Inspection Reports for Majestic Care of North Vernon
701 HENRY STREET, IN, 47265
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 12, 2025, identified multiple deficiencies related to medication management, infection control, food safety, and staff licensure compliance. Earlier inspections showed a mixed pattern with recurring issues in medication storage and administration, infection prevention, and maintaining a safe, sanitary environment. Several complaint investigations were substantiated, including failures to notify physicians of condition changes, improper restraint use, and incomplete abuse investigations, though many complaints were found unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The overall trend indicates ongoing challenges with regulatory compliance, particularly in clinical care and safety practices, with no clear sustained improvement over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
281% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 101
Capacity: 101
Deficiencies: 9
Date: Jun 12, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from June 8 to June 12, 2025.
Findings
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.
Deficiencies (9)
Failed to ensure residents were deemed appropriate to self-administer medications prior to leaving medications at bedside unsupervised for 2 residents.
Failed to revise a resident's care plan related to prophylactic antibiotic usage for 1 resident.
Failed to follow physician's orders related to hold parameters for cardiac medications for 3 residents.
Failed to ensure proper placement of urinary catheter drainage bag for 1 resident.
Failed to follow physician's orders related to medication administration for 1 resident (crushing a 'do not crush' potassium chloride ER tablet).
Failed to store medications appropriately related to outdated/undated medications on 3 medication carts.
Failed to follow appropriate guidelines related to hair coverings in the kitchen, store foods in a sanitary manner, and failed to follow infection control guidelines related to hand hygiene during dining observations.
Failed to follow appropriate infection control guidelines during wound dressing change and indwelling urinary catheter management for 4 residents.
Allowed a Certified Nurse Aide (CNA) to work with an expired license.
Report Facts
Survey dates: 5
Census: 101
Total capacity: 101
Residents reviewed for care plans: 21
Residents reviewed for quality of care: 21
Residents reviewed for infection control: 21
Medication carts observed: 4
Staff license expiration date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Kern | Executive Director | Signed the inspection report |
| Kelsey Brown | Nurse Practitioner | Gave new order to change potassium to liquid form |
| Dr. Neese | Reviewed hold parameters for cardiac medications and notified about potassium order |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 12, 2025
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure Survey.
Findings
Majestic Care of North Vernon 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 Annual Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 98
Capacity: 98
Deficiencies: 0
Date: May 1, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00457842 and IN00455935.
Complaint Details
Complaint IN00457842 - No deficiencies related to the allegations were cited. Complaints IN00455935 - No deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00457842 and IN00455935 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 3
Medicaid census: 90
Other payor census: 5
Inspection Report
Complaint Investigation
Census: 96
Capacity: 96
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
This visit was for the investigation of Complaint IN00453604.
Complaint Details
Complaint IN00453604 - No deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations 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 complaint investigation.
Report Facts
Census: 96
Total Capacity: 96
Medicare Census: 1
Medicaid Census: 89
Other Payor Census: 6
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 24, 2025
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00447341 completed on December 19, 2024.
Complaint Details
Complaint IN00447341 was investigated and found to be corrected as of the review date January 24, 2025.
Findings
Majestic Care of North Vernon was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 98
Capacity: 98
Deficiencies: 0
Date: Jan 8, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00450689, IN00449675, and IN00449588.
Complaint Details
Complaints IN00450689, IN00449675, and IN00449588 were investigated with no deficiencies found related to the allegations.
Findings
No deficiencies related to the allegations were cited for any of the three complaints investigated. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF: 98
Total Capacity: 98
Medicare Census: 4
Medicaid Census: 90
Other Payor Census: 4
Inspection Report
Complaint Investigation
Census: 97
Capacity: 97
Deficiencies: 1
Date: Dec 19, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00447341 regarding failure to notify the physician of a change in condition for a resident.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to notify the physician of a change in condition for Resident B.
