Inspection Reports for Majestic Care of New Haven
1201 DALY DRIVE, IN, 46774
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 11, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving emergency preparedness, life safety code compliance, medication labeling, resident supervision during smoking, and some issues with resident care and environmental cleanliness. Several complaint investigations were substantiated with related deficiencies, including failure to supervise residents properly, medication administration errors, and inadequate behavioral management plans. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, with recent follow-up surveys showing compliance and correction of previously cited issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
305% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 65
Capacity: 65
Deficiencies: 0
Jun 11, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00460510.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00460510 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 65
Census total residents: 65
Census Medicare residents: 1
Census Medicaid residents: 40
Census Other payor residents: 24
Inspection Report
Follow-Up
Census: 70
Capacity: 120
Deficiencies: 0
May 20, 2025
Visit Reason
This was a Post Survey Revisit (PSR) to the Emergency Preparedness Survey conducted on 03/05/25 and the first PSR conducted on 04/02/25, conducted in conjunction with the Life Safety Code Complaint PSR that exited on 05/20/25.
Findings
At this PSR survey, Majestic Care of New Haven was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered except for a detached building housing the emergency generator and used for storage of maintenance equipment.
Report Facts
Facility capacity: 120
Census: 70
Inspection Report
Follow-Up
Census: 70
Capacity: 120
Deficiencies: 0
May 20, 2025
Visit Reason
This was a Post Survey Revisit (PSR) to the investigation of Complaint Number IN00456495 conducted on 04/02/25, conducted in conjunction with the Life Safety Code Recertification PSR.
Findings
At this PSR survey, Majestic Care of Haven Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for a detached building housing the emergency generator and maintenance equipment storage.
Complaint Details
Complaint Number IN00456495 was investigated and found corrected at this revisit.
Report Facts
Facility capacity: 120
Census: 70
Inspection Report
Complaint Investigation
Census: 70
Capacity: 120
Deficiencies: 1
Apr 2, 2025
Visit Reason
The inspection was conducted as an investigation of Complaint Number IN00456495 by the Indiana Department of Health in accordance with 42 CFR 483.90(a), in conjunction with the Life Safety Code Recertification Post Survey Revisit.
Findings
The facility was found not in compliance with Medicare/Medicaid participation requirements related to smoking policy procedures. Specifically, the facility failed to ensure proper supervision of a resident who smokes, resulting in a smoking-related incident with smoke detected in a resident's room. No damage was found, but the resident was not properly supervised during the smoke break.
Complaint Details
Complaint Number IN00456495 was substantiated with a federal/state deficiency cited at K741 related to failure to properly supervise a resident during smoking, resulting in smoke in the resident's room.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to follow smoking policy procedures to ensure residents requiring staff supervision were properly and safely supervised during smoking. | SS=F |
Report Facts
Facility capacity: 120
Census: 70
Deficiency cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lorri Maples | Administrator | Named in relation to the smoking incident and exit conference |
Inspection Report
Life Safety
Census: 69
Capacity: 120
Deficiencies: 6
Mar 5, 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 on 03/05/2025 to assess compliance with emergency preparedness and life safety code requirements.
Findings
The facility was found in substantial compliance with Emergency Preparedness requirements but failed to conduct annual staff knowledge demonstration for emergency preparedness training. Life Safety Code survey found multiple deficiencies including failure to maintain latching hardware on smoke barrier doors, improper delayed egress locking arrangements, inaccessible courtyard exit doors, improper disposal of cigarette butts in smoking areas, and combustible decorations exceeding allowed limits on corridor doors.
Severity Breakdown
SS=C: 1
SS=E: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to conduct annual training and testing for Emergency Preparedness Program including staff knowledge demonstration. | SS=C |
| Failed to maintain latching hardware on 1 of 5 smoke barrier doors, which did not latch properly. | SS=E |
| Failed to ensure 1 of 6 delayed egress locking arrangements were installed and functioning according to code. | SS=E |
| Failed to ensure means of egress through 1 of 2 courtyard exit doors were readily accessible; code not posted and padlock malfunctioned. | SS=E |
| Failed to ensure 1 of 3 smoking areas maintained by disposing cigarette butts in a metal or noncombustible container with self-closing cover devices. | SS=E |
| Failed to ensure 1 of 9 corridor doors covered by combustible decorations exceeding 30% of the door surface. | SS=E |
Report Facts
Facility capacity: 120
Census: 69
Residents potentially affected by smoke barrier door deficiency: 30
Residents potentially affected by courtyard exit door deficiency: 40
Residents potentially affected by combustible decoration deficiency: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lorri Maples | Administrator | Named in relation to findings and exit conference |
| Maintenance Director | Named in relation to findings and exit conference but no full name provided |
Inspection Report
Life Safety
Census: 69
Capacity: 120
Deficiencies: 6
Mar 5, 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 on 03/05/2025 to assess compliance with emergency preparedness and life safety code requirements.
