Inspection Reports for Majestic Care of South Bend
52654 N IRONWOOD RD, SOUTH BEND, IN, 46635
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 18, 2025, found Majestic Care of South Bend in compliance with no deficiencies cited related to the complaint investigated. Prior inspections showed a mixed record with multiple citations primarily involving resident care issues such as medication administration, staffing shortages, and care planning, as well as recurring Life Safety Code deficiencies related to emergency preparedness, fire safety, and electrical hazards. Several complaint investigations were substantiated over time, including failures in abuse reporting, supervision leading to resident elopement, and verbal abuse by staff, but many complaints were also found unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to be improving recently, with the latest inspections showing compliance and correction of earlier cited deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
26 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
519% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
62 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
Date: Jun 18, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00459527.
Complaint Details
Complaint IN00459527 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. Majestic Care of South Bend was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00459527.
Report Facts
Residential Census: 62
Inspection Report
Complaint Investigation
Census: 56
Capacity: 56
Deficiencies: 0
Date: May 8, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00458559 and IN00454881 at Majestic Care of South Bend.
Complaint Details
Investigation of Complaints IN00458559 and IN00454881 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00458559 and IN00454881 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 3
Medicaid census: 52
Other census: 1
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 0
Date: Jan 16, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00449941.
Complaint Details
Complaint IN00449941 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 applicable regulations.
Report Facts
Census: 59
Total Capacity: 59
Payor Type Census: 1
Payor Type Census: 51
Payor Type Census: 7
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
This visit was conducted for the investigation of three complaints (IN00449506, IN00449354, and IN00448351) and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaints IN00449506, IN00449354, and IN00448351 were investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in any of the three 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 regarding the complaints and the COVID-19 Focused Infection Control Survey.
Report Facts
Census: 66
Total Capacity: 66
Medicare Census: 2
Medicaid Census: 61
Other Payor Census: 3
Inspection Report
Re-Inspection
Census: 63
Capacity: 103
Deficiencies: 0
Date: Dec 10, 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 that exited on 10/17/24.
Findings
At this PSR, Majestic Care of South Bend was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 0
Date: Oct 25, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00445845 and IN00445717.
Complaint Details
Investigation of Complaints IN00445845 and IN00445717 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00445845 and IN00445717 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 70
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 63
Census Payor Type - Other: 4
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Date: Oct 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00445495.
Complaint Details
Complaint IN00445495 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00445495 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 3
Medicaid census: 62
Other payor census: 3
Inspection Report
Life Safety
Census: 68
Capacity: 103
Deficiencies: 11
Date: Oct 17, 2024
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency preparedness, fire drills, fire door inspections, sprinkler system maintenance, electrical receptacle protection, and use of extension cords. Deficiencies were noted in emergency preparedness policies, communication plans, emergency plan testing, kitchen exhaust cleaning documentation, fire door assembly inspections, sprinkler system backflow testing, electrical receptacle testing, and fire drill documentation.
Deficiencies (11)
Failed to ensure emergency preparedness policies included subsistence needs for staff and residents, including food, water, medical supplies, and alternate energy sources.
Failed to ensure emergency preparedness communication plan included primary and alternate means for communication with staff and emergency agencies.
Failed to conduct emergency plan exercises at least twice per year including unannounced staff drills.
Failed to provide documentation of annual or semiannual cleaning and inspection of kitchen exhaust system.
Failed to maintain kitchen extinguishing system manual activation pull station between 42 and 48 inches above floor.
Failed to ensure annual testing of backflow prevention device in sprinkler system piping.
Failed to ensure electrical receptacle in North pantry was protected with a cover plate.
Failed to conduct quarterly fire drills for all shifts in all quarters as required.
Failed to ensure annual inspection and testing of fire door assemblies were completed and documented.
Failed to ensure all non-hospital-grade electrical receptacles at resident room locations were tested annually.
Used an extension cord as a substitute for fixed wiring in resident room 203.
Report Facts
Certified beds: 103
Census: 68
Deficiency counts: 11
Fire drills missing: 4
Backflow prevention test date: Aug 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bud Johnson | Executive Director | Named in exit conference and plan of correction |
| Maintenance Director | Interviewed regarding multiple deficiencies including emergency preparedness, fire drills, fire door inspections, sprinkler system, and electrical issues |
Inspection Report
Annual Inspection
Census: 74
Capacity: 74
Deficiencies: 13
Date: Oct 4, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of multiple complaints.
Complaint Details
This survey included the investigation of Complaints IN00442540, IN00443587, IN00442738, and IN00441959. No deficiencies related to the allegations in these complaints were cited.
Findings
The facility was found to have deficiencies in areas including reasonable accommodations, Medicaid/Medicare coverage notices, transfer/discharge notices, care planning, ADL care, tube feeding management, medication error rates, food storage sanitation, infection prevention and control, personal refrigerator monitoring, and personnel records. Corrective actions and education plans were implemented for each deficiency.
Deficiencies (13)
Failed to provide a dependent resident an assistive device (wheelchair) for accommodation of needs.
