Inspection Reports for
Majestic Care of West Allen
6050 S CR 800 E 92, FORT WAYNE, IN, 46814
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
210% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
83% occupied
Based on a June 2025 inspection.
Occupancy over time
Inspection Report
Life Safety
Census: 80
Capacity: 96
Deficiencies: 4
Date: Jun 12, 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 06/12/2025.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies were identified related to sprinkler system maintenance, Dutch door latching, smoke barrier door damage, and electrical equipment testing.
Deficiencies (4)
Failed to ensure a full hydrostatic flush was performed on 1 of 1 automatic sprinkler piping systems as required by NFPA 25.
Failed to ensure both leaves on 1 of 1 Dutch doors latched into the frame and met required specifications.
Failed to ensure 1 of 4 smoke barrier doors were properly inspected and repaired; service hall smoke doors had holes and were damaged.
Failed to ensure 25 of 25 Patient Care Related Electrical Equipment were retested after being replaced.
Report Facts
Deficiencies cited: 4
Residents affected: 80
Total capacity: 96
PCREE items failed testing: 25
Smoke barrier doors inspected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zach Krumwied | Executive Director | Signed the report and participated in exit conference |
| Maintenance Director | Interviewed and involved in findings related to sprinkler system, doors, and electrical equipment | |
| Administrator | Interviewed and involved in exit conference |
Inspection Report
Re-Inspection
Census: 76
Capacity: 76
Deficiencies: 0
Date: May 28, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on May 8, 2025, including the PSR to the Investigation of Complaint IN00458229 completed on May 8, 2025.
Complaint Details
Complaint IN00458229 was investigated and found to be corrected.
Findings
Majestic Care of West Allen 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 PSR to the Investigation of Complaint IN00458229.
Report Facts
Census Bed Type: 76
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 68
Census Payor Type - Other: 6
Inspection Report
Annual Inspection
Census: 78
Capacity: 78
Deficiencies: 6
Date: May 8, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00458229.
Complaint Details
Complaint IN00458229 was investigated during this visit. Deficiencies related to the allegations were cited at F689, F812, and F921.
Findings
The facility was found deficient in multiple areas including ADL care related to toenail care, security and supervision of residents in restricted areas, nutrition and hydration status maintenance, food safety and sanitation, garbage disposal, and maintenance of the physical environment.
Deficiencies (6)
Failed to ensure toenail care was provided for 1 of 7 residents reviewed (Resident 52).
Failed to ensure staff areas remained secure and smoking materials were secured for 1 of 12 residents reviewed (Resident 53).
Failed to ensure care plan interventions were implemented, weight losses were reported and addressed timely resulting in significant weight loss of 6.6% in 30 days for 1 of 3 residents reviewed (Resident 37).
Failed to store and serve food and drinks to maintain food safety for 78 residents consuming food and drinks from the kitchen.
Failed to dispose of garbage and refuse properly for 3 dumpsters.
Failed to maintain the dining room, the 300 hall and one resident room in a safe, functional, sanitary, and comfortable environment.
Report Facts
Census: 78
Total Capacity: 78
Weight Loss Percentage: 6.6
Residents Participating in Smoking Activities: 12
Residents with Medicare: 3
Residents with Medicaid: 70
Residents with Other Payor: 5
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 0
Date: Apr 9, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00455946.
Complaint Details
Investigation of Complaint IN00455946 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00455946 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 77
Total Capacity: 77
Medicaid Census: 72
Other Payor Census: 5
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00447418.
Complaint Details
Investigation of Complaint IN00447418 found 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: 80
Total Capacity: 80
Medicaid Census: 73
Other Payor Census: 7
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Date: Oct 24, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00444748.
Complaint Details
Complaint IN00444748 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00444748 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 80
Census Payor Type Medicare: 2
Census Payor Type Medicaid: 73
Census Payor Type Other: 5
Inspection Report
Life Safety
Census: 78
Capacity: 96
Deficiencies: 0
Date: Oct 3, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/15/24 by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this PSR, Majestic Care of West Allen 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 Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 96
Census: 78
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Date: Sep 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441924.
Complaint Details
Complaint IN00441924 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00441924 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF beds: 79
Census total residents: 79
Census Medicare residents: 2
Census Medicaid residents: 62
Census other payor residents: 15
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 27, 2024
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey was completed.
