication error |
| Nurse Practitioner | Nurse Practitioner | Documented update on Clozaril registry and monitoring orders |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Date: May 14, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00434429, IN00434445, and IN00434515.
Complaint Details
Complaints IN00434429, IN00434445, and IN00434515 were investigated with no deficiencies found related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00434429, IN00434445, and IN00434515 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 68
Total Capacity: 68
Medicare Census: 2
Medicaid Census: 57
Other Payor Census: 9
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 0
Date: May 6, 2024
Visit Reason
This visit was conducted for the investigation of four complaints: IN00432957, IN00432985, IN00433267, and IN00433747.
Complaint Details
Complaints IN00432957, IN00432985, IN00433267, and IN00433747 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 67
Total Capacity: 67
Medicare Census: 2
Medicaid Census: 58
Other Payor Census: 7
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Date: Apr 16, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00430158.
Complaint Details
Complaint IN00430158 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 58
Census Payor Type - Other: 8
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Date: Mar 5, 2024
Visit Reason
This visit was conducted for the investigation of complaint IN00427169.
Complaint Details
Complaint IN00427169 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaint IN00427169 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF: 68
Census Payor Type Medicaid: 62
Census Payor Type Other: 6
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 29, 2024
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey conducted on January 11, 2024.
Findings
Majestic Care of Fort Wayne was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 65
Capacity: 70
Deficiencies: 0
Date: Jan 23, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code (LSC) Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
Majestic Care of Fort Wayne was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility is fully sprinklered except for a detached wood shed used for storage of maintenance supplies, and has a fire alarm system with smoke detection in corridors and resident rooms.
Report Facts
Facility capacity: 70
Census: 65
Inspection Report
Annual Inspection
Census: 67
Capacity: 67
Deficiencies: 3
Date: Jan 11, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of multiple complaints (IN00425094, IN00424619, IN00424609, IN423698, and IN00425759).
Complaint Details
Complaint IN00424619 was substantiated with deficiencies cited related to abuse and trauma-informed care. Other complaints (IN00425094, IN00424609, IN423698) had no deficiencies related to the allegations.
Findings
The facility was found to have deficiencies related to abuse of a resident and failure to ensure trauma-informed care for residents with PTSD. Additionally, the facility failed to accurately report nursing hours to the Payroll-Based Journal system for the third quarter of 2023.
Deficiencies (3)
Failed to ensure 1 of 4 residents reviewed were free from abuse; a CNA threw a full cup of ice water on Resident 22.
Failed to ensure residents with trauma had triggers identified for 3 of 3 residents reviewed (Residents 18, 58, and 270).
Failed to ensure accurate reporting to the Payroll-Based Journal system regarding nursing hours for third quarter 2023.
Report Facts
Residents reviewed for abuse: 4
Residents reviewed for trauma-informed care: 3
Resident census: 67
Total licensed capacity: 67
Dates of survey: 5
PBJ reporting failure dates: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Blackburn | Regional Nurse Consultant | Signed the report and involved in investigation |
| CNA 2 | Certified Nurse Assistant | Identified as responsible for abuse incident involving Resident 22; removed and terminated |
| CNA 3 | Certified Nurse Assistant | Terminated for failure to report abuse |
| Executive Director | Interviewed regarding abuse investigation and staff education | |
| Director of Nursing Services | Interviewed regarding abuse incident and reporting | |
| Social Services Director | Interviewed regarding abuse incident and trauma-informed care |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 11, 2024
Visit Reason
The inspection was conducted due to a complaint investigation (Complaint IN00424619) regarding alleged abuse of Resident 22 by a Certified Nurse Assistant (CNA 2).
Complaint Details
The complaint investigation was related to Complaint IN00424619 concerning abuse of Resident 22 by CNA 2. The investigation substantiated the abuse, resulting in termination of CNA 2 and CNA 3 (for failure to report).
Findings
The facility failed to ensure Resident 22 was free from abuse when CNA 2 threw a full cup of ice water on the resident. The investigation included interviews, video footage review, and staff statements. CNA 2 was terminated for abuse and CNA 3 was terminated for failure to report the abuse. Additional findings included failure to identify trauma triggers for three residents and inaccurate reporting of nursing hours to the Payroll-Based Journal system.
Deficiencies (3)
Failed to protect Resident 22 from abuse when CNA 2 threw ice water on the resident.
