Inspection Reports for Majestic Care of Sheridan
803 S HAMILTON ST, IN, 46069
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 5, 2025, found the facility in compliance with fire safety and licensure requirements and cited no deficiencies. Earlier inspections showed a pattern of deficiencies primarily related to life safety code issues such as fire alarm and sprinkler system maintenance, exit discharge conditions, and emergency preparedness, as well as some concerns with resident care documentation and medication practices. Complaint investigations during this period were mostly unsubstantiated, with one substantiated complaint that did not result in cited deficiencies. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s recent inspections indicate improvement, with the latest visits showing compliance following prior citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
174% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
99% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Re-Inspection
Census: 79
Capacity: 80
Deficiencies: 0
Date: Jun 5, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/16/25 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and applicable state and national fire safety codes. The facility is fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 80
Census: 79
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Date: May 19, 2025
Visit Reason
This visit was for the investigation of complaints IN00458020 and IN00458509.
Complaint Details
Complaint IN00458020 and Complaint IN00458509 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00458020 and IN00458509 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 79
Census Payor Type - Medicaid: 72
Census Payor Type - Other: 7
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 25, 2025
Visit Reason
The visit was conducted as a paper compliance review for the Recertification and State Licensure survey.
Findings
Majestic Care of Sheridan 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: 79
Capacity: 80
Deficiencies: 4
Date: Apr 16, 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 04/16/2025.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included failure to provide an approved method for returning cooking appliances under the kitchen hood extinguishing system, failure to maintain fire alarm system semi-annual inspections, failure of smoke barrier doors to close completely, and failure to complete annual inspection and testing of fire door assemblies.
Deficiencies (4)
Failed to provide an approved method for returning cooking appliances to their approved design location under the kitchen hood extinguishing system after maintenance or cleaning.
Failed to maintain 1 of 1 fire alarm systems with required semi-annual visual inspections and testing.
Failed to ensure 1 of 4 sets of smoke barrier doors would restrict smoke movement by closing completely, leaving a six-inch gap due to air pressure.
Failed to ensure annual inspection and testing of 5 of 5 fire door assemblies were completed as required.
Report Facts
Certified beds: 80
Census: 79
Fire door assemblies: 5
Smoke barrier doors: 4
Staff potentially affected: 6
Residents potentially affected: 30
Residents potentially affected: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abigail Rector | Administrator in Training | Named in relation to the exit conference and survey. |
| Regional Director of Plant Operations | Interviewed regarding deficiencies and corrective actions. | |
| Maintenance Director | Responsible for corrective actions and educated on deficiencies. | |
| Executive Director | Provided education and oversight for corrective actions. |
Inspection Report
Renewal
Census: 77
Capacity: 77
Deficiencies: 3
Date: Apr 3, 2025
Visit Reason
This visit was for a Recertification and State Licensure survey conducted from March 30 to April 3, 2025.
Findings
The facility was found deficient in notifying the ombudsman of a resident's transfer to the hospital, following physician orders for medication administration and notification, and completing quarterly smoking assessments for residents at risk related to smoking.
Deficiencies (3)
Failed to ensure the ombudsman was notified of a resident's transfer and discharge to the hospital for 1 of 2 residents reviewed.
Failed to ensure physician's orders were followed, medications were held, and the physician was notified when vital signs were below ordered parameters for 1 of 5 residents reviewed.
Failed to ensure quarterly smoking assessments were completed for 2 of 2 residents reviewed for accident hazards related to smoking.
Report Facts
Census: 77
Total Capacity: 77
Residents reviewed for transfer and discharge: 2
Residents reviewed for quality of care: 5
Residents reviewed for smoking assessment: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Kirkwood | HFA, RN | Facility representative who signed the report |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Date: Jan 31, 2025
Visit Reason
This visit was for the investigation of Complaint IN00451980.
Complaint Details
Complaint IN00451980 - No deficiencies related to the allegations are 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 Bed Type: 79
Census Payor Type Medicaid: 69
Census Payor Type Other: 10
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Date: Dec 4, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448470.
Complaint Details
Complaint IN00448470 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 SNF/NF: 78
Census Payor Type Medicare: 1
Census Payor Type Medicaid: 61
Census Payor Type Other: 16
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 17, 2024
Visit Reason
The document is a paper compliance submission for the Post Survey Revisit (PSR) related to the Life Safety Code Recertification and State Licensure Survey.
Findings
Majestic Care of Sheridan was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies, and 410 IAC 16.2.
Inspection Report
Re-Inspection
Census: 78
Capacity: 80
Deficiencies: 1
Date: Jun 3, 2024
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 04/18/24 to verify compliance with federal and state requirements.