Findings
The facility was found in substantial compliance with Emergency Preparedness requirements but failed to conduct annual staff training with documented knowledge demonstration. Life Safety Code deficiencies included failure to maintain latching hardware on smoke barrier doors, improper delayed egress locking arrangements, inaccessible courtyard exit doors, improper disposal of cigarette butts in smoking areas, and combustible decorations covering corridor doors.
Severity Breakdown
SS=C: 1
SS=E: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to conduct annual training and testing for the Emergency Preparedness Program including staff knowledge demonstration. | SS=C |
| Failed to maintain latching hardware on 1 of 5 smoke barrier doors, which did not latch properly. | SS=E |
| Failed to ensure 1 of 6 delayed egress locking arrangements operated correctly; delayed egress on front door not working. | SS=E |
| Failed to ensure means of egress through 1 of 2 courtyard exit doors were readily accessible; courtyard gate lock malfunctioned. | SS=E |
| Failed to ensure 1 of 3 smoking areas had cigarette butts disposed in a metal or noncombustible container with self-closing cover. | SS=E |
| Failed to ensure 1 of 9 corridor doors was not covered by combustible decorations exceeding 30% of the door area. | SS=E |
Report Facts
Facility capacity: 120
Census: 69
Residents potentially affected: 30
Residents potentially affected: 40
Residents potentially affected: 30
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Feb 27, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00453482 and IN00454391.
Findings
No deficiencies related to the allegations in complaints IN00453482 and IN00454391 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00453482 and IN00454391 found no deficiencies related to the allegations.
Report Facts
Census Bed Type: 68
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 45
Census Payor Type - Other: 22
Total Census: 68
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 0
Feb 12, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00453280.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00453280 found no deficiencies related to the allegations.
Report Facts
Medicare census: 1
Medicaid census: 48
Other payor census: 21
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 7, 2025
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey conducted on January 27, 2025.
Findings
Majestic Care of New Haven 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
Renewal
Census: 71
Capacity: 71
Deficiencies: 1
Jan 21, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from January 21 to January 27, 2025.
Findings
The facility failed to ensure proper labeling of opened medications on one of two medication carts reviewed, specifically inhalers for Residents 55, 9, and 49. Expired and unlabeled inhalers were found, and corrective actions were implemented including destruction of expired inhalers and staff education.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure labeling of opened medications on 1 of 2 medication carts reviewed, including expired inhalers for Residents 55, 9, and 49. | SS=D |
Report Facts
Census: 71
Total Capacity: 71
Medicaid Census: 56
Other Payor Census: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alesha Lucas | RN, DNS | Named as Director of Nursing involved in interview and corrective action plan |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Jan 9, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00449434, IN00450551, and IN00450683.
Findings
No deficiencies related to the allegations in complaints IN00449434, IN00450551, and IN00450683 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00449434, IN00450551, and IN00450683 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 72
Total Capacity: 72
Census Payor Type - Medicaid: 53
Census Payor Type - Other: 19
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 0
Nov 8, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00445939 and IN00446824.
Findings
No deficiencies related to the allegations in complaints IN00445939 and IN00446824 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00445939 and Complaint IN00446824 were investigated; no deficiencies related to the allegations were found.
Report Facts
Census Bed Type: 73
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 55
Census Payor Type - Other: 12
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Oct 23, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00445713.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00445713 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 76
Total Capacity: 76
Medicaid Census: 59
Other Payor Census: 17
Medicare Census: 0
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Oct 7, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00442423.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00442423 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 3
Medicaid census: 57
Other payor census: 15
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 0
Aug 29, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00440774 and IN00440985 at Majestic Care of New Haven.
Findings
No deficiencies related to the allegations in complaints IN00440774 and IN00440985 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00440774 and IN00440985 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Census Bed Type: 71
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 55
Census Payor Type - Other: 15
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Jul 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437886.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00437886 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 2
Medicaid residents: 49
Other residents: 23
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 2
Jun 14, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00433504, IN00434551, IN00435108, IN00436439, IN00436491, IN00436501, and IN00436524) concerning the facility.
Findings
The facility was found deficient in ensuring proper assessment and care planning for a resident with a contagious condition (head lice), and in the appropriate use and documentation of psychotropic medications for residents. Specific deficiencies included failure to implement isolation protocols and treatment plans for head lice, and failure to ensure psychotropic medications were given with targeted behaviors identified and non-pharmacological interventions in place.