Failed to ensure residents with trauma had triggers identified for 3 residents (Resident 18, Resident 58, Resident 270).
Failed to accurately report nursing hours to the Payroll-Based Journal system for third quarter 2023.
Report Facts
Residents reviewed for abuse: 4
Residents with trauma triggers not identified: 3
Resident 22 BIMS score: 13
Resident 18 BIMS score: 10
Resident 58 BIMS score: 15
Resident 270 BIMS score: 99
Dates with failure to have licensed nursing coverage 24 hours/day: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nurse Assistant | Named in abuse finding for throwing ice water on Resident 22; terminated for abuse |
| CNA 3 | Certified Nurse Assistant | Failed to report abuse; terminated |
| Executive Director | Conducted investigation and interviews regarding abuse allegation | |
| Regional Consulting Nurse | Participated in investigation and interviews regarding abuse allegation | |
| Director of Nursing Services | Director of Nursing | Interviewed regarding abuse allegation and staffing reporting |
| Social Services Director | Interviewed regarding abuse allegation and trauma care planning |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to an allegation of abuse involving Resident 22 and CNA 2 at Majestic Care of Fort Wayne.
Complaint Details
This citation is related to Complaint IN00424619. The investigation confirmed abuse occurred involving Resident 22 and CNA 2. CNA 2 was terminated for abuse and CNA 3 for failure to report the abuse.
Findings
The facility failed to ensure Resident 22 was free from abuse when CNA 2 threw a full cup of ice water on her. The investigation included interviews, video footage review, and statements from staff and residents. CNA 2 was terminated for the abuse and CNA 3 was terminated for failure to report the abuse.
Deficiencies (1)
Failed to protect Resident 22 from abuse when CNA 2 threw ice water on her.
Report Facts
Residents reviewed: 4
Resident abuse questionnaires completed: 7
Resident 22 BIMS score: 13
Date of incident: Dec 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nurse Assistant | Named in abuse finding for throwing water on Resident 22 |
| CNA 3 | Certified Nurse Assistant | Terminated for failure to report the abuse |
| Executive Director | Conducted investigation and interviews related to abuse allegation | |
| Regional Consulting Nurse | Participated in investigation and interviews related to abuse allegation | |
| Director of Nursing Services | Interviewed regarding knowledge of abuse incident | |
| Social Services Director | Reported staff concerns and spoke with Resident 22 about the abuse |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 0
Date: Jan 11, 2024
Visit Reason
This visit was for Investigation of Complaint IN00425759, conducted in conjunction with a Recertification and State Licensure Survey and investigations of additional complaints IN00425094, IN00424619, IN00424609, and IN00423698.
Complaint Details
Complaint IN00425759 - No deficiencies related to the allegations are cited.
Findings
Majestic Care of Fort Wayne was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Investigation of Complaint IN00425759, with no deficiencies related to the allegations cited.
Report Facts
Census Bed Type: 67
Census Payor Type - Medicaid: 60
Census Payor Type - Other: 7
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Date: Nov 21, 2023
Visit Reason
This visit was conducted to investigate complaints IN00419699, IN00419727, and IN00421945.
Complaint Details
Investigation of complaints IN00419699, IN00419727, and IN00421945 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00419699, IN00419727, and IN00421945 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 68
Total Capacity: 68
Medicare Census: 1
Medicaid Census: 60
Other Payor Census: 7
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 12, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00415764 completed on August 28, 2023.
Complaint Details
Investigation of Complaint IN00415764 completed with paper compliance.
Findings
Majestic Care of Fort Wayne 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 Complaint Investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 28, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to an incident of alleged abuse involving Resident B and a staff member (RN 1) at Majestic Care of Fort Wayne.
Complaint Details
This Federal tag relates to Complaint IN00415764. The complaint involved substantiated abuse by RN 1 against Resident B, confirmed by video evidence and staff interviews.
Findings
The facility substantiated the abuse allegation after reviewing camera footage showing RN 1 slapping Resident B on the cheek. RN 1 was suspended and later terminated. Resident B showed no physical injury or adverse effects and continued normal daily routines. The facility initiated abuse in-servicing for all staff and followed up with psychosocial support for Resident B.
Deficiencies (1)
Facility failed to ensure abuse protocols were implemented for 1 of 3 incidents reviewed involving Resident B.