Failed to ensure a SNF-ABN form was provided following the end of Medicare skilled services for a resident.
Failed to provide notice of transfer form for residents hospitalized.
Failed to provide notice of bed hold policy when residents were hospitalized.
Failed to develop a person-centered care plan regarding fluid needs for a resident.
Failed to ensure care plan conferences were completed every quarter for residents reviewed.
Failed to ensure residents were assisted with personal hygiene and showers as scheduled.
Failed to follow physician's orders related to flushing a G-tube and changing tubing for residents with G-tubes.
Failed to ensure medication error rate was below 5%, with 2 errors in 25 opportunities observed.
Failed to store and prepare food in a sanitary manner related to labeling and dating of opened food and disposal of expired spices.
Failed to ensure infection control practices for respiratory equipment storage, catheter care, blood sugar monitoring, and glucometer cleaning.
Failed to maintain a safe and sanitary environment related to monitoring personal refrigerator temperatures and disposing of expired food.
Failed to maintain employee health records related to preemployment physical examination and annual dementia training for staff.
Report Facts
Census: 74
Total Capacity: 74
Medication Pass Opportunities: 25
Medication Errors: 2
Medication Error Rate: 8
Residents Reviewed for Care Plans: 18
Residents Reviewed for ADL: 4
Residents Reviewed for G-tube: 2
Residents Reviewed for Infection Control: 3
Residents with Personal Refrigerators Reviewed: 3
Employees Reviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bud Johnson | Executive Director | Signed the inspection report. |
| CNA 2 | Employee whose file lacked preemployment physical examination. | |
| RN 10 | Employee who did not complete required annual dementia training. | |
| RN 11 | Nurse observed during medication pass with medication errors. | |
| QMA 3 | Qualified Medication Aide | Mentioned in relation to resident care and oral hygiene. |
| QMA 14 | Qualified Medication Aide | Observed cleaning glucometer improperly. |
| CNA 4 | Observed performing catheter care. | |
| CNA 8 | Provided information about respiratory equipment cleaning. | |
| Unit Manager | Provided multiple interviews and policies related to care and infection control. | |
| Director of Nursing | Provided interviews and policies related to care and medication administration. | |
| Director of Human Resources | Provided information about employee records and training. |
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 4, 2024
Visit Reason
The inspection was conducted as a Paper Compliance Review to the Recertification and State Licensure Survey.
Findings
Majestic Care of South Bend was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the Paper Compliance Review to the Recertification and State Licensure Survey.
Report Facts
Facility Number: 124
Provider Number: 155219
AIM Number: 100266730
Inspection Report
Re-Inspection
Census: 72
Capacity: 72
Deficiencies: 0
Date: Sep 17, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) conducted on September 16 and 17, 2024, to follow up on previous complaint investigations completed on August 23, 2024.
Complaint Details
This visit was related to the investigation of complaints IN00436970, IN00437316, IN00441105, and IN00441005. Complaints IN00436970 and IN00437316 were corrected as of this visit.
Findings
Majestic Care of South Bend was found to be in compliance with relevant federal and state regulations during the PSR visits related to multiple complaint investigations, with all cited complaints corrected.
Report Facts
Census: 72
Total Capacity: 72
Medicare Census: 1
Medicaid Census: 66
Other Payor Census: 5
Inspection Report
Re-Inspection
Census: 72
Capacity: 72
Deficiencies: 0
Date: Sep 17, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00441105 and IN00441005 completed on 8/23/24, conducted in conjunction with a PSR to a PSR completed on 8/23/24 for Complaints IN00437316 and IN00436970.
Complaint Details
This visit was related to complaint investigations IN00441105, IN00441005, IN00437316, and IN00436970. Complaints IN00441105 and IN00441005 were corrected as of this visit.
Findings
Majestic Care of South Bend 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 Investigations of the referenced complaints. Complaints IN00441105 and IN00441005 were corrected.
Report Facts
Census Bed Type: 72
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 66
Census Payor Type - Other: 5
Inspection Report
Re-Inspection
Census: 81
Capacity: 81
Deficiencies: 1
Date: Aug 23, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00437316, IN00436970, and IN00436698 completed on July 15, 2024, and was conducted in conjunction with the Investigation of Complaints IN00441446, IN00441105, IN00441005, IN00440374, and IN00439081.
Complaint Details
Complaint IN00437316 - Not Corrected. Complaint IN00436970 - Not Corrected. Complaint IN00436698 - Corrected.
Findings
The facility failed to ensure sufficient licensed nursing staff to provide care and services, directly affecting 4 residents reviewed. Staffing levels were below the required average range on multiple dates, and the facility had not implemented a systemic plan of correction to prevent recurrence of this deficiency cited previously on 7/3/2024.
Deficiencies (1)
Failed to ensure sufficient number of licensed nurses (RN/LPN) to provide care and services, affecting 4 residents.
