Majestic Care of Deming Park

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's right to be free of sexual abuse was protected for 1 of 3 residents reviewed for abuse (Resident G). The deficient practice was corrected 12/10/25, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident-to-resident abuse to the Indiana Department of Health in a timely manner for 2 of 4 residents reviewed for abuse (Resident B and C). This deficient practice was corrected by 11/3/25 prior to the start of the survey and was therefore Past Noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from neglect, when staff failed to visualize a confused resident during their shift resulting in the resident eloping from the facility for 1 of 3 residents reviewed for neglect (Resident B). The immediate jeopardy began on 10/11/25 when the facility failed to protect the resident's right to be free from neglect when a resident with a traumatic brain injury and at risk of elopement was able to exit the facility sometime after 9:30 p.m., on 10/11/25, or early morning, on 10/12/25, despite wearing a WanderGuard (a type of wander management system used in senior living communities and healthcare facilities to prevent residents at risk of wandering from leaving the premises unsupervised) bracelet. The facility alarm system failed to alert staff of the resident exiting with a WanderGuard. [...]

Inspectors wroteBased on record reviews, interviews, and observation, the facility failed to supervise and prevent a confused resident at risk of elopement from eloping from the facility sometime after 9:30 pm on 10/11/25 into the early morning of 10/12/25 (Resident B). A resident with a traumatic brain injury and at risk of elopement was able to exit the facility sometime after 9:30 p.m. on 10/11/25 or early morning on 10/12/25 despite wearing a WanderGuard bracelet (a type of wander management system used in senior living communities and healthcare and healthcare facilities to prevent residents at risk of wandering from leaving the premises unsupervised). The facility alarm system failed to alert staff of the resident exiting with a WanderGuard. The night shift nurse and night shift CNA on 10/11/25 failed to visualize the resident during their 8-hour shift. On 10/12/25 around 7 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sanitary area for handwashing, the dishwasher functionality was effectively checked, foods were covered when stored, and foods were discarded once past the best if used by date. This deficient practice had the potential to effect 61 of 61 residents who received food from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure a dedicated Infection Preventionist (IP-a healthcare professional who specializes in preventing the spread of infections within healthcare facilities) was designated to oversee the facility's Infection Prevention program.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's call light was kept within their reach for 1 of 24 residents reviewed for call lights (Resident B).

Inspectors wrote2. During the initial pool interview, on 6/19/25 at 11:12 a.m., Resident E indicated he was supposed to get two showers a week and had not had any this current week and only one the week before. The aides were asking him to sign off the shower sheet even though he was not getting one. Resident E's record was reviewed on 6/23/25 at 10:11 a.m. The profile indicated the resident had been admitted to the facility on [DATE], for diagnoses which included, but were not limited to, hemiplegia and hemiparesis due to cerebral infarction (weakness or paralysis on one side of the body caused by damage to the brain from a stroke). An admission Minimum Data Set (MDS) assessment, dated 6/6/25, indicated the resident had no cognitive deficit and no documentation for refusal of care. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure nail care was provided for a resident who required assistance with activities of daily living (ADLs) for 1 of 24 residents reviewed for ADLs (Resident B).

Inspectors wroteBased on record review and interview, the facility failed to ensure a physician's order was accurately transcribed from a pharmacy recommendation for 1 of 5 residents reviewed for unnecessary medications (Resident 38).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an insulin pen medication was labeled to indicate date opened during 1 of 2 medication cart observations (Resident 29).

Inspectors wroteBased on observation and interview, the facility failed to ensure infection control procedures were followed to prevent possible contamination of work surfaces with potential to affect residents for 1 of 1 glucometer (a small, portable device that measures the amount of glucose (sugar) in your blood) test observation.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was transferred in a safe manner for 1 of 1 residents reviewed for transfers (Resident C).

Inspectors wroteBased on interview and record review, the facility lacked documentation of showers being provided related to resident preferences for 3 of 24 residents reviewed for choices (Residents 57, 14, and 11).