Report Facts
Date of incident: Aug 22, 2023
Date of investigation completion: Aug 28, 2023
BIMS Score: 9
Resident wandering frequency: 1-3 days
Care Plan Revision Date: Feb 8, 2023
Infraction date: Aug 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Named in abuse incident involving Resident B; suspended and terminated after investigation |
| CNA 2 | Certified Nursing Aide | Witnessed abuse incident and reported it to Administrator and DNS |
| DNS | Director of Nursing Services | Notified RN 1 of suspension and involved in abuse investigation |
| Administrator | Conducted investigation and substantiated abuse after reviewing video | |
| LPN 3 | Licensed Practical Nurse | Witnessed the suspension form signing for RN 1 |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 1
Date: Aug 24, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00414691, IN00415268, and IN00415764. The investigation focused on allegations of abuse involving Resident B and staff.
Complaint Details
Complaint IN00415764 was substantiated with federal deficiencies cited at F600 related to abuse. Complaints IN00414691 and IN00415268 had no deficiencies related to the allegations.
Findings
The facility substantiated abuse by a nurse (RN 1) who slapped Resident B on the cheek after the resident pushed over a computer monitor. RN 1 was suspended and later terminated. The resident showed no injury or psychosocial distress following the incident. The facility implemented staff inservicing on abuse prevention and ongoing monitoring.
Deficiencies (1)
Failure to ensure facility abuse protocols were implemented for 1 of 3 incidents reviewed involving Resident B.
Report Facts
Census: 66
Total Capacity: 66
Medicare Census: 1
Medicaid Census: 59
Other Payor Census: 6
Deficiency Completion Date: Aug 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregg Fuller | Executive Director | Signed the report |
| RN 1 | Registered Nurse | Named in abuse incident involving Resident B; suspended and terminated |
| CNA 2 | Certified Nursing Aide | Witnessed abuse incident and reported it to Administrator |
| DNS | Director of Nursing Services | Notified RN 1 of suspension and participated in investigation |
| LPN 3 | Licensed Practical Nurse | Witnessed suspension form signing |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 0
Date: Jul 26, 2023
Visit Reason
This visit was conducted for the investigation of complaint IN00412985.
Complaint Details
Complaint IN00412985 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicaid residents: 59
Other payor residents: 7
Inspection Report
Complaint Investigation
Census: 65
Capacity: 65
Deficiencies: 0
Date: Jul 14, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00411853 and IN00412827.
Complaint Details
Investigation of Complaints IN00411853 and IN00412827 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00411853 and IN00412827 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF: 65
Total Capacity: 65
Census Payor Type Medicare: 1
Census Payor Type Medicaid: 57
Census Payor Type Other: 7
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 11, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00411119 completed on June 26, 2023.
Complaint Details
Investigation of Complaint IN00411119; paper compliance review completed with findings of compliance.
Findings
Majestic Care of Fort Wayne was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 26, 2023
Visit Reason
The inspection was conducted in response to a complaint investigation regarding Resident B being left unattended in the shower room for several hours after a shift change.
Complaint Details
This Federal tag relates to complaint IN00411119. The complaint involved Resident B being left in the shower room for several hours unattended, which was substantiated by the investigation. The family filed a grievance on 6/12/2023, and corrective actions including staff education and care plan changes were taken. The family was notified and agreed with the resolution.
Findings
The facility failed to ensure Resident B was treated with dignity and respect, as Resident B was left in the shower room for several hours unattended during a staffing change. The investigation revealed staff communication failures and lack of awareness of Resident B's decline since hospice admission. Corrective actions including staff education and care plan revisions were implemented.
Deficiencies (1)
Failed to ensure Resident B was treated with dignity and respect by leaving them unattended in the shower room for several hours after shift change.