Report Facts
Census: 81
Total Capacity: 81
Medicare Census: 6
Medicaid Census: 70
Other Payor Census: 5
Licensed Nurse Hours per Patient per Day (PPD): 0.81
Licensed Nurse Hours per Patient per Day (PPD): 0.771
Licensed Nurse Hours per Patient per Day (PPD): 0.592
Licensed Nurse Hours per Patient per Day (PPD): 0.8
Licensed Nurse Hours per Patient per Day (PPD): 0.78
Licensed Nurse Hours per Patient per Day (PPD): 0.759
Licensed Nurse Hours per Patient per Day (PPD): 0.759
Licensed Nurse Hours per Patient per Day (PPD): 0.79
Licensed Nurse Hours per Patient per Day (PPD): 0.65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Smith | Administrator | Signed report and provided facility assessment tool and staffing policy |
| RN 2 | Interviewed and indicated insufficient staffing and workload challenges | |
| QMA 3 | Interviewed and reported short staffing and missed scheduled showers | |
| CNA 4 | Interviewed and reported insufficient staffing and difficulty providing care | |
| CNA 5 | Interviewed and reported no improvement in staffing and overwhelming workload | |
| CNA 6 | Interviewed and reported staffing challenges and inability to complete scheduled showers | |
| Regional Director of Operations | Interviewed and confirmed staffing levels below required levels on multiple dates |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 3
Date: Aug 23, 2024
Visit Reason
This visit was for the investigation of multiple complaints and a post survey revisit related to complaints concerning the facility's dialysis services and transfer/discharge procedures.
Complaint Details
The investigation involved complaints IN00441446, IN00441105, IN00441005, IN00440374, and IN00439081. Deficiencies related to complaints IN00441105 and IN00441005 were substantiated with citations at F623 and F698. Other complaints had no deficiencies related to allegations.
Findings
The facility failed to ensure proper notification and documentation for resident transfers to hospitals for dialysis, failed to continue dialysis services after the in-house dialysis center closure resulting in residents missing treatments and requiring emergency hospital transfers, and failed to ensure licensed nurses followed standards of practice during medication administration, including observation of medication consumption.
Deficiencies (3)
Failed to ensure residents transferred to hospital for dialysis received proper notification including appeal rights, bed hold policy, and Ombudsman information.
Failed to ensure residents continued to receive dialysis services after the closure of the facility-based dialysis center, resulting in missed treatments and emergency hospitalizations.
Failed to ensure licensed nurse observed medication consumption during administration for one resident.
Report Facts
Residents reviewed for dialysis services: 7
Residents transferred to hospital for dialysis: 3
Dialysis frequency: 5
Dialysis frequency changed: 3
Facility census: 81
Facility total capacity: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 11 | Agency Staffing Nurse | Observed medication pass and left medications unattended in Resident Q's room. |
| LPN 12 | Unit Manager | Sent Residents D and E to hospital due to missed dialysis and lack of transfer documentation. |
| Transport Employee 7 | Responsible for arranging transportation for dialysis residents; reported issues with dialysis referrals and transport. | |
| Nurse Practitioner | Facility Nurse Practitioner | Instructed sending residents to ER if dialysis missed; involved in care of residents missing dialysis. |
| Admission Coordinator | Handled dialysis admission processes for multiple residents; reported delays and cancellations. | |
| Regional Nurse Consultant | Confirmed lack of transfer documentation and dialysis lab draws; provided dialysis communication records. | |
| Interim Administrator | Provided facility policies and acknowledged dialysis service closure and related issues. |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 4
Date: Jul 15, 2024
Visit Reason
Investigation of Complaints IN00437987, IN00437316, IN00436970, and IN00436698 at Majestic Care of South Bend.
Complaint Details
Complaint IN00437987 had no deficiencies related to allegations. Complaints IN00437316, IN00436970, and IN00436698 had federal/state deficiencies cited related to CPR failure, staffing, medication administration, and cleanliness issues.
Findings
The facility was found to have multiple deficiencies including failure to immediately initiate CPR resulting in resident death, insufficient nursing staff affecting multiple residents, failure to administer medications and treatments as ordered, and failure to maintain cleanliness in shower rooms.
Deficiencies (4)
Failed to immediately initiate CPR in accordance with resident's advanced directives resulting in resident death.
Failed to ensure sufficient licensed nursing staff to provide care and services to residents.
Failed to ensure residents received medications and treatments in accordance with physician orders and facility policy.
Failed to ensure shower rooms were cleansed after use, leaving unsanitary conditions.
Report Facts
Census: 75
Total Capacity: 75
PPD (Per Patient Day) Staffing: 0.473
PPD (Per Patient Day) Staffing: 0.594
Deficiency Counts: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Only licensed nurse on duty during resident's death, involved in CPR delay. |
| QMA 2 | Qualified Medication Aide | Reported resident complaints and involved in CPR initiation delay. |
| CNA 4 | Certified Nursing Assistant | Observed CPR event and assisted with resident care during emergency. |
| CNA 5 | Certified Nursing Assistant | Assisted resident during day of incident, communicated resident's condition. |
| Interim Director of Nursing | Interim DON | On call during incident, provided guidance on resident transfer. |
| Unit Manager | Unit Manager | Responsible for shower room cleanliness and nursing unit staffing. |
| Housekeeping Manager | Housekeeping Manager | Responsible for cleaning protocols and shower room maintenance. |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 83
Deficiencies: 0
Date: May 10, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00433517, IN00433294, and IN00431813.