Inspectors wroteA. Based on observations, record reviews, and interviews, the facility failed to complete a respiratory assessment on a resident prior to receiving a nebulizer treatment for 1 of 1 resident observed (Resident 8) B. Based on observations, record reviews, and interviews, the facility failed to ensure proper storage of respiratory equipment for 3 of 3 residents reviewed for respiratory care. (Residents 8, 14, and 54). C. Based on observations, record reviews, and interviews, the facility failed to obtain a physician order for oxygen supplementation for 1 of 3 residents reviewed for respiratory care (Resident 14).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure refrigerator temperatures were up to date, and outdated food was discarded during 2 of 3 kitchen observations.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an indwelling urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) bag and tubing were prevented from contact with the floor for 1 of 2 residents reviewed for catheter/UTI (urinary tract infection-an infection in any part of the urinary system)(Resident 56), and to ensure that indwelling urinary catheter care (clean the area where the catheter exits your body and the catheter itself with soap and water every day) was for 2 of 2 residents reviewed for catheter/UTI documented (Residents 56 and 41).

Inspectors wroteA. Based on interview and record review, the facility failed to ensure a dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) resident received a tray for meals missed while at dialysis for 1 of 1 residents reviewed for dialysis (Resident 27). B. Based on record review and interview, the failed to ensure documentation of an assessment of a residents arteriovenous (AV) dialysis fistula (a connection that's made between an artery and a vein for dialysis access) for 1 of 1 residents observed for dialysis (Resident 27).

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure proper administration of inhaled medication during the medication administration pass for 2 of 4 residents observed, resulting in a medication error rate of 11.54 percent and 3 errors out of 26 opportunities for errors (Resident 8 and 13).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure medications were labeled properly and the facility failed to ensure expired medications were disposed of for 2 of 2 medication storage rooms reviewed for medication storage (Resident 43).

Inspectors wroteBased on interview and record review, the facility failed to assess and treat a resident's urinary catheter and follow-up on continued hematuria resulting in immediate jeopardy when the resident with a history of UTI and septic shock did not have a follow-up with a Urologist for continued hematuria and blood clots, had a change in condition with his urinary catheter, and was sent to the hospital several hours later in septic shock and respiratory failure for 1 of 5 residents reviewed for change in condition (Resident B). The immediate jeopardy began on [DATE] when Resident B, with a history of urinary catheter, severe sepsis with septic shock, and urinary tract infection (UTI) on [DATE], had a distended abdomen and low urine output in the foley drain bag on [DATE] at 10:19 p.m. The catheter was changed, and bloody urine was returned. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy and procedure for safe mechanical lift transfer for 1 of 2 residents observed for transfers (Resident K). Findings Include: On 3/5/24 at 11:14 a.m., during observation and interview with Resident K, the resident was sitting up in wheelchair and she was alert and oriented. She recalled an event which occurred about a week prior. She indicated Certified Nurse Aide (CNA) 5 placed her in a lift pad and attached the pad to the mechanical lift. CNA 5 left the room and did not return. The resident indicated CNA 5 was the only staff person in the room at the time. She was unsure of the time she remained in the pad. She was asleep when the therapist came in to check on her. She indicated she was told by the staff it had not been very long. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure comfortable hot water temperatures for 18 of 45 rooms reviewed for water temperatures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hot water temperatures were maintained within safe range for 3 of 3 residents reviewed for accidents (Residents 17, 97, and 196).

Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan was developed for the diagnosis of dementia and the baseline care plan for rehabilitation potential and special services was accurate for 1 of 3 new admission residents' care plans reviewed (Resident 96).

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan meetings were conducted for 1 of 16 residents reviewed for timing of care plan meetings (Resident 27).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure opened insulin vials and an insulin pen were not stored past their expiration date for 2 of 2 medication carts reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain refrigerator and freezer temperatures for 7 out of 7 logs observed during the initial kitchen tour and the facility failed to ensure proper handling of food during 1 of 2 dining observations.