Complaint Details
The investigation was triggered by complaints IN00433504, IN00434551, IN00435108, IN00436439, IN00436491, IN00436501, and IN00436524. Some complaints resulted in deficiencies cited, while others did not. Deficiencies related to complaints IN00434551, IN00436439, IN00436491, and IN00436524 were cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a resident with a known contagious condition (head lice) was assessed and care planned. | SS=D |
| Failure to ensure residents were not given psychotropic medications without specific targeted behaviors identified and non-pharmacological interventions in place. | SS=D |
Report Facts
Census: 79
Total Capacity: 79
Survey Dates: 3
Psychotropic Medication Stop Date: 14
Haloperidol Dose: 5
Trazodone Dose: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident E | Resident with head lice infection | Subject of deficiency related to infection control and care planning |
| Resident D | Resident with psychotropic medication issues | Subject of deficiency related to psychotropic medication use without targeted behaviors |
| Resident J | Resident with psychotropic medication issues | Subject of deficiency related to psychotropic medication use without targeted behaviors |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding Resident E's care and isolation orders |
| Licensed Practical Nurse 2 | LPN | Interviewed regarding Resident E and Resident J's care |
| Nurse Practitioner 3 | NP | Provided treatment and assessments for Resident E |
| Nurse Practitioner 4 | NP | Provided treatment and assessments for Resident E |
| Nurse Practitioner 5 | NP | Provided treatment and assessments for Resident E |
| Social Services Director | SSD | Interviewed regarding behavior documentation and psychotropic medication monitoring |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 14, 2024
Visit Reason
Paper compliance review to the Investigation of Complaints IN00434551, IN00436439, IN00436524, and IN00436691.
Findings
Majestic Care of New Haven 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.
Complaint Details
Investigation of Complaints IN00434551, IN00436439, IN00436524, and IN00436691 completed on June 14, 2024; facility found in compliance.
Inspection Report
Re-Inspection
Census: 88
Capacity: 120
Deficiencies: 0
May 16, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 04/16/2024.
Findings
At this PSR survey, Majestic Care of New Haven was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered except for a detached building housing the emergency generator and maintenance equipment storage.
Report Facts
Facility capacity: 120
Census: 88
Inspection Report
Routine
Census: 88
Capacity: 120
Deficiencies: 12
Apr 16, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with Medicare and Medicaid participation requirements and fire safety codes.
Findings
The facility was found not in compliance with Emergency Preparedness training and testing requirements, life safety code door egress and locking arrangements, fire door inspections, sprinkler head maintenance, electrical safety, fire drills, smoking area safety, and oxygen cylinder storage. Corrective actions were initiated for each deficiency.
Severity Breakdown
SS=F: 5
SS=E: 7
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to conduct annual Emergency Preparedness training and demonstrate staff knowledge. | SS=F |
| Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills. | SS=F |
| Failed to ensure means of egress doors were readily accessible and properly marked with codes and signage. | SS=E |
| Failed to maintain latching hardware on smoke barrier doors. | SS=E |
| Failed to replace sprinkler heads showing signs of lint loading and corrosion. | SS=E |
| Housekeeping corridor door was propped open, impeding proper closure and smoke resistance. | SS=E |
| Failed to maintain electrical junction box cover with exposed wiring. | SS=E |
| Failed to conduct fire drills on each shift for 2 of 4 quarters. | SS=F |
| Failed to provide metal or noncombustible containers with self-closing covers in smoking areas. | SS=E |
| Failed to complete annual inspection and testing of fire door assemblies. | SS=F |
| Failed to ensure power strips and extension cords were not used as substitutes for fixed wiring. | SS=E |
| Failed to separate and mark full and empty oxygen cylinders to avoid confusion. | SS=E |
Report Facts
Facility capacity: 120
Census: 88
Fire door assemblies inspected: 5
Fire drills missing: 2
Sprinkler heads needing replacement: 2
Oxygen cylinders unmarked: 25
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Mar 27, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00430364.
Findings
No deficiencies related to the allegations in Complaint IN00430364 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00430364 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 57
Census Payor Type - Other: 16
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 27, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Majestic Care of New Haven 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
Annual Inspection
Census: 83
Capacity: 83
Deficiencies: 8
Mar 8, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of three complaints (IN00429186, IN00429187, IN00429228).
Findings
The facility was found deficient in several areas including management of resident personal funds, failure to follow physician orders, inadequate RN coverage, improper medication labeling and storage, sanitation and infection control practices, and incomplete COVID-19 vaccination documentation and administration.