Complaint Details
Complaints IN00433517, IN00433294, and IN00431813 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00433517, IN00433294, and IN00431813 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare residents: 3
Medicaid residents: 78
Other payor residents: 2
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Date: Mar 27, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00430917 and IN00429810.
Complaint Details
Complaint IN00430917 and Complaint IN00429810 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00430917 and IN00429810 were cited. The facility was found to be in compliance with applicable federal and state regulations.
Report Facts
Census SNF/NF beds: 79
Census total residents: 79
Census Medicare residents: 4
Census Medicaid residents: 72
Census other payor residents: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 25, 2024
Visit Reason
The inspection was conducted as a Paper Compliance Review related to the investigation of Complaint IN00427142 completed on 2/20/24.
Complaint Details
Complaint IN00427142 was investigated and the facility was found to be in compliance.
Findings
Majestic Care of South Bend 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
Census: 76
Capacity: 76
Deficiencies: 2
Date: Feb 18, 2024
Visit Reason
This visit was for the investigation of complaints IN00427142, IN00426761, IN00426428, and IN00426266. The investigation focused on allegations of resident-to-resident abuse.
Complaint Details
Complaint IN00427142 was substantiated with federal/state deficiencies cited at F609 and F610 related to failure to report and investigate resident-to-resident abuse. Complaints IN00426761, IN00426428, and IN00426266 had no deficiencies related to the allegations.
Findings
The facility failed to report an allegation of resident-to-resident abuse to local law enforcement within 24 hours as required by policy, and did not thoroughly investigate the incident, including failure to obtain statements from staff and residents. The incident involved two residents who had a physical altercation resulting in reddened areas on their foreheads. The facility reported the incident to the Indiana Department of Health but did not notify law enforcement due to no serious bodily injury. The facility has since implemented audits and education to improve reporting and investigation procedures.
Deficiencies (2)
The facility did not report an allegation of abuse to local law enforcement within 24 hours.
The facility did not thoroughly investigate an allegation of resident-to-resident abuse.
Report Facts
Census: 76
Total Capacity: 76
Medicare Residents: 8
Medicaid Residents: 64
Other Residents: 4
Safety Checks: 15
Audit Frequency: 3
Audit Duration Weeks: 4
Audit Duration Months: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 9 | RN | Documented incident in progress notes and involved in investigation |
| Administrator | Interviewed regarding reporting and investigation of incident | |
| Director of Nursing | DON | Interviewed regarding investigation and reporting procedures |
| Environmental Service Manager | Witnessed incident and notified RN 9 | |
| Social Service Director | SSD | Interviewed residents and documented statements related to incident |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 7, 2024
Visit Reason
Paper Compliance Review to the Investigation of Complaint IN00425453 completed on 2024-01-11.
Complaint Details
Investigation of Complaint IN00425453 completed on 2024-01-11; facility found in compliance.
Findings
Majestic Care of South Bend was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Paper Compliance Review to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 2
Date: Jan 8, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00425453, IN00424888, IN00424749, IN00423457, and IN00421638) regarding the facility.
Complaint Details
Complaint IN00425453 was substantiated with federal/state deficiencies cited at F684 related to quality of care and notification of changes. Other complaints (IN00424888, IN00424749, IN00423457, IN00421638) had no deficiencies related to the allegations.
Findings
The facility was found deficient related to Complaint IN00425453 for failing to ensure timely notification of a resident's representative and appropriate interventions during an acute change in condition for Resident F. Other complaints had no deficiencies cited. The resident was eventually transferred to the ER after delayed notification and intervention.
Deficiencies (2)
Failed to ensure a resident's representative was notified timely when there was an acute change in the resident's condition (Resident F).
Failed to ensure appropriate interventions were provided when there was an acute change of condition (Resident F).
Report Facts
Census: 77
Total Capacity: 77
Survey Dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rayne Wise | Executive Director | Signed the report |
| LPN 2 | Documented progress notes and involved in notification delay and resident care | |
| Director of Nursing | DON | Involved in notification of resident's son and education on Change of Condition Policy |
| NP | Nurse Practitioner | Provided clinical assessment and involved in care decisions |
| Administrator | Provided facility policies during interviews |
Inspection Report
Life Safety
Census: 78
Capacity: 103
Deficiencies: 0
Date: Dec 6, 2023
Visit Reason
A 2nd Post Survey Revisit (PSR) was conducted for the 1st PSR survey that was conducted on 10/26/23 for the Life Safety Code survey conducted on 09/11/23 by the Indiana Department of Health in accordance to 42 CFR 483.90(a).