Findings
At this PSR survey, Majestic Care of Sheridan was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to failure to maintain automatic sprinkler system supervisory attachments. Specifically, the facility's dry sprinkler system did not have a tamper switch on the main control valve as required.
Deficiencies (1)
Failed to maintain automatic sprinkler system supervisory attachments; the dry sprinkler system did not have a tamper switch on the main control valve.
Report Facts
Certified beds: 80
Census: 78
Deficiency completion date: Jun 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Kirkwood | HFA, RN | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Director of Maintenance | Interviewed regarding sprinkler system tamper switch deficiency |
Inspection Report
Routine
Census: 77
Capacity: 80
Deficiencies: 15
Date: Apr 18, 2024
Visit Reason
Routine Emergency Preparedness and Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code, and other regulatory standards including deficiencies in emergency power system maintenance, fire safety, sprinkler system maintenance, fire drills, combustible decorations, and generator testing.
Deficiencies (15)
Failed to implement emergency power system inspection, testing, and maintenance requirements; weekly inspection documentation missing; emergency generator lacked remote emergency stop button.
Failed to maintain building construction type for Type V(111) in automatic transfer switch rooms; 2 inch hole above electrical panel not repaired.
Exit discharge blocked by porch swing and debris; exit discharge walking surface had abrupt elevation changes.
Exit discharge lighting obscured by bird's nest; emergency lighting monthly testing documentation missing.
Failed to ensure annual maintenance documentation for smoke detectors in resident rooms was complete.
Kitchen range hood fire suppression system not maintained properly; electrical appliances did not shut down during inspection.
Dry sprinkler system lacked tamper switch; failed 3-year leak test with leaking pipes and corroded sprinkler; fire department connection drain leaking; main control valve not locked or supervised.
Weekly sprinkler gauge and control valve inspection documentation missing for 44 weeks.
One sprinkler head was painted and corroded, scheduled for replacement.
Failed to conduct quarterly fire drills at unexpected times on second shift for 4 of 4 quarters.
Curtains in main dining room lacked flame propagation documentation and were not treated with fire retardant.
Combustible decoration (plastic wreath) on resident room door lacked fire retardant documentation.
Annual fire door inspection incomplete; one door failed to fully self-close and latch.
Emergency generator weekly inspection and monthly load testing documentation missing for 46 weeks; lacked remote emergency stop button outside generator enclosure.
Emergency generator load testing documentation missing for 11 months.
Report Facts
Certified beds: 80
Census: 77
Weeks missing generator inspection documentation: 46
Weeks missing sprinkler gauge and control valve inspection documentation: 44
Months missing generator load testing documentation: 11
Fire drills not conducted at unexpected times: 4
Generator rating: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Kirkwood | HFA, RN | Laboratory Director or Provider/Supplier Representative who signed the report. |
Inspection Report
Renewal
Census: 77
Capacity: 77
Deficiencies: 2
Date: Mar 25, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over March 19, 20, 21, 22, and 25, 2024.
Findings
The facility was found deficient in medication administration practices, specifically setting up more than one medication administration at a time for residents, and improper storage of medications and chemicals in medication storage rooms.
Deficiencies (2)
Facility failed to ensure only one medication administration was set up at a time for 2 of 2 residents reviewed (Residents 34 and 282).
Facility failed to store chemicals in a safe manner and failed to ensure only medications were stored in the refrigerator/freezer unit for 1 of 2 medication storage rooms.
Report Facts
Census: 77
Total Capacity: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Kirkwood | HFA, RN | Signed as Laboratory Director's or Provider/Supplier Representative |
| RN 4 | Observed and interviewed regarding medication administration practices | |
| RN 3 | Interviewed regarding medication storage and destroyed medications | |
| Director of Nursing | Interviewed regarding storage policies in medication rooms | |
| Executive Director | Interviewed regarding medication administration and storage policies |
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 25, 2024
Visit Reason
Paper compliance review for the Recertification and State Licensure survey conducted on March 25, 2024.
Findings
Majestic Care of Sheridan 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
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Date: Aug 31, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00415586 and IN00413525.
Complaint Details
Complaint IN00415586 and Complaint IN00413525 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations in complaints IN00415586 and IN00413525 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 80
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 73
Census Payor Type - Other: 6
Total Census: 80
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Date: Jun 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00403851.
Complaint Details
Complaint IN00403851 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00403851 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: 71
Census other payor residents: 6
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 18, 2023
Visit Reason
The document is a paper compliance report for the Post Survey Revisit (PSR) related to the Life Safety Code Recertification and State Licensure Survey that exited on 02/06/23 and 03/13/23.
Findings
Majestic Care of Sheridan 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.
Inspection Report
Re-Inspection
Census: 80
Capacity: 80
Deficiencies: 1
Date: Mar 13, 2023
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 previously conducted on 02/06/23.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to issues with exit discharge surfaces. Specifically, 2 of over 5 exit discharges had uneven, obstructed, or unsafe walking surfaces, presenting trip hazards.