Report Facts
Hours Resident B was left in shower room: 4
Date of incident: Jun 8, 2023
Date grievance filed: Jun 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nurse Aide | Named in corrective action forms related to the incident. |
| CNA 5 | Certified Nurse Aide | Assisted Resident B with shower and was scheduled to leave at 8:03 PM; named in corrective action forms. |
| CNA 8 | Certified Nurse Aide | Assisted Resident B in shower room and handed clothes; named in corrective action forms. |
| CNA 9 | Certified Nurse Aide | Reported Resident B came to nurses' station asking for shower; named in corrective action forms. |
| CNA 10 | Certified Nurse Aide | Found Resident B in shower room at midnight; named in corrective action forms. |
| CNA 11 | Certified Nurse Aide | Reported CNA 10 found Resident B in shower room around midnight. |
| CNA 13 | Certified Nurse Aide | Named in corrective action forms related to the incident. |
| Administrator | Reported the incident per policy and provided facility policy and investigation details. | |
| DNS | Director of Nursing Services | Provided information on staff education and reporting of the incident. |
| ADON | Assistant Director of Nursing | Participated in staff education in-service. |
| Unit Manager | Participated in staff education in-service. |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 1
Date: Jun 26, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00411119 and IN00411535. Complaint IN00411119 resulted in federal deficiencies related to the allegations, while complaint IN00411535 had no deficiencies cited.
Complaint Details
Complaint IN00411119 was substantiated with federal deficiencies cited at F557 related to the allegations. Complaint IN00411535 was not substantiated with no deficiencies cited.
Findings
The facility failed to ensure one resident (Resident B) was treated with dignity and respect, as Resident B was left in the shower room for several hours after a shift change. The investigation revealed a breakdown in staff communication and hand-off procedures, resulting in Resident B being unattended in the shower room for approximately four hours. Corrective actions including staff education and revised care plans were implemented.
Deficiencies (1)
Failure to treat Resident B with dignity and respect, including being left in the shower room unattended for several hours after shift change.
Report Facts
Census: 64
Total Capacity: 64
Time Resident Left in Shower: 4
Number of CNAs with Corrective Action: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregg Fuller | Laboratory Director's or Provider/Supplier Representative | Signed the report |
| Unnamed Administrator | Administrator | Provided interviews and information about the incident and investigation |
| DNS | Director of Nursing Services | Provided staff education and interviews regarding the incident and corrective actions |
| ADON | Assistant Director of Nursing | Assisted with staff education |
| CNA 2 | Certified Nurse Aide | Involved in incident, received corrective action |
| CNA 5 | Certified Nurse Aide | Involved in incident, left Resident B unattended in shower, received corrective action |
| CNA 8 | Certified Nurse Aide | Involved in incident, received corrective action |
| CNA 9 | Certified Nurse Aide | Involved in incident, received corrective action |
| CNA 10 | Certified Nurse Aide | Found Resident B unattended in shower room at midnight |
| CNA 11 | Certified Nurse Aide | Reported CNA 10 found Resident B in shower room |
| CNA 13 | Certified Nurse Aide | Received corrective action |
Inspection Report
Original Licensing
Census: 60
Capacity: 66
Deficiencies: 0
Date: Jun 6, 2023
Visit Reason
A preoccupancy survey was conducted for the addition of four beds in rooms 116, 117, 126, and 127, increasing from 1 to 2 beds per room, to ensure compliance with regulatory requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, life safety from fire codes, and the National Fire Protection Association Life Safety Code. The facility is fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Number of beds added: 4
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 0
Date: May 5, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00406427, IN00406444, IN00407467, and IN00407492 at Majestic Care of Fort Wayne.
Complaint Details
Complaints IN00406427, IN00406444, IN00407467, and IN00407492 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type: 64
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 56
Census Payor Type - Other: 4
Inspection Report
Re-Inspection
Census: 63
Capacity: 66
Deficiencies: 0
Date: Mar 7, 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 01/24/23 by the Indiana Department of Health.
Findings
At this PSR survey, Majestic Care of Fort Wayne was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility was fully sprinklered except for a detached wood shed used for storage.
Report Facts
Facility capacity: 66
Census: 63
Inspection Report
Life Safety
Census: 60
Capacity: 66
Deficiencies: 8
Date: Jan 24, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but had multiple deficiencies related to Life Safety Code including failure to conduct required 3-year 4-hour load testing of the emergency generator, failure to replace battery-operated smoke alarms older than 10 years, improper storage in combustible storage rooms, unsecured electrical boxes, blocked laundry room vents, overdue annual fire door inspections, and failure to test non-hospital grade electrical receptacles in resident rooms annually.
Deficiencies (8)
Failed to conduct required 3-year 4-hour load testing of the emergency generator.
Failed to replace 40 of 40 battery-operated smoke alarms in resident rooms that were older than 10 years.