Report Facts
Census: 97
Total Capacity: 97
Medicare Residents: 2
Medicaid Residents: 91
Other Payor Residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Kern | Executive Director | Signed the report |
| Registered Nurse 2 | Interviewed; unable to recall resident or provide additional information beyond documentation | |
| Licensed Practical Nurse 3 | Documented resident found unresponsive | |
| Director of Nursing | Interviewed; confirmed no physician notification documented on date of resident's condition change |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 102
Deficiencies: 0
Date: Oct 11, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443530.
Complaint Details
Complaint IN00443530 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 relevant regulations.
Report Facts
Census: 102
Total Capacity: 102
Medicare Census: 2
Medicaid Census: 81
Private Pay Census: 7
Other Payor Census: 12
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 30, 2024
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00439556 unrelated findings.
Complaint Details
Investigation of Complaint IN00439556 unrelated findings; paper compliance review completed.
Findings
Majestic Care of North Vernon 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 unrelated findings.
Inspection Report
Complaint Investigation
Census: 110
Capacity: 110
Deficiencies: 2
Date: Sep 4, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00439556 regarding alleged verbal abuse of Resident C by staff members.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to report an allegation of verbal abuse in a timely manner for Resident C.
Failed to appropriately investigate an allegation of abuse for Resident C, including lack of interviews with resident and other residents.
Report Facts
Census: 110
Total Capacity: 110
Medicare Census: 5
Medicaid Census: 94
Other Payor Census: 11
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 15, 2024
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Majestic Care of North Vernon 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: 105
Capacity: 120
Deficiencies: 0
Date: Aug 5, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to follow up on a previous survey that exited on 07/08/2024.
Findings
At this Life Safety Code survey, Majestic Care Of North Vernon 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 NFPA 101 Life Safety Code. The facility was fully sprinkled with appropriate fire alarm and smoke detection systems.
Inspection Report
Life Safety
Census: 101
Capacity: 120
Deficiencies: 10
Date: Jul 8, 2024
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with 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.
Deficiencies (10)
Closet door in beauty shop lacked a locking mechanism that could be unlocked from inside during emergencies.
Bathrooms near Executive Director's office had slide locks preventing doors from being opened from outside in emergencies.
Doors to Housekeeping rooms 3 and 4 lacked self-closing devices.
Failed to document monthly sprinkler system inspections as required by NFPA 25.
Failed to inspect monthly four fire extinguishers in various rooms.
Resident sleeping room door (A107) did not close completely and latch.
Electrical box in central nurses' station lacked a cover plate.
Failed to conduct 3rd shift quarterly fire drills for one quarter in 2024.
Metal container with self-closing cover in smoking area contained combustible materials.
Failed to ensure annual fuel quality test was performed for diesel generator.
Report Facts
Certified beds: 120
Census: 101
Deficiencies cited: 10
Fire drills missed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Phil Ford | Executive Director | Named in exit conferences and plan of correction requests |
| Maintenance Director | Interviewed regarding deficiencies and observations | |
| Maintenance Assistant | Performed corrective actions such as installing electrical box cover |
Inspection Report
Renewal
Census: 99
Capacity: 99
Deficiencies: 2
Date: Jul 2, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on June 26, 27, 28, July 1, and 2, 2024.
Findings
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.
Deficiencies (2)
Failed to maintain residents' snack refrigerators related to storage of non-food items and unlabeled food items in 3 of 4 refrigerators reviewed (C-Hall, A-Hall, D-Hall).
Failed to provide a homelike environment related to odors for 1 of 4 hallways reviewed (B-Hall) due to strong urine odor.
Report Facts
Census: 99
Licensed Capacity: 99
Inspection Dates: 5
Audit Frequency: 5
Audit Duration: 6
Snack Refrigerator Audits: 2
B-Hall Odor Audits: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Phil R Ford | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding food storage and odor issues | |
| Head of Maintenance | Interviewed regarding urine odor and ventilation issues on B-Hall | |
| Housekeeping Supervisor | Interviewed regarding urine odor and cleaning challenges on B-Hall | |
| Certified Nurse Aide 5 | Interviewed regarding urine issues on B-Hall |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 101
Deficiencies: 0
Date: May 31, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00433095.