Deficiencies (1)
Failed to ensure 2 of over 5 exit discharges had a level walking surface, were free of obstructions, and constructed of hard packed all-weather travel surface.
Report Facts
Certified beds: 80
Census: 80
Affected exit discharges: 2
Total exit discharges observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Kirkwood | HFA, RN | Laboratory Director or Provider/Supplier Representative who signed the report |
| Maintenance Director | Named in relation to findings about exit discharge deficiencies and corrective actions |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Date: Feb 13, 2023
Visit Reason
This visit was for the investigation of Complaint IN00399255.
Complaint Details
Complaint IN00399255 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The complaint IN00399255 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations regarding the complaint.
Report Facts
Census: 76
Total Capacity: 76
Medicare residents: 1
Medicaid residents: 66
Other residents: 9
Inspection Report
Life Safety
Census: 79
Capacity: 80
Deficiencies: 16
Date: Feb 6, 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 and life safety requirements.
Findings
The facility was found not in compliance with emergency preparedness requirements related to emergency power system inspection and testing, and life safety code requirements including means of egress obstructions, exit discharge conditions, hazardous area door self-closing devices, cooking equipment shutoff access, fire alarm and sprinkler system out-of-service policies, corridor door smoke resistance and latching, electrical safety including GFCI protection and receptacle faceplates, fire drills timing, portable space heater use, electrical outlet testing documentation, emergency generator battery backup lighting, and oxygen storage room signage.
Deficiencies (16)
Failed to implement emergency power system equipment inspection, testing, and maintenance requirements; missing emergency battery powered light near generator.
Exit discharge paths not readily accessible; chained padlocked gate in exit discharge path.
Over corridor means of egress obstructed by wheeled equipment without wheels.
Means of egress doors equipped with locks requiring tool or key from egress side; exit door codes not posted.
Exit discharge surfaces uneven, cracked, and presenting trip hazards.
Hazardous area door to Infection Control Room lacked self-closing device.
Staff lacked access to shutoff switch for cooktop in therapy area.
Fire alarm system out of service policy incomplete; missing ISDH Gateway contact information.
Sprinkler system out of service policy incomplete; missing ISDH Gateway contact information.
Corridor doors failed to resist passage of smoke; gaps and holes in doors; doors propped open with doorstop; doors failed to latch.
Wet location electrical outlets lacked GFCI protection; missing outlet faceplates.
Fire drills not conducted at unexpected times under varying conditions.
Portable space heater used in facility where prohibited.
Electrical outlet receptacle testing documentation not current within 12 months.
Emergency task generator battery backup light missing near generator.
Oxygen storage/transfer room lacked signage indicating when transferring oxygen is occurring.
Report Facts
Certified beds: 80
Census: 79
Fire drills: 4
Generator exercise frequency: 12
Generator exercise interval: 20
Generator long exercise interval: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Kirkwood | HFA, RN | Signed the report |
| Maintenance Director | Interviewed and acknowledged findings related to emergency preparedness and life safety deficiencies | |
| Executive Director | Interviewed and acknowledged findings; involved in education and corrective action |
Inspection Report
Renewal
Census: 78
Capacity: 78
Deficiencies: 4
Date: Jan 11, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on January 4, 5, 6, 9, 10, and 11, 2023.
Findings
The facility was found deficient in multiple areas including failure to follow physician recommendations for resident care, unsecured medication carts, improper food storage and handling, and unsanitary environmental conditions in shower rooms and resident equipment.
Deficiencies (4)
Failed to ensure a resident's physician recommendations and comprehensive care plan were followed to reduce the risk of aspiration for 1 of 1 resident reviewed for quality of care (Resident 53).
Failed to ensure a medication cart was secured for 1 of 4 medication carts reviewed for medication storage (100 Hall cart).
Failed to label, date and store refrigerated and freezer foods properly, failed to prevent freezer burn, failed to date canned items when received, failed to date frozen meats when thawing, and failed to serve food in a sanitary manner affecting all 78 residents.
Failed to maintain a safe, functional, sanitary, and comfortable environment related to accumulation of black substance on shower room floors, missing tiles, and soiled resident equipment for 1 resident and 2 shower rooms.
Report Facts
Census Bed Type: 78
Survey Dates: January 4, 5, 6, 9, 10, and 11, 2023
Medicare Census: 9
Medicaid Census: 60
Other Payor Census: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Kirkwood | HFA, RN | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 11, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure survey completed on January 11, 2023.
Findings
Majestic Care of Sheridan 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
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00393434.
Complaint Details
Complaint IN00393434 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: 78
Medicare census: 9
Medicaid census: 60
Other payor census: 9
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