Inspection Reports for
Majestic Care of North Vernon

The facility failed to maintain safe water temperatures in 5 of 9 resident bathrooms and 1 of 2 common area bathrooms, with temperatures exceeding the recommended 115 degrees Fahrenheit. The Maintenance Director took immediate action to adjust temperatures and restrict access to the visitor restroom.

The complaint was substantiated. The resident suffered a fracture during an x-ray procedure performed by a contracted x-ray technician who did not receive adequate assistance from facility staff. The resident had a contracture and was non-verbal, requiring staff assistance to safely complete the x-ray. The fracture was confirmed by subsequent x-rays and orthopedic evaluation.

The facility failed to properly assist a resident with a contracture during an x-ray procedure, resulting in a fracture to the resident's right arm. The x-ray technician attempted to reposition the resident's arm without adequate assistance, causing pain and injury. The facility and contracted x-ray company lacked proper coordination and training to safely perform the procedure.

This citation relates to Complaint 1599379. The complaint was substantiated based on interviews and record review confirming the nurse's inappropriate actions toward Resident C.

The facility failed to ensure staff treated a resident with respect and dignity. A Licensed Practical Nurse was found to have thrown away a resident's cornbread and milk after the resident did not follow instructions to remain seated, leading to the nurse's termination.

The facility was found deficient in multiple areas including medication self-administration assessments, care plan revisions for prophylactic antibiotic use, adherence to cardiac medication hold parameters, urinary catheter care, pharmacy medication administration, medication storage and labeling, food safety and hygiene practices, infection prevention and control, and staff licensure compliance.

The facility was found deficient in multiple areas including medication administration, care planning, catheter care, infection control, medication storage, and food safety. Several residents were affected by failures in following physician orders, proper medication handling, catheter management, and infection prevention protocols.

Complaint IN00447341 was substantiated with a federal/state deficiency cited at F580 related to failure to notify the physician of a change in condition for Resident B.

The facility failed to notify the physician of a change in condition for 1 of 3 residents reviewed (Resident B), who was found lethargic and later unresponsive without documented physician notification on the date of the event.

This citation relates to Complaint IN00447341.

The facility failed to notify the physician of a change in condition for 1 of 3 residents reviewed. Resident B was lethargic and later found unresponsive without a pulse, but there was no documentation of physician notification on the date of the condition change.

Complaint IN00439556 involved allegations of verbal abuse by LPN staff towards Resident C on 08/29/24. Multiple staff interviews confirmed verbal abuse occurred. The facility delayed reporting the incident to the Indiana Department of Health until 09/03/24. The investigation was incomplete, lacking resident and other resident interviews.

The facility failed to report an allegation of verbal abuse in a timely manner and failed to appropriately investigate the allegation of abuse for Resident C. The investigation lacked interviews with the resident and other residents. The facility provided education to DNS and ED on reporting and investigation procedures and implemented a quality assurance program to monitor compliance.

The complaint involved an allegation of verbal abuse by LPN 4 toward Resident C on 08/29/2024. The allegation was initially not reported timely to the Indiana Department of Health and the investigation was incomplete, lacking resident and witness interviews. The allegation was ultimately reported on 09/03/2024.

The facility failed to timely report an allegation of verbal abuse and failed to appropriately investigate the allegation involving Resident C. The investigation lacked interviews with the resident and other residents, and the Director of Nursing did not come to the facility on the night of the incident.

The facility was found not in compliance with several Life Safety Code requirements including locking mechanisms on doors, self-closing devices on hazardous area doors, monthly inspection documentation for sprinkler systems and fire extinguishers, proper door latching, electrical box cover plates, fire drills, smoking area maintenance, and annual fuel quality testing for the generator.

The facility was found deficient in maintaining sanitary food storage in resident snack refrigerators and providing a homelike environment free of odors, specifically a strong urine odor in the B-Hall secured unit. Corrective actions and systemic changes were planned to address these issues.

The facility failed to maintain residents' snack refrigerators properly, with non-food items and unlabeled food found in multiple refrigerators. Additionally, the facility did not provide a homelike environment due to persistent strong urine odors in the B-Hall secured unit.

This citation relates to Complaint IN00425571.

The facility failed to prevent the use of a physical restraint on Resident B, who was found with a fleece blanket tied around her waist while in a wheelchair without a physician's order. Staff interviews confirmed the blanket was used as an improvised restraint to prevent the resident from falling, contrary to facility policy.