Findings
At this Life Safety Code PSR, Majestic Care of South Bend was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), 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. The facility was fully sprinklered with a fire alarm system and smoke detection throughout.
Report Facts
Facility capacity: 103
Census: 78
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 0
Date: Nov 6, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00420882, IN00420919, and IN00421063 at Majestic Care of South Bend.
Complaint Details
Investigation of complaints IN00420882, IN00420919, and IN00421063 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00420882, IN00420919, and IN00421063 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 81
Total Census: 81
Medicare Census: 2
Medicaid Census: 60
Other Payor Census: 19
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 27, 2023
Visit Reason
The inspection was conducted as a Paper Compliance Review related to the Complaint Investigation IN00415686 completed on 2023-08-28.
Complaint Details
The complaint investigation IN00415686 was completed on 2023-08-28 and the facility was found to be in compliance.
Findings
Majestic Care of South Bend was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the Paper Compliance Review to the Complaint Investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 27, 2023
Visit Reason
Paper Compliance Review to the Recertification and State Licensure Survey and Complaint Investigation for IN00412401 and IN00409479 completed on August 28, 2023.
Findings
Majestic Care of South Bend was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 in regard to the Paper Compliance Review to the Recertification and State Licensure Survey and Complaint Investigation.
Inspection Report
Follow-Up
Census: 78
Capacity: 103
Deficiencies: 4
Date: Oct 26, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted to verify correction of previous deficiencies.
Findings
The facility was found not in compliance with Life Safety Code requirements including sprinkler system maintenance, smoking area safety, fire door maintenance, and improper use of power cords. Deficiencies cited in the prior survey were not fully corrected, and systemic plans of correction were not implemented to prevent reoccurrences.
Deficiencies (4)
Failed to ensure a full hydrostatic flush was performed on 1 of 2 automatic sprinkler piping systems as required by NFPA 25.
Failed to ensure 1 of 1 smoking areas were maintained by disposing cigarette butts in a metal or noncombustible container with self-closing cover devices.
Failed to maintain 1 of 1 rolling fire door in accordance with NFPA 80; fire door failed inspection due to malfunction in release/test box and inability to reset tension.
Failed to ensure 2 of 2 power strips were not used as a substitute for fixed wiring to provide power equipment with a high current draw.
Report Facts
Facility capacity: 103
Census: 78
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rayne Wise | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative's Signature. |
| Maintenance Director | Present during inspection and interviewed regarding sprinkler system, smoking area, fire door, and power cord deficiencies. |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 82
Deficiencies: 1
Date: Oct 10, 2023
Visit Reason
The visit was conducted for the investigation of Complaint IN00419004 regarding a resident elopement incident.
Complaint Details
Complaint IN00419004 was substantiated with findings related to the resident elopement incident and failure to provide adequate supervision.
Findings
The facility failed to provide adequate supervision to a high-risk resident with severe cognitive deficits, resulting in the resident eloping from the facility. The immediate jeopardy began on 10/3/23 but was removed on 10/4/23 after corrective actions were implemented.
Deficiencies (1)
Failure to supervise a resident with severe cognitive deficits and wandering behaviors, resulting in elopement.
Report Facts
Census: 82
Total Capacity: 82
Resident Elopement Risk Score: 13
Dates of Survey: October 10, 11 & 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services | Named in relation to notification of immediate jeopardy and involvement in resident supervision |
| Social Service Director | Social Service Director | Observed resident sitting outside and involved in incident reporting |
| Psychiatric Services Nurse Practitioner | Psychiatric Services Nurse Practitioner | Provided clinical observations about the resident's condition and safety risks |
| Front Desk Receptionist/Administrative Assistant | Front Desk Receptionist/Administrative Assistant | Witnessed resident exiting the facility and sitting outside |
| Marketing/Admission Director | Marketing/Admission Director | Sat with resident outside and involved in supervision attempts |
| Administrator | Administrator | Involved in investigation and communication with cab company and police |
| LPN 2 | Licensed Practical Nurse | Staff on resident's unit unaware of elopement until notified |
Inspection Report
Life Safety
Census: 89
Capacity: 103
Deficiencies: 15
Date: Sep 11, 2023
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including exit signage illumination, kitchen fire suppression system inspection, fire alarm and sprinkler system policies and maintenance, fire door inspections, smoking area maintenance, portable fire extinguisher inspections, corridor door functionality, portable space heater use, electrical equipment safety, and oxygen cylinder storage.
Deficiencies (15)
Failed to ensure 1 of 16 exit signs was continuously illuminated in the Main Dining area.
Failed to ensure 1 of 1 kitchen fire suppression system was inspected semi-annually and exhaust fans were not working.
Failed to provide correct written fire watch policy for fire alarm system out of service for more than 4 hours.
Failed to ensure a full hydrostatic flush was performed on 1 of 2 automatic sprinkler piping systems.
Failed to provide correct written policies for sprinkler system out-of-service for more than 10 hours.
Failed to inspect 8 of 20 portable fire extinguishers monthly.
Failed to ensure 1 of 2 storage room corridor doors had proper latching and resisted passage of smoke.