Complaint Details
The visit included investigation of complaints IN00429186, IN00429187, and IN00429228. No deficiencies related to the allegations in these complaints were cited.
Severity Breakdown
SS=D: 3
SS=E: 5
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure monies available to residents were accessed and paid properly for 2 of 3 residents reviewed. | SS=D |
| Failed to ensure physician orders were followed for 1 of 3 residents reviewed (daily weights not obtained or documented). | SS=D |
| Failed to ensure a Registered Nurse was onsite for an 8 hour shift 5 days of 90 reviewed. | SS=E |
| Failed to ensure medications were dated when opened for 4 of 21 residents reviewed. | SS=D |
| Failed to ensure 2 out of 2 garbage receptacles in kitchen were covered. | SS=E |
| Failed to implement a compliance program to ensure prior identified medication labeling was compliant. | SS=E |
| Failed to ensure masking, hand hygiene, and equipment disinfection practices were implemented and maintained. | SS=E |
| Failed to ensure COVID-19 immunizations were provided to 4 of 5 residents reviewed. | SS=E |
Report Facts
Residents reviewed for personal funds management: 3
Residents reviewed for physician order compliance: 3
Residents reviewed for medication labeling: 21
Residents residing in facility: 83
Residents reviewed for COVID-19 immunization: 5
RN coverage missing days: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| R. Shane McFall | Executive Director | Signed the report. |
| RN 3 | Interviewed regarding undated insulin vials and medication handling. | |
| Business Office Manager (BOM) | Interviewed regarding resident funds management and VA benefits. | |
| Director of Nursing (DON) | Interviewed regarding daily weights, infection control, and COVID-19 vaccination. | |
| Qualified Medication Aide (QMA) 5 | Observed and interviewed regarding glucometer sanitation and infection control practices. | |
| Regional Nurse | Provided policy and interviewed regarding infection control and medication labeling. |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 86
Deficiencies: 0
Jan 16, 2024
Visit Reason
This visit was for the investigation of complaints IN00424696 and IN00424931.
Findings
No deficiencies related to the allegations in complaints IN00424696 and IN00424931 were cited. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Investigation of complaints IN00424696 and IN00424931 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Census SNF/NF beds: 86
Census total residents: 86
Census Medicare residents: 3
Census Medicaid residents: 56
Census other payor residents: 27
Inspection Report
Complaint Investigation
Census: 86
Capacity: 86
Deficiencies: 0
Dec 18, 2023
Visit Reason
This visit was conducted for the investigation of three complaints: IN00421894, IN00422523, and IN00423773.
Findings
No deficiencies related to the allegations in complaints IN00421894, IN00422523, and IN00423773 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00421894, IN00422523, and IN00423773 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 86
Total Capacity: 86
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 61
Census Payor Type - Other: 18
Inspection Report
Complaint Investigation
Census: 86
Capacity: 86
Deficiencies: 0
Oct 31, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420377.
Findings
No Federal or State deficiencies related to the complaint allegations were cited. The facility was found to be compliant with relevant regulations.
Complaint Details
Investigation of Complaint IN00420377 found no deficiencies related to the allegations.
Report Facts
Census Bed Type: 86
Medicare Census: 1
Medicaid Census: 68
Other Payor Census: 17
Inspection Report
Complaint Investigation
Census: 86
Capacity: 86
Deficiencies: 0
Oct 13, 2023
Visit Reason
This visit was conducted for the investigation of four complaints: IN00417444, IN00417917, IN00419012, and IN00419160.
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.
Complaint Details
Complaints IN00417444, IN00417917, IN00419012, and IN00419160 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 86
Total Capacity: 86
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 65
Census Payor Type - Other: 18
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 2, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00416168 completed on August 31, 2023.
Findings
Majestic Care of New Haven 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.
Complaint Details
Investigation of Complaint IN00416168 completed on August 31, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 87
Capacity: 87
Deficiencies: 1
Aug 31, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00415204 and IN00416168. No deficiencies were found related to complaint IN00415204, while federal and state deficiencies related to complaint IN00416168 were cited.
Findings
The facility failed to ensure one of three residents reviewed was free from misappropriation of property. A Certified Nursing Aide (CNA 2) was found in possession of a resident's credit card after the resident had been discharged. The incident was reported to local law enforcement and the card issuer, with corrective actions including staff education and ongoing audits to prevent recurrence.