Complaint Details
Complaint IN00433095 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 Payor Type - Medicare: 6
Census Payor Type - Medicaid: 87
Census Payor Type - Other: 8
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 28, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00425571 completed on January 29, 2024.
Complaint Details
Investigation of Complaint IN00425571 completed on January 29, 2024; facility found in compliance.
Findings
Majestic Care of North Vernon 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: 107
Capacity: 107
Deficiencies: 1
Date: Jan 28, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00425571 regarding allegations of improper use of physical restraints on a resident.
Complaint Details
Complaint IN00425571 was substantiated with a federal/state deficiency cited at F604 related to the allegation of improper physical restraint.
Findings
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.
Deficiencies (1)
Failure to prevent physical restraint of a resident by tying a blanket around her waist without a physician's order.
Report Facts
Census Bed Type: 107
Medicare Census: 7
Medicaid Census: 81
Other Payor Census: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Phil R Ford | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative |
| LPN 6 | Licensed Practical Nurse | Interviewed regarding the restraint incident and assessment of Resident B |
| CNA 2 | Certified Nurse Aide | Placed blanket restraint on Resident B and was removed from the hallway |
| CNA 4 | Certified Nurse Aide | Witnessed the restraint incident and reported it |
| LPN 5 | Licensed Practical Nurse | Present on memory care unit during incident and assisted in removing the blanket restraint |
| Dietary Aide 3 | Dietary Aide | Reported the blanket restraint to LPN 6 |
| Administrator | Interviewed about the incident and staff reports | |
| DON | Director of Nursing | Received reports about the restraint incident and provided facility policy |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 107
Deficiencies: 0
Date: Jan 5, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00422087.
Complaint Details
Complaint IN00422087 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00422087 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 107
Total Capacity: 107
Medicare Census: 7
Medicaid Census: 88
Other Payor Census: 12
Inspection Report
Complaint Investigation
Census: 103
Capacity: 103
Deficiencies: 0
Date: Oct 23, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00419793.
Complaint Details
Complaint IN00419793 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00419793 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 6
Medicaid census: 85
Other payor census: 12
Inspection Report
Follow-Up
Census: 104
Capacity: 120
Deficiencies: 0
Date: Jul 31, 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 06/12/23.
Findings
At this PSR survey, Majestic Care of North Vernon was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements, including fire safety and sprinkler systems.
Report Facts
Certified beds: 120
Census: 104
Resident sleeping rooms surveyed: 61
Inspection Report
Re-Inspection
Census: 109
Capacity: 109
Deficiencies: 0
Date: Jun 14, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on May 15, 2023.
Findings
Majestic Care of North Vernon 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.
Report Facts
Census SNF/NF: 109
Census Payor Type Medicare: 11
Census Payor Type Medicaid: 86
Census Payor Type Other: 12
Inspection Report
Complaint Investigation
Census: 110
Capacity: 110
Deficiencies: 0
Date: Jun 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408911 at Majestic Care of North Vernon.
Complaint Details
Investigation of Complaint IN00408911 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 Bed Type: 110
Medicare Census: 11
Medicaid Census: 84
Other Payor Census: 15
Inspection Report
Life Safety
Census: 110
Capacity: 120
Deficiencies: 9
Date: Jun 12, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with emergency preparedness, life safety, and fire safety regulations.
Findings
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.
Deficiencies (9)
Emergency generator annunciator panel 'overcrank' status indicator light was illuminated indicating system trouble and was not reset.
One of seven means of egress was obstructed by dehumidifiers and cords, preventing full instant use in case of emergency.
Kitchen exhaust system was not inspected semiannually as required by NFPA 96.