Findings
Majestic Care of West Allen 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: 81
Capacity: 96
Deficiencies: 10
Date: Aug 15, 2024
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 08/15/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included sprinkler clearance obstruction, improperly installed portable fire extinguishers, corridor door not latching, missing GFCI protection in wet locations, inadequate fire drill variation, use of a prohibited portable space heater, lack of 36-month emergency generator testing documentation, and improper use of power strips and extension cords.
Deficiencies (10)
Failed to maintain at least 18 inches clearance below sprinkler deflectors due to boxes stacked in memory care office.
Portable fire extinguisher in memory care unit staff closet was not properly secured.
One portable fire extinguisher in laundry room missing inspection tag, pull pin, and tamper resistant seal.
One corridor door (room 111) did not close and latch properly.
Two wet location receptacles lacked ground fault circuit interrupter (GFCI) protection and failed testing.
Fire drills failed to vary conditions at unexpected times on first and second shifts for 3 of 4 quarters.
Portable space heater found under reception desk, prohibited by facility policy.
Failed to document 36-month emergency generator testing for 1 of 1 emergency generators.
Medical supply room refrigerator powered by surge protector instead of fixed wiring.
Power strip in resident room 101 did not meet required UL rating for patient care vicinity.
Report Facts
Deficiencies cited: 10
Residents affected by sprinkler clearance deficiency: 10
Residents affected by fire extinguisher deficiencies: 10
Residents affected by corridor door deficiency: 32
Residents affected by GFCI deficiency: 10
Residents affected by portable space heater deficiency: 5
Residents affected by generator testing deficiency: 96
Residents affected by power cord deficiency: 96
Residents affected by power strip deficiency: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zach Krumwied | Executive Director | Named during exit conference and in relation to review of findings. |
| Maintenance Director | Interviewed and acknowledged multiple deficiencies including sprinkler obstruction, fire extinguisher issues, door latch failure, GFCI testing, portable space heater, generator testing, and power strip use. |
Inspection Report
Annual Inspection
Census: 79
Capacity: 79
Deficiencies: 2
Date: Jul 30, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the investigation of two complaints (IN00437880 and IN00439160). No deficiencies were cited related to the complaints.
Complaint Details
Complaint IN00437880 and Complaint IN00439160 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in two areas: failure to ensure grooming services for facial hair for one resident, and failure to identify triggers to prevent re-traumatization for two residents with trauma histories. Plans of correction included care plan updates, staff education, audits, and monitoring.
Deficiencies (2)
Failure to ensure grooming of facial hair for Resident 16 who required assistance with personal care.
Failure to identify triggers to prevent potential re-traumatization for Residents 3 and 16 who were trauma survivors.
Report Facts
Census: 79
Total Capacity: 79
Behavior incidents: 38
Behavior incidents: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zach Krumwied | Executive Director | Signed the report and mentioned in interviews regarding facility operations and deficiencies |
| Administrator | Interviewed regarding Resident 16's grooming and trauma triggers; name not fully provided | |
| Regional Nurse Consultant | Interviewed regarding Resident 16's care and preferences; name not fully provided | |
| Director of Nursing | Interviewed regarding Resident 16's care and facility policies; name not fully provided | |
| Social Service Director | Interviewed regarding trauma care plans and facility care plan reviews; name not fully provided |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 82
Deficiencies: 0
Date: Jun 20, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00436058, IN00436503, and IN00436703.
Complaint Details
Investigation of complaints IN00436058, IN00436503, and IN00436703 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00436058, IN00436503, and IN00436703 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 82
Total Capacity: 82
Medicare Census: 1
Medicaid Census: 77
Other Payor Census: 4
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 0
Date: May 10, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00432280, IN00432625, and IN00433876.
Complaint Details
Complaints IN00432280, IN00432625, and IN00433876 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 73
Census Payor Type - Other: 5
Inspection Report
Complaint Investigation
Census: 83
Capacity: 83
Deficiencies: 0
Date: Mar 28, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00429412 and IN00430954.
Complaint Details
Complaint IN00429412 - No deficiencies related to the allegations are cited. Complaint IN00430954 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in Complaints IN00429412 and IN00430954 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 83
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 70
Census Payor Type - Other: 9
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 0
Date: Feb 20, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00426341, IN00426871, and IN00427035.
Complaint Details
Complaints IN00426341, IN00426871, and IN00427035 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00426341, IN00426871, and IN00427035 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF beds: 77
Total census: 77
Medicare census: 5
Medicaid census: 64
Other payor census: 8
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Date: Jan 10, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00423769 and IN00424206.