Complaint Details
Complaint IN00416168 was substantiated with federal/state deficiencies cited. Complaint IN00415204 had no deficiencies related to the allegation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident was free from misappropriation of property related to possession of a resident's credit card by a CNA. | SS=D |
Report Facts
Census: 87
Total Capacity: 87
Medicare Census: 2
Medicaid Census: 63
Other Payor Census: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marie Wallace | AIT | Laboratory Director's or Provider/Supplier Representative's signature on report |
| CNA 2 | Certified Nursing Aide | Named in misappropriation of property finding |
| Executive Director | Notified local law enforcement regarding misappropriation incident | |
| Director of Nursing Services | DNS | Notified local law enforcement and provided statements regarding the incident and staff schedules |
| Business Office Manager | BOM | Contacted bank to terminate credit card and shredded card per law enforcement instructions |
Inspection Report
Re-Inspection
Census: 83
Capacity: 120
Deficiencies: 0
Jul 5, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 05/25/23 by the Indiana Department of Health.
Findings
At this PSR survey, Majestic Care of New Haven was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Report Facts
Facility capacity: 120
Census: 83
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 28, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00410096 completed on June 19, 2023.
Findings
Majestic Care of New Haven 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.
Complaint Details
Investigation of Complaint IN00410096; paper compliance review found the facility in compliance.
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 2
Jun 19, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410096 regarding federal and state deficiencies related to resident care and medication administration.
Findings
The facility failed to ensure food preferences were followed for 3 of 5 residents reviewed and failed to ensure medications were administered per physician orders for 1 of 4 residents reviewed. Specific issues included residents receiving meals that did not match their preferences or meal tickets and missed insulin administrations.
Complaint Details
Complaint IN00410096 was substantiated with federal/state deficiencies cited at F561 (self-determination and food preferences) and F684 (quality of care related to medication administration).
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure food preferences were followed for 3 of 5 residents reviewed (Resident B, Resident C, Resident D). | SS=D |
| Facility failed to ensure medications were given per physician orders for 1 of 4 residents reviewed (Resident B). | SS=D |
Report Facts
Census: 81
Total Capacity: 81
Medicare Residents: 3
Medicaid Residents: 60
Other Residents: 18
Missed insulin administrations: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carmela Tuttle | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Director of Nursing (DON) | Interviewed regarding resident care and medication administration; provided schedule and policy | |
| Unit Manager 2 | Interviewed regarding dietary preferences and meal delivery | |
| Administrator | Interviewed regarding dietary preferences and meal choice forms |
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 7, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey completed on May 12, 2023.
Findings
Majestic Care of New Haven 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: 88
Capacity: 120
Deficiencies: 5
May 25, 2023
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies including unsafe exit ramp handrails, failure to perform required hydrostatic flush on sprinkler systems, corroded sprinkler heads, incomplete fire drills on all shifts, and improper use of power strips as substitutes for fixed wiring.
Severity Breakdown
SS=E: 2
SS=F: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Exit discharge ramp and steps handrails were loose, broken, and unsteady, making them unsafe for use. | SS=E |
| Failed to perform a full hydrostatic flush on 2 of 2 automatic sprinkler piping systems as required by NFPA 25. | SS=F |
| One sprinkler head in the 400-hall hot water heater room showed signs of corrosion and was not replaced. | SS=F |
| Failed to conduct fire drills on each shift for 1 of 4 quarters as required. | SS=F |
| Power strip was used as a substitute for fixed wiring to provide power to high current draw equipment in the Case Managers office. | SS=E |
Report Facts
Facility capacity: 120
Census: 88
Residents potentially affected by handrail deficiency: 25
Residents potentially affected by corroded sprinkler: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carmela Tuttle | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Maintenance Director | Interviewed regarding handrail deficiency, sprinkler system flushing, sprinkler corrosion, fire drill documentation, and power strip usage | |
| Administrator | Interviewed and participated in exit conference regarding deficiencies |
Inspection Report
Annual Inspection
Census: 91
Capacity: 91
Deficiencies: 3
May 12, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of multiple complaints and a Post Survey Revisit to previous complaint investigations.
Findings
The facility was found deficient in medication labeling and storage, food sanitation and dishwashing temperature compliance, and environmental cleanliness and maintenance. Several medication carts had unlabeled or improperly labeled medications affecting multiple residents. The kitchen had sanitation issues including debris and improper dishwashing temperatures. Multiple resident rooms and common areas had maintenance and cleanliness deficiencies such as peeling paint, debris, and odors.