Combustible storage room was not separated by smoke resistant partitions or doors.
One electrical box in the east wing T.V. room was not securely fastened in place.
Laundry room had fuel-fired dryers with fresh air intake blocked by cardboard.
Failed to ensure annual inspection and testing of 2 of 2 fire door assemblies were completed.
Failed to ensure non-hospital grade electrical receptacles at 40 resident sleeping rooms were tested at least annually.
Failed to maintain emergency power standby system with required 4-hour continuous run test within last 36 months.
Report Facts
Facility capacity: 66
Census: 60
Battery-operated smoke alarms: 40
Electrical receptacles: 40
Fire door assemblies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregg Fuller | Administrator | Named in relation to findings and exit conference |
| Maintenance Director | Named in relation to multiple findings and corrective actions | |
| Executive Director | Named in relation to education and oversight of corrective actions |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 23, 2023
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey was completed.
Findings
Majestic Care of Fort Wayne was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 9, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to monitor adverse side effects and effectiveness of medications for certain residents, specifically focusing on pain management and monitoring of insulin and opioid medications.
Complaint Details
The complaint investigation found that the facility failed to monitor adverse side effects and effectiveness of medication for 3 of 8 residents reviewed (Resident 12, Resident 55, and one other). Specific failures included lack of pain level assessments for scheduled pain medications, no monitoring for side effects of opioids, and no monitoring for signs and symptoms of hypoglycemia or hyperglycemia in diabetic residents.
Findings
The facility failed to ensure monitoring of adverse side effects and effectiveness of medications for 3 of 8 residents reviewed, including inadequate pain level assessments and lack of monitoring for side effects of scheduled opioid medications and insulin. Documentation of pain assessments was inconsistent, especially for scheduled pain medications, and monitoring for hypoglycemia and hyperglycemia was insufficient.
Deficiencies (1)
Failure to ensure each resident's drug regimen was free from unnecessary drugs and failure to monitor adverse side effects and effectiveness of medications for residents, including inadequate pain assessment and monitoring for side effects of opioids and insulin.
Report Facts
Residents reviewed: 8
Residents affected: 3
Pain level scores documented: 1
BIMS score: 10
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN2 | Interviewed regarding medication side effect monitoring and pain level documentation | |
| Assistant Director of Nursing (ADON) | Present during interview with RN2 regarding medication monitoring practices | |
| Director of Nursing (DON) | Interviewed regarding medication side effect monitoring and pain level documentation practices |
Inspection Report
Renewal
Census: 63
Capacity: 63
Deficiencies: 1
Date: Jan 9, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on January 3, 4, 5, 6, and 9, 2023.
Findings
The facility failed to ensure adverse side effects and effectiveness of medication were monitored for 3 of 8 residents reviewed, specifically regarding monitoring for hypoglycemia, hyperglycemia, and opioid side effects. Documentation of pain levels for scheduled pain medication was also lacking.
Deficiencies (1)
Failure to monitor adverse side effects and effectiveness of medication for residents, including lack of monitoring for signs and symptoms of hypoglycemia, hyperglycemia, and opioid side effects.
Report Facts
Census: 63
Total Capacity: 63
Medicare Residents: 6
Medicaid Residents: 48
Other Residents: 9
Residents Reviewed: 8
Residents with Monitoring Deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gregg Fuller | Executive Director | Signed the report |
| RN2 | Interviewed regarding medication side effect monitoring and pain level documentation | |
| Director of Nursing | DON | Interviewed regarding medication side effect monitoring and pain level documentation |
| Assistant Director of Nursing | ADON | Present during interview with RN2 regarding pain level documentation |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 0
Date: Nov 17, 2022
Visit Reason
This visit was conducted for the investigation of complaint IN00393821 at Majestic Care of Fort Wayne.
Complaint Details
Complaint IN00393821 was substantiated with no deficiencies identified.
Findings
The complaint investigation was substantiated with no deficiencies found. The facility was found to be in compliance with relevant federal regulations.
Report Facts
Census Bed Type: 60
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 52
Census Payor Type - Other: 7
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 0
Date: Oct 7, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00390174.
Complaint Details
Complaint IN00390174 was investigated and found unsubstantiated due to lack of evidence.
Findings
The complaint IN00390174 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 2
Medicaid census: 52
Other census: 10
Viewing
Loading inspection reports...