Fire alarm system annunciator failed inspection and repair documentation was not available; smoke detectors failed sensitivity testing without repair documentation; fire alarm panel clocks showed incorrect time.
Two corridor doors to resident rooms had impediments to closing and latching and a hole in a door that would not resist smoke passage.
Fuel fired water heaters lacked current inspection certificates from the State of Indiana.
Documentation of fire drills for second and third shifts in certain quarters was not available.
Annual inspection and testing of all fire door assemblies was not fully documented or itemized by location as required.
Documentation of electrical receptacle testing for all resident sleeping rooms was not available for review.
Report Facts
Certified beds: 120
Census: 110
Fire drills missing documentation: 2
Smoke detectors failed sensitivity testing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Phil Ford | Executive Director | Named in relation to exit conference and review of findings. |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 106
Deficiencies: 0
Date: May 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408689.
Complaint Details
Complaint IN00408689 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 Bed Type: 106
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 79
Census Payor Type - Other: 16
Total Census: 106
Inspection Report
Annual Inspection
Census: 106
Capacity: 106
Deficiencies: 9
Date: May 15, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from May 8 to May 15, 2023.
Findings
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.
Deficiencies (9)
Failure to ensure resident rights were posted and readily accessible to residents.
Failure to complete neurological evaluations/checks following falls for 3 of 22 residents reviewed.
Failure to prevent pressure ulcers that resulted in Stage 3 pressure ulcers and failure to follow physician's orders for pressure ulcer treatment for 3 of 7 residents reviewed.
Failure to implement Care Plan interventions for 1 of 5 residents reviewed for falls.
Failure to administer oxygen as ordered by the physician for 1 of 2 residents reviewed for respiratory care.
Failure to appropriately follow physician's orders related to once a day medication administration for 1 of 6 residents reviewed for pharmacy services.
Failure to store medications appropriately in medication carts and medication room, including expired and unlabeled medications.
Failure to maintain residents' snack refrigerators related to unlabeled items, outdated items, and storage of non-resident food items for 2 of 3 refrigerators reviewed.
Failure to demonstrate ongoing corrective actions to address unresolved quality deficiencies related to pressure ulcers previously cited.
Report Facts
Survey dates: 6
Census: 106
Total capacity: 106
Residents reviewed for Quality of Care: 22
Residents reviewed for pressure ulcers: 7
Residents reviewed for falls: 5
Residents reviewed for respiratory care: 2
Residents reviewed for pharmacy services: 6
Medication expiration days: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Phil Ford | Executive Director | Signed the report |
| QMA 2 | Qualified Medication Aide | Interviewed regarding resident rights posting and food storage |
| QMA 9 | Qualified Medication Aide | Interviewed regarding fall care plan interventions and oxygen administration |
| LPN 6 | Licensed Practical Nurse | Interviewed regarding medication cart storage and oxygen administration |
| RN 12 | Registered Nurse | Interviewed regarding medication storage and medication room |
| DON | Director of Nursing | Provided multiple interviews and documentation |
| ADON | Assistant Director of Nursing | Interviewed regarding pressure ulcers and oxygen administration |
| Wound Nurse Practitioner | Interviewed regarding pressure ulcer care | |
| QMA 4 | Qualified Medication Aide | Interviewed regarding food storage |
| CNA 11 | Certified Nurse Aide | Interviewed regarding skin checks |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 13, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00400655 completed on March 17, 2023.
Complaint Details
Investigation of Complaint IN00400655 completed on March 17, 2023; facility found in compliance.
Findings
Majestic Care of North Vernon 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: 102
Capacity: 102
Deficiencies: 1
Date: Mar 17, 2023
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00403474, IN00400900, IN00400692, IN00400655, IN00398221, and IN00396246) at Majestic Care of North Vernon.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide wound care using appropriate infection control guidelines related to hand hygiene during wound treatments for 1 of 3 residents reviewed for wounds (Resident F).