Complaint Details
This visit included investigation of complaints IN00406133, IN00406429, IN00406523, IN00406930, IN00406935, IN00406945, IN00407313, IN00407498, and IN00408066. No deficiencies related to the allegations of complaints IN00406133, IN00406429, IN00406523, IN00406930, IN00406935, IN00406945, IN00407313, and IN00407498 were cited.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure proper labeling of medications for 3 of 3 medication carts reviewed, affecting 5 of 10 residents. | SS=E |
| Failed to ensure dishes, service ware, and utensils were cleaned and sanitized at proper temperatures and stored in a sanitary manner. | SS=E |
| Failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, including multiple maintenance and cleanliness issues in resident rooms and common areas. | SS=E |
Report Facts
Census: 91
Total Capacity: 91
Residents affected by medication labeling deficiency: 5
Dishwasher temperature readings: 150
Dishwasher temperature readings: 188
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Blackburn | RN, Regional Nurse Consultant | Signed the inspection report |
Inspection Report
Re-Inspection
Census: 91
Capacity: 91
Deficiencies: 0
May 12, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00405006 and IN00405242 completed on April 4, 2023, conducted in conjunction with a Recertification and State Licensure Survey and multiple other complaint investigations.
Findings
Majestic Care of New Haven was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to unrelated deficiencies cited during the Investigation of Complaints IN00405006 and IN00405242.
Complaint Details
This visit was related to multiple complaint investigations including IN00405006, IN00405242, IN00406133, IN00406429, IN00406523, IN00406930, IN00406935, IN00406945, IN00407313, IN00407498, and IN00408066.
Report Facts
Census SNF/NF beds: 91
Census Medicare residents: 4
Census Medicaid residents: 66
Census Other residents: 21
Inspection Report
Complaint Investigation
Census: 91
Capacity: 91
Deficiencies: 0
May 12, 2023
Visit Reason
The visit was conducted for the investigation of complaint IN00408066, in conjunction with a Recertification and State Licensure Survey, multiple other complaint investigations, and a Post Survey Revisit to previous complaints.
Findings
Majestic Care of New Haven 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 IN00408066, with no deficiencies related to the allegations cited.
Complaint Details
Complaint IN00408066 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 91
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 66
Census Payor Type - Other: 21
Inspection Report
Complaint Investigation
Census: 93
Capacity: 93
Deficiencies: 1
Apr 4, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00405006 and IN00405242. No deficiencies related to the allegations were cited, but an unrelated deficiency was identified.
Findings
The facility failed to develop and implement an effective behavioral management plan for one resident (Resident Q), which resulted in a resident-to-resident altercation and caused three other residents to fear for their safety. Resident Q exhibited multiple behavioral symptoms including yelling, screaming, threatening others, and refusal of medications. The facility did not adequately identify triggers or implement interventions to manage these behaviors, and staff and other residents expressed concerns about safety.
Complaint Details
The investigation of complaints IN00405006 and IN00405242 found no deficiencies related to the allegations. However, an unrelated deficiency was cited regarding behavioral management.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop and implement an effective behavioral management plan for a resident with mental disorder and psychosocial adjustment difficulties. | SS=G |
Report Facts
Census: 93
Total Capacity: 93
Medication refusals: 5
Medication refusals: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Interviewed regarding Resident Q's medication refusals and behavioral triggers |
| Staff 5 | Staff | Confidential interview about residents' fear of Resident Q's outbursts |
| Therapy Director | Therapy Director | Present during Resident Q's aggressive behavior on 4/4/23 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 31, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00403443 completed on March 17, 2023.
Findings
Majestic Care of New Haven 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.
Complaint Details
Investigation of Complaint IN00403443 completed on March 17, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 94
Capacity: 94
Deficiencies: 1
Mar 16, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00402095 and IN00403443 at Majestic Care of New Haven.
Findings
Complaint IN00402095 had no deficiencies related to the allegations. Complaint IN00403443 resulted in federal/state deficiencies related to grievances, specifically the facility's failure to ensure grievances were resolved promptly for one resident regarding access to Tylenol caplets.
Complaint Details
The complaint investigation focused on grievances filed by Resident M regarding delays and denial in receiving Tylenol caplets instead of tablets, which upset her stomach. The resident was eventually provided a locked box with Tylenol caplets for self-administration after multiple grievances and a physician order change. The grievance was substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to ensure grievances were resolved promptly for 1 of 1 residents reviewed (Resident M) related to access to Tylenol caplets for pain management. | SS=D |
Report Facts
Census: 94
Total Capacity: 94
Medicare Census: 12
Medicaid Census: 64
Other Payor Census: 18
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 7, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00401904 completed on February 21, 2023.
Findings
Majestic Care of New Haven 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.
Complaint Details
Investigation of Complaint IN00401904 completed on February 21, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 7, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00399608 completed on February 7, 2023.