Failed to maintain smoking area by disposing cigarette butts in metal containers with self-closing covers.
Failed to maintain annual testing of 1 of 1 rolling fire door in accordance with NFPA 80.
Failed to ensure annual inspection and testing of 5 of 5 fire door assemblies were completed.
Failed to ensure 1 of 1 portable space heater was not used in the facility.
Failed to ensure 4 of 4 power strips were not used as a substitute for fixed wiring to provide power to high current draw equipment.
Failed to ensure 1 of 1 flexible cord was not used as a substitute for fixed wiring.
Failed to ensure 1 of 1 flexible cord was installed properly and used in a safe manner.
Failed to ensure oxygen cylinders in 2 of 2 transfilling/storage rooms were properly secured from falling.
Report Facts
Certified beds: 103
Census: 89
Exit signs deficient: 1
Fire extinguishers not inspected: 8
Fire door assemblies: 5
Oxygen cylinders unsecured: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to fire safety deficiencies and corrective actions | |
| Executive Director | Provided in-service training to Maintenance Director on various fire safety policies and procedures |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 88
Deficiencies: 1
Date: Aug 28, 2023
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00415753, IN00415686, IN00414945, IN00414477, IN00412401, IN00409697, IN00409479) in conjunction with a Recertification and State Licensure Survey.
Complaint Details
Complaint IN00415686 was substantiated with federal/state deficiencies cited at F600 related to verbal abuse. Other complaints had no deficiencies cited or were partially substantiated with deficiencies at F921 and F755.
Findings
The facility was found to have federal/state deficiencies related to verbal abuse of a resident (Resident E) by a staff member (CNA 6). Several complaints were substantiated with deficiencies cited at tags F600, F921, and F755. The facility implemented corrective actions including staff education and suspension of the involved CNA.
Deficiencies (1)
Facility failed to ensure 1 of 4 residents interviewed were free of verbal abuse (Resident E).
Report Facts
Census: 88
Total Capacity: 88
Medicare Census: 7
Medicaid Census: 73
Other Payor Census: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 6 | Certified Nursing Assistant | Named in verbal abuse finding and suspended pending investigation |
| RN 5 | Registered Nurse | Involved in investigation and de-escalation of verbal abuse incident |
| Shawn Blackburn | Regional Nurse Consultant | Signed the inspection report |
Inspection Report
Annual Inspection
Census: 88
Deficiencies: 19
Date: Aug 28, 2023
Visit Reason
This visit was for the Recertification and State Licensure Survey and the investigation of multiple complaints.
Complaint Details
Complaints IN00414945, IN00414477, IN00412401, IN00409697, IN00409479, IN00415753, and IN00415686 were investigated. Deficiencies were cited related to complaints IN00412401, IN00409479, and IN00415686.
Findings
The facility was found deficient in multiple areas including resident trust fund access, abuse prevention, notification of discharge to Ombudsman, care planning, ADL care, vision and hearing services, nutrition, respiratory care, trauma-informed care, pharmacy services, medication administration, medication storage, dental services, food safety, infection control, and environmental safety.
Deficiencies (19)
Facility failed to ensure 28 residents with resident trust accounts had access to more than $50 daily and reasonable access after hours and weekends.
Facility failed to ensure documentation of notification to a Medicaid resident exceeding allowable limit.
Facility failed to ensure 1 of 4 residents were free from verbal abuse.
Facility failed to notify Ombudsman timely of resident discharge for 1 of 1 resident reviewed.
Facility failed to develop care plan for impaired vision for 1 of 28 residents reviewed.
Facility failed to revise care plan and include resident in care plan meetings for 1 of 29 residents reviewed.
Facility failed to provide shaving and nail care for dependent residents.
Facility failed to arrange ophthalmology follow-up appointment for 1 of 1 resident reviewed for vision and hearing.
Facility failed to ensure oxygen and respiratory equipment use was ordered and care planned for 2 of 28 residents reviewed for respiratory needs.
Facility failed to provide trauma-informed care plan for 1 of 1 resident reviewed for PTSD.
Facility failed to ensure medication was available for administration in 2 of 3 residents reviewed who received anxiolytic medication.
Facility failed to ensure pharmacy recommendation for PRN medication was re-evaluated and signed by physician for 1 of 5 residents reviewed.
Facility failed to ensure insulin was administered at the correct time for 1 of 2 residents reviewed.
Facility failed to ensure medication error rate was less than 5%, with 5 errors observed in 39 opportunities.
Facility failed to ensure medications were labeled and dated in 1 of 2 medication storage rooms and 1 of 2 medication carts.
Facility failed to ensure dental examinations and referrals were completed timely for 3 residents reviewed for dental services.
Facility failed to ensure food items and drinks were covered when transporting meal trays to residents.
Facility failed to ensure nursing staff followed manufacturer's recommendations for cleaning glucometer.
Facility failed to ensure shower drains were free of debris in the north shower room.