Complaint IN00425571 was substantiated with a federal/state deficiency cited at F604 related to the allegation of improper physical restraint.

The facility failed to prevent a resident from being physically restrained with a blanket tied around her waist while in a wheelchair, without a physician's order for restraints. The incident involved Resident B and was confirmed through interviews and record reviews.

The facility was found not in compliance with emergency preparedness requirements, life safety code, and fire safety standards including issues with emergency power system annunciator, means of egress obstructions, kitchen exhaust inspection, fire alarm system maintenance, corridor door deficiencies, fuel fired water heater inspections, fire drills documentation, fire door inspections, electrical receptacle testing, and emergency generator annunciator panel operation.

The facility was cited for multiple deficiencies including failure to post resident rights, incomplete neurological evaluations after falls, failure to prevent and treat pressure ulcers, failure to implement fall care plan interventions, improper oxygen administration, medication errors including duplicate orders, improper medication storage, and inadequate food storage practices. The facility also lacked ongoing effective QAPI measures to address pressure ulcer deficiencies.

The facility was found deficient in multiple areas including failure to post resident rights, incomplete neurological evaluations after falls, inadequate pressure ulcer prevention and care, failure to implement fall prevention care plans, improper oxygen administration, medication errors including duplicate dosing, improper medication storage, and poor management of resident snack refrigerators. The facility also lacked effective ongoing quality assurance measures to address unresolved deficiencies related to pressure ulcers.

Complaint IN00400655 was substantiated with a federal/state deficiency cited at F686 related to failure in wound care and hand hygiene. Other complaints (IN00403474, IN00400900, IN00400692, IN00398221, IN00396246) had no deficiencies related to their allegations.

The facility was found deficient related to one complaint (IN00400655) involving failure to provide wound care using appropriate infection control guidelines, specifically hand hygiene during wound treatments for one resident. Other complaints had no deficiencies related to their allegations. Unrelated deficiencies were also cited.

Complaint IN00400655 related to wound care and medication storage was substantiated with findings of failure in hand hygiene during wound treatment and missing narcotics.

The facility failed to provide appropriate wound care using proper infection control guidelines related to hand hygiene during wound treatments for one resident. Additionally, the facility failed to ensure proper storage and safe keeping of narcotics for one resident, resulting in missing medication.

Complaint IN00400655 triggered the investigation. The complaint related to wound care and medication storage issues. The complaint was substantiated as deficiencies were found.

The facility failed to provide appropriate wound care using proper infection control guidelines related to hand hygiene during wound treatments for one resident. Additionally, the facility failed to ensure proper storage and safe keeping of narcotics for one resident, resulting in missing medication doses.

Complaint IN00394434 was substantiated with a federal/state deficiency cited at F636. Complaint IN00392739 was unsubstantiated due to lack of evidence. Complaint IN00392475 was substantiated but no deficiencies related to the allegation were cited.

The facility failed to provide appropriate care plan interventions for a severely cognitively impaired resident related to safe environment supervision during meal time, resulting in a resident found unresponsive with a piece of hamburger in her mouth despite a prescribed pureed diet. Complaint IN00394434 was substantiated with a related deficiency cited at F636. Complaint IN00392739 was unsubstantiated due to lack of evidence. Complaint IN00392475 was substantiated but no deficiencies were cited.

Complaint IN00390086 was unsubstantiated due to lack of evidence. Complaint IN00390208 was substantiated with a federal/state deficiency cited at F584. Complaint IN00389984 was substantiated but no deficiencies related to the allegation were cited.

The facility failed to maintain a safe, clean, comfortable, and homelike environment as required, specifically failing to provide adequate housekeeping and sanitation in 5 of 14 resident rooms observed. Multiple rooms had dirt, debris, dust, and other cleanliness issues. The facility provided a plan of correction including cleaning affected rooms, staff education, and ongoing monitoring.

At this revisit, the facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code requirements due to failure to maintain means of egress free of obstructions in 2 of 8 egress paths. The deficiency affected over 20 residents, staff, and visitors.

The facility was found not in compliance with several emergency preparedness and life safety requirements including emergency power system testing and documentation, fire alarm system maintenance, means of egress obstructions and door functionality, hazardous area protections, fire drills documentation, smoking regulations, and storage security for nonflammable gases.