Findings
Majestic Care of New Haven was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00399608 completed on February 7, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 94
Capacity: 94
Deficiencies: 1
Feb 17, 2023
Visit Reason
This visit was conducted for the investigation of four complaints (IN00401360, IN00401556, IN00401904, IN00402004) regarding the facility's compliance with regulations.
Findings
The investigation substantiated three complaints, with federal/state deficiencies cited related to complaint IN00401904 involving medication administration practices. The facility failed to ensure staff presence during medication administration for two residents, leading to improper medication handling.
Complaint Details
Complaint IN00401360 - Substantiated with no deficiencies cited. Complaint IN00401556 - Substantiated with no deficiencies cited. Complaint IN00401904 - Substantiated with deficiencies cited at F761. Complaint IN00402004 - Unsubstantiated due to lack of evidence.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure staff were present during medication administration for 2 of 5 residents, resulting in medications being left unattended and improperly handled. | SS=D |
Report Facts
Census: 94
Total Capacity: 94
Medicare Residents: 12
Medicaid Residents: 61
Other Payor Residents: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carmela Tuttle | HFA | Signed as Laboratory Director's or Provider/Supplier Representative |
| LPN 2 | Licensed Practical Nurse | Named in medication administration deficiency and interviews regarding medication handling |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration policies and practices |
| Executive Director | Executive Director | Interviewed regarding medication administration practices |
| Qualified Medication Assistant 5 | Qualified Medication Assistant | Interviewed regarding medication administration practices |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 91
Deficiencies: 1
Feb 7, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399608, which was substantiated with related federal and state deficiencies cited.
Findings
The facility failed to maintain a clean environment for 4 of 9 residents reviewed, with observations of unclean bathrooms, sticky and stained floors, dried brown matter on toilets and floors, overflowing trash, and inadequate cleaning schedules due to housekeeping staff shortages.
Complaint Details
Complaint IN00399608 was substantiated with federal/state deficiencies cited at F921.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to maintain a clean environment for residents, including unclean bathrooms and floors with dried brown matter and strong urine smell. | SS=E |
Report Facts
Census: 91
Total Capacity: 91
Medicare residents: 9
Medicaid residents: 63
Other payor residents: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carmela Tuttle | HFA | Facility representative signing the report |
| Executive Director | Provided list of interviewable residents and cleaning schedule | |
| Housekeeper 2 | Interviewed regarding housekeeping staffing and cleaning practices | |
| Director of Nursing | Interviewed regarding cleanliness observations and standards |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 88
Deficiencies: 0
Jan 17, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00398717 and IN00398738.
Findings
Both complaints IN00398717 and IN00398738 were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00398717 - Substantiated with no deficiencies cited. Complaint IN00398738 - Substantiated with no deficiencies cited.
Report Facts
Census: 88
Total Capacity: 88
Medicare Census: 9
Medicaid Census: 65
Other Payor Census: 14
Inspection Report
Complaint Investigation
Census: 90
Capacity: 90
Deficiencies: 0
Dec 1, 2022
Visit Reason
This visit was conducted for the investigation of three complaints: IN00394797, IN00394855, and IN00395085.
Findings
Complaints IN00394797 and IN00394855 were substantiated but no deficiencies related to the allegations were cited. Complaint IN00395085 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00394797 - Substantiated with no deficiencies cited. Complaint IN00394855 - Substantiated with no deficiencies cited. Complaint IN00395085 - Unsubstantiated due to lack of evidence.
Report Facts
Census SNF/NF beds: 90
Total census: 90
Medicare census: 10
Medicaid census: 65
Other payor census: 15
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 22, 2022
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00391835 and IN00392831.
Findings
Majestic Care of New Haven was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
The visit was a paper compliance review of complaints IN00391835 and IN00392831, completed on November 3, 2022, with findings indicating compliance.
Inspection Report
Complaint Investigation
Census: 95
Capacity: 95
Deficiencies: 1
Nov 3, 2022
Visit Reason
The visit was conducted for the investigation of four complaints (IN00391835, IN00392193, IN00392831, and IN00393490). Three complaints were substantiated with related federal/state deficiencies cited, and one complaint was unsubstantiated due to lack of evidence.
Findings
The facility failed to ensure that residents received bathing for 2 of 9 residents reviewed (Resident B and Resident J). Documentation showed multiple refusals of bathing without proper communication with residents' Power of Attorney. Staff interviews confirmed refusals and lack of notification to responsible parties. The facility's policy requires attempts to identify underlying causes of refusals and appropriate documentation.