Complaint Details
Complaint IN00423769 and Complaint IN00424206 were investigated; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00423769 and IN00424206 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 72
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 62
Census Payor Type - Other: 7
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 1
Date: Nov 28, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00421807 regarding federal/state deficiencies related to medication cart security.
Complaint Details
Complaint IN00421807 was substantiated with federal/state deficiencies cited at F761 related to medication cart security.
Findings
The facility failed to ensure medication carts were secured/locked during observations on the 100 hall, with two medication carts found unlocked and unattended. The facility acknowledged the deficiency and implemented corrective actions including locking carts and auditing procedures.
Deficiencies (1)
Medication carts were not secured/locked during observations on the 100 hall.
Report Facts
Residents on 100 hall: 29
Total census: 78
Total capacity: 78
Medicare residents: 2
Medicaid residents: 68
Other payor residents: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SeAndra Robinson | RN DNS | Named as Laboratory Director's or Provider/Supplier Representative's Signature on report. |
| Qualified Medication Aide 2 | Qualified Medication Aide | Interviewed regarding medication cart security on 100 hall. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 28, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00421807 completed on November 28, 2023.
Complaint Details
Investigation of Complaint IN00421807 completed with findings of compliance.
Findings
Majestic Care West Allen 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: 82
Capacity: 82
Deficiencies: 0
Date: Nov 2, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00419875, IN00420038, IN00420095, and IN00420425 at Majestic Care of West Allen.
Complaint Details
Complaints IN00419875, IN00420038, IN00420095, and IN00420425 were investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the investigation of the complaints.
Report Facts
Census SNF/NF: 82
Total licensed capacity: 82
Medicare census: 3
Medicaid census: 71
Other payor census: 8
Inspection Report
Complaint Investigation
Census: 82
Capacity: 82
Deficiencies: 0
Date: Sep 14, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416072.
Complaint Details
Investigation of Complaint IN00416072 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00416072 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 82
Total Capacity: 82
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 72
Census Payor Type - Other: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 11, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00414847 and IN00415402 completed on August 22, 2023.
Complaint Details
The visit was related to complaint investigations IN00414847 and IN00415402; the facility was found in compliance.
Findings
Majestic Care West Allen 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 Investigations.
Inspection Report
Follow-Up
Census: 80
Capacity: 96
Deficiencies: 0
Date: Sep 11, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 07/31/23 by the Indiana Department of Health.
Findings
At this PSR survey, Majestic Care of West Allen was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility was fully sprinklered except for a detached garage used to store maintenance supplies and equipment.
Report Facts
Facility capacity: 96
Census: 80
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 1
Date: Aug 22, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00414847 and IN00415402 regarding medication administration issues.
Complaint Details
The investigation was triggered by complaints IN00414847 and IN00415402. Federal/state deficiencies related to the allegations were cited at F684.
Findings
The facility failed to ensure medications were administered as ordered for 2 of 5 residents reviewed (Resident B and Resident C). Multiple medications were not given on several dates as documented in the Medication Administration Records (MAR). The Director of Nursing was unable to provide documentation explaining the missed medications.
Deficiencies (1)
Failure to administer medications as ordered for Resident B and Resident C.
Report Facts
Census: 79
Total Capacity: 79
Missed medication dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zach Krumwied | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding missed medication documentation but no full name provided |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 8, 2023
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey completed on July 20, 2023.
Findings
Majestic Care of West Allen 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: 80
Capacity: 96
Deficiencies: 12
Date: Jul 31, 2023
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 several Life Safety Code requirements including means of egress obstructions, exit door locking, emergency lighting, exit signage, smoke barrier door maintenance, sprinkler installation and maintenance, electrical safety, and gas equipment storage and handling.
Deficiencies (12)
Failed to ensure 1 of 4 means of egress were continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency.
Failed to ensure the means of egress through 2 of 5 exit doors and 1 of 1 exit gates were readily accessible and keypad exit codes were not posted.
Failed to ensure 3 of 3 battery powered emergency lights were maintained and tested properly.
Failed to ensure exit paths did not have conflicting exit signs and lacked directional signage.
Failed to maintain latching hardware on 1 of 4 smoke barrier doors to the 200-hall.