Report Facts
Census: 88
Medication error rate: 12.82
Residents affected by trust fund access issue: 28
Residents audited for medication administration: 10
Residents audited for glucometer cleaning: 10
Residents audited for insulin administration timing: 10
Residents audited for dental services: 5
Residents audited for meal tray coverage: 10
Shower room audits: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Blackburn | RN, Regional Nurse Consultant | Signed report |
| RN 5 | Involved in abuse investigation and resident care | |
| CNA 6 | Involved in abuse investigation and resident care | |
| LPN 3 | Involved in medication misappropriation investigation | |
| LPN 4 | Involved in medication misappropriation investigation | |
| RN 2 | Involved in medication misappropriation investigation |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 0
Date: May 25, 2023
Visit Reason
This visit was conducted for the investigation of three complaints: IN00409068, IN00406707, and IN00405653.
Complaint Details
Complaints IN00409068, IN00406707, and IN00405653 were investigated and no deficiencies related to the allegations were found.
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 regulations.
Report Facts
Census SNF/NF: 85
Total Capacity: 85
Census Payor Type Medicare: 4
Census Payor Type Medicaid: 73
Census Payor Type Other: 8
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 25, 2023
Visit Reason
The visit was conducted as a Paper Compliance Review related to Complaint IN00403393 completed on March 13, 2023.
Complaint Details
Complaint IN00403393 was investigated and the facility was found to be in compliance.
Findings
Majestic Care of South Bend was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the Paper Compliance Review to the Complaint Investigation.
Inspection Report
Annual Inspection
Census: 85
Capacity: 85
Deficiencies: 0
Date: Mar 24, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00403921 and Complaint IN00404257.
Complaint Details
Investigation of Complaint IN00403921 and Complaint IN00404257 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00403921 and Complaint IN00404257 were cited. The facility was found to be in compliance with applicable federal and state regulations.
Report Facts
Census Bed Type: 85
Census Payor Type - Medicare: 14
Census Payor Type - Medicaid: 67
Census Payor Type - Other: 4
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 1
Date: Mar 6, 2023
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00402382, IN00401464, IN00400135, IN00399728, IN00403393, and IN00403645) at Majestic Care of South Bend.
Complaint Details
Complaint IN00403393 was substantiated with federal/state deficiencies cited at F561 related to failure to ensure showers were received per resident choice. Other complaints investigated had no deficiencies related to the allegations.
Findings
The facility failed to ensure that residents received showers according to their schedules and preferences, affecting 5 of 6 residents reviewed for activities of daily living. Documentation discrepancies and lack of shower sheets were noted, indicating failure to support resident self-determination in personal hygiene.
Deficiencies (1)
Facility failed to ensure showers were received per resident choices for 5 of 6 residents reviewed for activities of daily living.
Report Facts
Census: 79
Total Capacity: 79
Medicare Census: 12
Medicaid Census: 63
Other Payor Census: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Franklin Ekete | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding shower documentation and deficiencies | |
| QMA 5 | Interviewed regarding shower sheets and schedules | |
| CNA 6 | Interviewed regarding shower frequency and documentation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 5, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to complaint investigations IN00391587 and IN00393836.
Complaint Details
The visit was a complaint investigation related to complaints IN00391587 and IN00393836, and the facility was found to be in compliance.
Findings
Majestic Care of South Bend was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00395477.
Complaint Details
Complaint IN00395477 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF beds: 64
Census Medicare residents: 4
Census Medicaid residents: 57
Census Other residents: 3
Total Census: 64
Inspection Report
Complaint Investigation
Census: 62
Capacity: 62
Deficiencies: 4
Date: Nov 17, 2022
Visit Reason
This visit was for the investigation of three complaints (IN00391587, IN00393836, and IN00394299) at Majestic Care of South Bend.
Complaint Details
Complaint IN00391587 was substantiated with a deficiency cited at F695 related to respiratory/tracheostomy care and suctioning. Complaint IN00393836 was substantiated with a deficiency cited at F677 related to ADL care. Complaint IN00394299 was substantiated but no deficiency was cited related to the allegations.
Findings
The facility was found to have substantiated deficiencies related to failure to report and investigate allegations of abuse, failure to provide adequate ADL care for dependent residents, and failure to properly identify rooms where oxygen was used or stored. Some unrelated deficiencies were also cited.
Deficiencies (4)
Failed to report an allegation of abuse for 1 of 3 residents reviewed (Resident K).
Failed to investigate an allegation of abuse for 1 of 3 residents reviewed (Resident K).
Failed to ensure residents who were incontinent were kept clean, dry and odor free for 2 of 4 residents reviewed (Residents G and H).
Failed to ensure rooms where oxygen was being used or stored were identified by oxygen signs for 10 of 12 resident rooms observed.
Report Facts
Census: 62
Total Capacity: 62
Medicare Census: 5
Medicaid Census: 55
Other Payor Census: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Franklin Ekete | Executive Director | Signed the report and involved in administrative oversight |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 0
Date: Sep 19, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00390045.
Complaint Details
Complaint IN00390045 - Unsubstantiated due to lack of evidence.