Complaint Details
Complaint IN00391835 and IN00392831 were substantiated with federal/state deficiencies cited at F677. Complaint IN00392193 was substantiated with no deficiencies cited. Complaint IN00393490 was unsubstantiated due to lack of evidence.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure residents received bathing for 2 of 9 residents reviewed, with inadequate documentation and communication regarding refusals. | SS=D |
Report Facts
Census: 95
Total Capacity: 95
Medicare Census: 7
Medicaid Census: 65
Other Payor Census: 23
Residents Reviewed for Bathing: 9
Residents with Bathing Deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Hesser | Nurse Consultant | Signed the report |
| RN 2 | Interviewed regarding Resident B's shower refusals and lack of POA communication | |
| LPN 4 | Interviewed about shower/bathing frequency and refusal procedures | |
| CNA 3 | Interviewed about shower refusals and documentation process |
Inspection Report
Re-Inspection
Census: 98
Capacity: 120
Deficiencies: 0
Oct 18, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 08/15/22.
Findings
At this PSR survey, Majestic Care of New Haven was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements. The facility was fully sprinklered except for a detached building housing the emergency generator and maintenance equipment storage.
Report Facts
Facility capacity: 120
Census: 98
Inspection Report
Complaint Investigation
Census: 82
Capacity: 82
Deficiencies: 0
Sep 20, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00388866 and IN00389741.
Findings
Complaint IN00388866 was unsubstantiated due to lack of evidence. Complaint IN00389741 was substantiated but no deficiencies related to the allegation were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00388866 - Unsubstantiated due to lack of evidence. Complaint IN00389741 - Substantiated. No deficiencies related to the allegation are cited.
Report Facts
Census: 82
Total Capacity: 82
Medicare Census: 9
Medicaid Census: 53
Other Payor Census: 20
Inspection Report
Re-Inspection
Census: 84
Capacity: 84
Deficiencies: 0
Aug 16, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on July 18, 2022, including a PSR to the Investigation of Complaint IN00384652 completed on July 18, 2022.
Findings
Majestic Care New Haven was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of Complaint IN00384652.
Complaint Details
Complaint IN00384652 was investigated and found to be corrected.
Report Facts
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 55
Census Payor Type - Other: 20
Inspection Report
Life Safety
Census: 82
Capacity: 120
Deficiencies: 16
Aug 15, 2022
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with multiple Life Safety Code requirements including emergency preparedness plan updates, egress door accessibility, corridor width, hazardous area door integrity, sprinkler spacing, fire extinguisher maintenance, corridor door smoke resistance, HVAC fire damper inspection, heating device safety, combustible air intake, smoking area combustibles, electrical cord usage, and oxygen transfilling room conditions.
Severity Breakdown
SS=F: 7
SS=E: 8
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to review and update the Emergency Preparedness Plan (EPP) annually. | SS=F |
| Failed to review and update the Emergency Preparedness Plan's Policies and Procedures annually. | SS=F |
| Failed to review and update the Emergency Preparedness Plan's Communication Plan annually. | SS=F |
| Failed to review and update the Emergency Preparedness Plan's Training and Testing Plan annually. | SS=F |
| Means of egress through 1 of 1 exit gates in the courtyard was locked with a chain and padlock, not readily accessible. | SS=E |
| Exit corridor width reduced below 44 inches due to obstruction by bed and cart. | SS=E |
| Laundry room corridor door was propped open, preventing automatic closing. | SS=E |
| Cooktop in therapy gym lacked a shutoff switch accessible to staff. | SS=E |
| Two sprinklers in resident lounge spaced only two feet apart, violating spacing requirements. | SS=E |
| Two portable fire extinguishers were past due for annual maintenance. | SS=E |
| Four corridor doors had holes allowing smoke passage and did not resist fire for at least 20 minutes. | SS=E |
| Fire dampers were not inspected or maintained as required by NFPA 90A. | SS=F |
| Laundry room fuel-fired dryers lacked adequate fresh air intake due to lint blockage. | SS=F |
| Combustible propane tanks stored inside a designated smoking area. | SS=E |
| Two flexible cords used as substitute for fixed wiring and a power strip in patient care area lacked required UL rating. | SS=E |
| Oxygen transfilling room was overcrowded, preventing staff from safely transfilling oxygen inside the room. | SS=E |
Report Facts
Facility capacity: 120
Census: 82
Sprinkler spacing: 2
Fire extinguishers past due: 2
Corridor doors with holes: 4
Extension cords observed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to emergency preparedness, fire safety, and maintenance issues | |
| Administrator | Named in multiple findings and exit conferences | |
| Executive Director | Named in multiple findings and corrective action education | |
| Director of Nursing | Named in oxygen transfilling room finding | |
| Therapy Director | Named in cooktop shutoff finding |
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