Failed to ensure corridor doors to 2 of 5 hazardous areas containing fuel fired equipment were provided with self-closing devices that latch.
Failed to ensure 1 of 2 receptacles within 6 feet from a sink were provided with ground fault circuit interrupter (GFCI) protection.
Failed to ensure 1 of 1 flexible cords were not used as a substitute for fixed wiring.
Failed to ensure 4 of 8 sprinklers in the kitchen were not loaded and free of corrosion.
Failed to ensure 2 of 2 lounges open to the corridor were provided with electrically supervised automatic smoke detection system.
Failed to ensure 5 of 12 cylinders of nonflammable gases such as oxygen were properly secured from falling and 12 of 12 oxygen cylinders were not separated and marked to avoid confusion.
Failed to ensure annual inspection and testing of 1 of 1 oxygen transfilling room fire doors were completed and the door was self-closing and latched.
Report Facts
Facility capacity: 96
Census: 80
Deficient sprinklers: 4
Obstructed emergency lights: 3
Obstructed pull stations: 1
Unsecured oxygen cylinders: 5
Unmarked oxygen cylinders: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zach Krumwied | Executive Director | Named in relation to exit conference and plan of correction |
| Maintenance Director | Interviewed and involved in findings and corrective actions throughout report |
Inspection Report
Renewal
Census: 82
Capacity: 82
Deficiencies: 2
Date: Jul 17, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from July 17 to July 20, 2023.
Findings
The facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, specifically due to environmental maintenance issues affecting 14 of 82 residents. Observations included missing bathroom door trim with protruding metal clips and a maintenance office door propped open with access to potentially harmful chemicals.
Deficiencies (2)
Missing trim along the bathroom door in room 217 with protruding metal clips that could cause injury.
Maintenance office door was propped open with access to cleaning chemicals visible and accessible from the hallway.
Report Facts
Residents affected: 14
Residents in room 217: 2
Residents attending bingo activity: 12
Census: 82
Total licensed capacity: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zach Krumwied | Executive Director | Signed the report and participated in interviews regarding findings |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 82
Deficiencies: 1
Date: Jun 29, 2023
Visit Reason
This visit was conducted for the investigation of four complaints (IN00410783, IN00411231, IN00411611, and IN00411878) regarding the facility's care and compliance.
Complaint Details
Complaints IN00410783, IN00411611, and IN00411878 were substantiated with federal/state deficiencies cited at F744. Complaint IN00411231 had no deficiencies related to the allegations.
Findings
The facility failed to ensure appropriate dementia care interventions were implemented for 3 of 4 residents reviewed, resulting in multiple behavioral and care issues including skin tears, wandering, aggression, and lack of individualized dementia care plans. Staff lacked awareness of specific person-centered interventions for dementia-related behaviors, and the facility did not have a dementia program in place but was in the process of implementing one.
Deficiencies (1)
Failure to implement appropriate dementia care interventions for residents with dementia-related behaviors.
Report Facts
Residents reviewed with dementia care deficiencies: 3
Total census: 82
Total capacity: 82
Behavior episodes for Resident K in June 2023: 115
Behavior episodes for Resident L in June 2023: 103
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00410783, IN00411878, and IN00411611 completed on June 29, 2023.
Complaint Details
The visit was related to complaint investigations IN00410783, IN00411878, and IN00411611. Compliance was found based on paper review.
Findings
Majestic Care of West Allen 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 of the investigations.
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Date: May 19, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00407012.
Complaint Details
Complaint IN00407012 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: 80
Total Capacity: 80
Medicare Census: 2
Medicaid Census: 75
Other Payor Census: 3
Inspection Report
Complaint Investigation
Census: 82
Capacity: 82
Deficiencies: 0
Date: Apr 25, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00405094.
Complaint Details
Complaint IN00405094 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00405094 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 6
Medicaid census: 67
Other payor census: 9
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 1
Date: Jan 19, 2023
Visit Reason
The visit was conducted for the investigation of Complaint IN00398620, which was substantiated.
Complaint Details
Complaint IN00398620 was substantiated. The investigation found verbal abuse by a Certified Nursing Assistant (CNA 2) towards residents, including use of explicit language and inappropriate commands. The facility took corrective action prior to the survey date.
Findings
The facility failed to protect residents from verbal abuse by a staff member for 2 of 4 residents reviewed. The deficient practice was corrected on 2023-01-05 after the facility completed measures including staff education and monitoring.