Report Facts
Census: 102
Total Capacity: 102
Medicare Residents: 3
Medicaid Residents: 84
Other Payor Residents: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mandi Paul | Regional Nurse Consultant | Signed the report |
| RN 2 | Registered Nurse | Named in wound care and hand hygiene deficiency |
| DON | Director of Nursing | Interviewed regarding awareness of RN failure in hand hygiene |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 12, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00394434 completed on November 18, 2022.
Complaint Details
Investigation of Complaint IN00394434 completed; facility found in compliance.
Findings
Majestic Care of North Vernon 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: 107
Capacity: 107
Deficiencies: 1
Date: Nov 16, 2022
Visit Reason
This visit was for the investigation of complaints IN00394434, IN00392739, and IN00392475.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to provide appropriate care plan interventions for a severely cognitively impaired resident related to safe environment supervision during meal time.
Report Facts
Census: 107
Total Capacity: 107
Medicare Census: 5
Medicaid Census: 88
Other Payor Census: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Mollenhoff | Director of Nursing Services | Named as Director of Nursing who was interviewed and provided facility policies and information related to the incident |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 28, 2022
Visit Reason
Paper compliance review to the Complaint Investigation IN00390208 completed on September 21, 2022.
Complaint Details
Complaint Investigation IN00390208 was reviewed for paper compliance and found to be in compliance.
Findings
Majestic Care of North Vernon 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
Re-Inspection
Census: 107
Capacity: 120
Deficiencies: 0
Date: Sep 27, 2022
Visit Reason
This was a Post Survey Revisit (PSR) to a prior PSR conducted on 09/16/22 for the Life Safety Code Recertification and State Licensure Survey originally conducted on 07/25/22 and 07/26/22 by the Indiana Department of Health.
Findings
At this PSR survey, Majestic Care of North Vernon was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code. The facility was fully sprinkled with appropriate fire alarm and smoke detection systems in place.
Report Facts
Resident sleeping rooms surveyed: 61
Inspection Report
Complaint Investigation
Census: 108
Capacity: 108
Deficiencies: 1
Date: Sep 21, 2022
Visit Reason
This visit was for the investigation of three complaints (IN00390086, IN00390208, and IN00389984). Two complaints were substantiated, with one resulting in a cited deficiency.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to provide housekeeping necessary to maintain a sanitary, orderly, and comfortable homelike environment for 5 of 14 resident rooms observed (Rooms 114, 115, 116, 104, and 105) with issues such as hair and dust behind faucets, dirt debris on floors, stool spots in toilets, food debris, dead bugs, cobwebs, and dust on furniture and equipment.
Report Facts
Resident rooms observed: 14
Rooms with housekeeping deficiencies: 5
Census: 108
Total licensed capacity: 108
Inspection Report
Re-Inspection
Census: 109
Capacity: 120
Deficiencies: 1
Date: Sep 16, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on previous Emergency Preparedness and Life Safety Code surveys conducted on 07/25/22 and 07/26/22.
Findings
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.
Deficiencies (1)
Failed to maintain the means of egress free from obstructions in 2 of 8 means of egress, including a large padded wheelchair blocking nearly half of an eight-foot-wide corridor and storage of meal carts, cardboard boxes, and oxygen concentrators in corridors.
Report Facts
Certified beds: 120
Census: 109
Means of egress obstructions: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Participated in observation and interview regarding means of egress obstructions | |
| Assistant Maintenance Director | Participated in observation and interview regarding means of egress obstructions |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 107
Deficiencies: 0
Date: Aug 2, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00385898 and was conducted in conjunction with the Post Survey Revisit to the Recertification and State Licensure Survey completed on June 29, 2022, and the PSR to the Investigation of Complaint IN00380062 completed on May 23, 2022.
Complaint Details
Complaint IN00385898 was substantiated with no deficiencies cited. Complaint IN00380062 was corrected.
