Inspection Reports for Majestic Care of Fort Wayne

This visit was conducted for the investigation of Complaint IN00461486.

No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with relevant federal and state regulations.

Complaint IN00461486 was investigated and found to have no deficiencies related to the allegation.

This visit was conducted for the investigation of complaints IN00457376 and IN00457800.

No deficiencies related to the allegations in complaints IN00457376 and IN00457800 were cited. The facility was found to be in compliance with relevant regulations.

Investigation of Complaints IN00457376 and IN00457800 found no deficiencies related to the allegations.

This visit was for the Investigation of Complaint IN00455843.

No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.

Complaint IN00455843 was investigated and found to have no deficiencies related to the allegation.

This visit was conducted for the investigation of complaint IN00450325.

No deficiencies related to the allegations in complaint IN00450325 were cited. The facility was found to be in compliance with applicable regulations.

Complaint IN00450325 was investigated and found to have no deficiencies related to the allegations.

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).

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.

This visit was for a Recertification and State Licensure Survey and included the Investigation of Complaint IN00449514.

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.

Complaint IN00449514 was investigated and no deficiencies related to the allegations were cited.

This visit was conducted for the investigation of complaints IN00447649 and IN00448085 at Majestic Care of Fort Wayne.

No deficiencies related to the allegations in complaints IN00447649 and IN00448085 were cited. The facility was found to be in compliance with relevant regulations.

Investigation of complaints IN00447649 and IN00448085 found no deficiencies related to the allegations; both complaints were not substantiated.

This visit was conducted for the investigation of Complaint IN00444017.

No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with relevant regulations.

Complaint IN00444017 was investigated and found to have no deficiencies related to the allegation.

This visit was conducted for the investigation of three complaints: IN00440726, IN00440928, and IN00441316.

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.

Complaint IN00440726, IN00440928, and IN00441316 were investigated with no deficiencies cited related to the allegations.

The visit was conducted as an investigation of Complaint IN00437523 regarding allegations of a significant medication error involving Resident K.

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.

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.

This visit was conducted for the investigation of Complaint IN00436120 regarding medication administration errors at the facility.

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.

Complaint IN00436120 was substantiated with federal/state deficiency cited at F758 related to medication administration errors.

This visit was conducted for the investigation of complaints IN00434429, IN00434445, and IN00434515.

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.

Complaints IN00434429, IN00434445, and IN00434515 were investigated with no deficiencies found related to the allegations.

This visit was conducted for the investigation of four complaints: IN00432957, IN00432985, IN00433267, and IN00433747.

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.

Complaints IN00432957, IN00432985, IN00433267, and IN00433747 were investigated and found to have no deficiencies related to the allegations.

This visit was conducted for the investigation of Complaint IN00430158.

No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.

Complaint IN00430158 was investigated and found to have no deficiencies related to the allegation.

This visit was conducted for the investigation of complaint IN00427169.

No deficiencies related to the allegations in complaint IN00427169 were cited. The facility was found to be in compliance with relevant regulations.

Complaint IN00427169 was investigated and found to have no deficiencies related to the allegations.

Paper compliance review to the Annual Recertification and State Licensure survey conducted on January 11, 2024.

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.

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.

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.

This visit was for a Recertification and State Licensure Survey, including the Investigation of multiple complaints (IN00425094, IN00424619, IN00424609, IN423698, and IN00425759).

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.

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.

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.

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.

Complaint IN00425759 - No deficiencies related to the allegations are cited.

This visit was conducted to investigate complaints IN00419699, IN00419727, and IN00421945.

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.

Investigation of complaints IN00419699, IN00419727, and IN00421945 found no deficiencies related to the allegations.

Paper compliance review to the Investigation of Complaint IN00415764 completed on August 28, 2023.

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.

Investigation of Complaint IN00415764 completed with paper compliance.

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.

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.

Complaint IN00415764 was substantiated with federal deficiencies cited at F600 related to abuse. Complaints IN00414691 and IN00415268 had no deficiencies related to the allegations.

This visit was conducted for the investigation of complaint IN00412985.

No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.

Complaint IN00412985 was investigated and found to have no deficiencies related to the allegations.

This visit was conducted for the investigation of complaints IN00411853 and IN00412827.

No deficiencies related to the allegations in complaints IN00411853 and IN00412827 were cited. The facility was found to be in compliance with relevant regulations.

Investigation of Complaints IN00411853 and IN00412827 found no deficiencies related to the allegations.

Paper compliance review to the Investigation of Complaint IN00411119 completed on June 26, 2023.

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.

Investigation of Complaint IN00411119; paper compliance review completed with findings of compliance.

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.

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.

Complaint IN00411119 was substantiated with federal deficiencies cited at F557 related to the allegations. Complaint IN00411535 was not substantiated with no deficiencies cited.

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.

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.

This visit was conducted for the investigation of complaints IN00406427, IN00406444, IN00407467, and IN00407492 at Majestic Care of Fort Wayne.

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.

Complaints IN00406427, IN00406444, IN00407467, and IN00407492 were investigated and found to have no deficiencies related to the allegations.

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.

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.

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.

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.

Paper compliance review to the Annual Recertification and State Licensure survey was completed.

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.

This visit was for a Recertification and State Licensure Survey conducted on January 3, 4, 5, 6, and 9, 2023.

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.

This visit was conducted for the investigation of complaint IN00393821 at Majestic Care of Fort Wayne.

The complaint investigation was substantiated with no deficiencies found. The facility was found to be in compliance with relevant federal regulations.

Complaint IN00393821 was substantiated with no deficiencies identified.

This visit was conducted for the investigation of Complaint IN00390174.

The complaint IN00390174 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.

Complaint IN00390174 was investigated and found unsubstantiated due to lack of evidence.