Deficiencies (1)
Failure to protect residents from verbal abuse by staff, including use of explicit language and verbal commands.
Report Facts
Census: 85
Total Capacity: 85
Medicare Residents: 4
Medicaid Residents: 74
Other Residents: 7
BIMS Score Resident B: 0
BIMS Score Resident E: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA 2) | Named in verbal abuse findings | |
| Qualified Nursing Assistant (QMA 3) | Witnessed and reported verbal abuse | |
| Assistant Director of Nursing (ADON) | Investigated and assessed verbal abuse incident | |
| Licensed Practical Nurse (LPN 4) | Reported and witnessed verbal abuse incident | |
| MDS Coordinator 5 | Reported and investigated verbal abuse incident | |
| Certified Nursing Assistant (CNA 6) | Provided definition and examples of verbal abuse |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 0
Date: Dec 20, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00396644.
Complaint Details
Complaint IN00396644 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint IN00396644 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: 85
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 74
Census Payor Type - Other: 5
Inspection Report
Complaint Investigation
Census: 90
Capacity: 90
Deficiencies: 0
Date: Nov 29, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00394503.
Complaint Details
Complaint IN00394503 was substantiated; however, no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 78
Census Payor Type - Other: 5
Inspection Report
Life Safety
Census: 87
Capacity: 96
Deficiencies: 0
Date: Oct 27, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
Majestic Care of West Allen was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is fully sprinklered except for a detached garage used for maintenance supplies and equipment.
Report Facts
Facility capacity: 96
Census: 87
Inspection Report
Annual Inspection
Census: 81
Capacity: 81
Deficiencies: 12
Date: Sep 21, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00389825.
Complaint Details
Complaint IN00389825 was investigated and found unsubstantiated due to lack of evidence.
Findings
The facility was found deficient in multiple areas including resident rights, care plan revisions, ADL care, activity provision, range of motion maintenance, accident prevention, respiratory care, RN coverage, dementia care, medication monitoring, garbage disposal, and sanitary environment.
Deficiencies (12)
Facility failed to ensure a resident was treated with dignity and respect (Resident 23).
Facility failed to ensure resident care plans were comprehensive and updated for 4 residents (44, 46, 69, 73).
Facility failed to provide personal hygiene related to grooming and shaving for 1 resident (44).
Facility failed to ensure resident centered activity plan was carried out for 1 resident (46).
Facility failed to ensure range of motion was maintained for 1 resident (46).
Facility failed to ensure residents were free from injuries related to accidents for 2 residents (45 and 81).
Facility failed to ensure oxygen therapy was administered according to physician's order and tubing was properly labeled for 3 residents (1, 16, 44).
Facility failed to ensure a Registered Nurse was present in the building for at least 8 hours per day for 2 days (9/17/22 and 9/18/22).
Facility failed to monitor and record behaviors for 1 resident with dementia (Resident 8).
Facility failed to ensure adequate monitoring of opioid side effects for 1 resident (27).
Facility failed to ensure garbage and waste were stored in a sanitary manner; dumpster lids were observed open multiple times.
Facility failed to provide a sanitary environment in 2 resident shared bathrooms (Rooms 116 and 120) with unclean bedpans, wash basins, and improperly stored personal items.
Report Facts
Census: 81
Total Capacity: 81
Survey Dates: 5
Residents on Medicare: 4
Residents on Medicaid: 73
Residents Private Pay: 3
Residents Other Pay: 1
RN coverage missing days: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Named in resident rights dignity violation for telling Resident 23 to 'shut up' |
| Executive Director | Provided incident report and statements related to resident rights complaint | |
| Nurse Consultant 7 | Interviewed regarding care plan deficiencies and range of motion care | |
| CNA 6 | Certified Nursing Aide | Observed providing catheter care and commented on grooming and resident care |
| QMA 11 | Qualified Medical Assistant | Interviewed regarding resident grooming and care refusals |
| Activity Director | Interviewed regarding resident activity participation | |
| LPN 12 | Licensed Practical Nurse | Interviewed regarding resident fall and injury |
| QMA 14 | Qualified Medication Assistant | Interviewed regarding oxygen tubing labeling |
| DON 8 | Director of Nursing | Interviewed regarding opioid side effect monitoring and RN coverage |
| Social Service Director | Interviewed regarding resident sexual behaviors and documentation |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 21, 2022
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Majestic Care of West Allen 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.
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