Findings
Complaint IN00385898 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00380062 was corrected. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of complaints.
Report Facts
Census SNF/NF: 107
Total Capacity: 107
Census Payor Type Medicare: 14
Census Payor Type Medicaid: 71
Census Payor Type Other: 22
Inspection Report
Re-Inspection
Census: 107
Capacity: 107
Deficiencies: 0
Date: Aug 1, 2022
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Investigation of Complaint IN00380062 completed on May 23, 2022, in conjunction with the PSR to the Recertification and State Licensure Survey completed on June 29, 2022, and the Investigation of Complaint IN00385898.
Complaint Details
Complaint IN00380062 was corrected. Complaint IN00385898 was substantiated with no deficiencies cited related to the allegations.
Findings
Complaint IN00380062 was corrected. Complaint IN00385898 was substantiated but no deficiencies related to the allegations 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 Complaint IN00380062.
Report Facts
Census SNF/NF: 107
Census Payor Type Medicare: 14
Census Payor Type Medicaid: 71
Census Payor Type Other: 22
Inspection Report
Follow-Up
Census: 107
Capacity: 107
Deficiencies: 0
Date: Aug 1, 2022
Visit Reason
This was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on June 29, 2022, conducted in conjunction with PSRs to investigations of complaints IN00380062 and IN00385898.
Complaint Details
Complaint IN00385898 was substantiated with no deficiencies cited. Complaint IN00380062 was corrected.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1. Complaint IN00385898 was substantiated but no deficiencies related to the allegations were cited, and Complaint IN00380062 was corrected.
Report Facts
Census: 107
Total Capacity: 107
Medicare Census: 14
Medicaid Census: 71
Other Payor Census: 22
Inspection Report
Routine
Census: 102
Capacity: 120
Deficiencies: 17
Date: Jul 26, 2022
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with federal and state regulations including emergency preparedness, fire safety, and facility operations.
Findings
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.
Deficiencies (17)
Emergency preparedness policies failed to include use of volunteers in emergencies and emergency staffing strategies.
Failed to implement emergency power system inspection, testing, and maintenance requirements including missing monthly load testing and weekly inspection documentation.
Exit door by Room A100 did not release to open with fire alarm activation, resulting in Immediate Jeopardy.
Means of egress were obstructed by wheelchair, meal carts, oxygen concentrators, and other items in corridors.
Exit door keypad lock installation incomplete and inoperable, preventing door release during fire alarm activation.
Hazardous areas such as fuel-fired heater rooms were not separated by smoke resistant partitions and doors.
Kitchen fire suppression system was not inspected semiannually as required.
Fire alarm system control panel batteries failed inspection and replacement documentation was missing.
Portable fire extinguisher operating instructions and pressure gauge were not facing outward in the cabinet.
Corridor door to oxygen storage room failed to latch and secure properly.
Smoke barrier walls and ceiling penetrations were not properly firestopped to maintain fire resistance rating.
Quarterly fire drills and staff training documentation were incomplete or missing for multiple shifts and quarters.
Smoking materials were not properly disposed of in metal containers with self-closing covers in outdoor staff smoking area.
Extension cords and power strips were used improperly as substitutes for fixed wiring in patient care areas.
Emergency generator monthly load testing and weekly inspection documentation were incomplete for several months.
Emergency generator remote annunciator panel indicated system trouble with 'not in auto' light illuminated.
Storage location for nonflammable gases was not secured against unauthorized entry and door locking mechanism failed.
Report Facts
Certified beds: 120
Census: 102
Deficiency count: 17
Fire drills missing documentation: 3
Emergency generator missing monthly load tests: 6
Emergency generator missing weekly inspections: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed and involved in findings related to emergency preparedness, fire safety, and facility maintenance | |
| Administrator | Interviewed and involved in exit conferences regarding findings | |
| Maintenance Director | Named in plan of correction for education and corrective actions |
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