Findings
The complaint IN00390045 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Report Facts
Census SNF/NF: 63
Census Payor Type Medicare: 9
Census Payor Type Medicaid: 54
Census Payor Type Other: 0
Inspection Report
Life Safety
Census: 61
Capacity: 103
Deficiencies: 11
Date: Sep 7, 2022
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with multiple Life Safety Code requirements including emergency preparedness plan deficiencies, hazardous area door issues, fire alarm system maintenance, sprinkler system installation, smoke barrier door obstructions, electrical safety including lack of GFCI protection, and improper use of power strips.
Deficiencies (11)
Failed to develop and maintain an emergency preparedness plan reviewed and updated at least annually.
Failed to develop and implement emergency preparedness policies and procedures reviewed and updated at least annually.
Failed to develop and maintain an emergency preparedness communication plan reviewed and updated at least annually.
Failed to develop and maintain an emergency preparedness training and testing program reviewed and updated at least annually.
Failed to analyze the LTC facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the LTC facility's emergency plan as needed.
Failed to ensure hazardous area door (Biohazard room corridor door) fully self-closes and latches.
Fire alarm system control panel had incorrect date and time displayed.
Failed to maintain sprinkler system escutcheon properly sealed in electrical closet ceiling.
Smoke barrier doors obstructed by a reclining chair preventing full closure.
Failed to provide ground fault circuit interrupter (GFCI) protection for electrical outlets within 6 feet of wet locations (hand washing sink in nurse's station).
Use of power strip in Social Services office for refrigerator and microwave instead of fixed wiring.
Report Facts
Facility certified beds: 103
Census: 61
Deficiencies with severity SS=C: 6
Deficiencies with severity SS=E: 5
Deficiencies with severity SS=F: 1
Inspection Report
Deficiencies: 0
Date: Sep 7, 2022
Visit Reason
The visit was conducted to complete the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey for Majestic Care of South Bend.
Findings
Majestic Care of South Bend was found in compliance with the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, as well as the Life Safety Code requirements and State Licensure regulations.
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 0
Date: Aug 26, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388722.
Complaint Details
Complaint IN00388722 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The complaint IN00388722 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare residents: 4
Medicaid residents: 56
Total residents: 60
Inspection Report
Annual Inspection
Census: 62
Capacity: 62
Deficiencies: 12
Date: Aug 5, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from August 1 to 5, 2022.
Findings
The facility was found deficient in multiple areas including resident rights, comprehensive assessments, quality of care, treatment of pressure ulcers, range of motion/mobility, dialysis care, pharmacy services, psychotropic medication monitoring, facility assessment, resident records, quality assurance activities, and immunizations.
Deficiencies (12)
Failed to ensure personal privacy for 2 residents when staff entered rooms without knocking or asking permission.
Failed to ensure accuracy of Minimum Data Set (MDS) assessments for 2 residents.
Failed to ensure adequate blood sugar check practices for 2 residents.
Failed to ensure treatment and services to prevent and heal pressure ulcers for 1 resident.
Failed to ensure restorative treatment for impaired range of motion for 1 resident.
Failed to ensure ongoing communication and assessments for 4 residents receiving dialysis.
Failed to ensure adequate labeling and open dates on medications for 11 residents.
Failed to ensure side effect monitoring for 1 resident receiving psychotropic medications.
Failed to ensure a complete and accurate facility assessment for the time period of 8/2021 through 7/2022.
Failed to maintain complete and accurate resident records for 4 residents.
Failed to ensure compliance was monitored regarding prior identified concerns including dialysis and medication storage for 14 residents and failed to ensure complete records of quality assurance meetings for 7 months.
Failed to maintain pneumonia immunization documentation and ensure residents were current on pneumococcal vaccination for 3 residents.
Report Facts
Survey dates: 5
Census: 62
Total capacity: 62
Residents affected by medication labeling deficiency: 11
Residents affected by dialysis communication deficiency: 4
Residents affected by quality assurance monitoring deficiency: 14
Months with incomplete quality assurance records: 7
Residents affected by pneumonia vaccine deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Named in blood sugar check and medication labeling findings |
| QMA 3 | Qualified Medical Assistant | Named in medication labeling findings |
| DNS | Director of Nursing Services | Named in multiple findings including privacy, MDS accuracy, wound care, dialysis, and quality assurance |
| ED | Executive Director | Named in multiple findings including facility assessment and quality assurance |
| RN 7 | Registered Nurse | Named in dialysis communication findings |
| PCT 8 | Patient Care Technician | Named in dialysis communication findings |
| Regional Nurse Consultant | Named in multiple findings including privacy, MDS accuracy, wound care, psychotropic medication monitoring, and immunizations |
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 5, 2022
Visit Reason
Paper Compliance to the Licensure and Recertification survey completed on August 5, 2022.
Findings
Majestic Care of South Bend was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC16.2 in regard to the Paper Compliance to the Licensure and Recertification survey.
Viewing
Loading inspection reports...
