Majestic Care of Fort Wayne

In the surveyor’s words

From the most serious findings on record at Majestic Care of Fort Wayne, in the surveyor’s own words.

• Actual harm, isolatedF760Jul 5, 2024

  Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed were free from a significant medication error. This error resulted in a change of condition and hospitalization (Resident K). Findings include: An anonymous complaint, submitted to the Indiana Department of Health, indicated Resident K had been administered a double dose of medication which was alleged to have contributed to his death. On [DATE] at 10:23 A.M., Resident K's record was reviewed. Diagnoses included Schizoaffective disorder, bipolar type, alcohol induced persisting dementia, moderate dementia with psychotic disturbance, generalized anxiety disorder, major depressive disorder, and chronic obstructive pulmonary disease (COPD) with current tobacco use. […]

• No harm, potential for more than minimal, widespreadF812Nov 12, 2021

  Based on observation, interview and record review the facility failed to ensure the kitchen was maintained clean and sanitary. This affected 58 of 58 residents who ate their meals from the kitchen. Findings include: 1. During an observation in the dining room on 11-7-2021 at 11:35 a.m., several residents were seated in the dining room. The tables had been cleaned, but there was food (yellow scrambled eggs) on the floor in several areas. The residents indicated lunch had not been served. An observation on 11-10-2021 at 11:39 a.m., indicated there were scrambled eggs and pieces of cereal on the dining room floor from breakfast, which had not been cleaned. 2. During an observation of the kitchen on 11-7-2021 at 11:37 a.m., the dietary staff were plating the noon meal. […]

• No harm, potential for more than minimal, widespreadF908Nov 12, 2021

  Based on observation, interview, and record, the facility failed to ensure the kitchen equipment was in working order. 58 of 58 residents residing in the facility ate their meals from the kitchen. Findings include: The kitchen was observed on 11-7-2021 at 11:37 a.m. The Kitchen Manager, a cook and a dietary aid were observed to be preparing the noon meal trays. The Kitchen Manager indicated the oven was not working as the temperature of the oven could not be controlled and was overcooking the food. She indicated the temperature of the oven would be set at 350 degrees Fahrenheit and then while baking, the temperature would fluctuate up to 500 degrees Fahrenheit. She indicated there were baffles for the oven on order and were to be delivered by 11-10-2021. […]

• No harm, potential for more than minimal, widespreadF921Nov 12, 2021

  During the initial tour of the facility on 11-7-21 at 11:34 a.m., a random resident indicated the shower had black mold in it. The resident then pointed to the shower room door, and said the mold was in there. The central bathing room was located on the west hall. A Certified Nursing Assistant 13 (CNA) was walking into the central bathing room. The CNA 13 explained she had to help another resident out and she would be leaving the room. During the observation, on 11-7-21 at 11:35 a.m. on the inside of the shower, in the left and right corners and along the back close to the ground there appeared to visible a black substance. More observation of the black substance was visible on the left side of the shower along and in between the tile. […]

• No harm, potential for more than minimal, widespreadF925Nov 12, 2021

  Based on observation, interview, and record review, the facility failed to ensure the kitchen was free from pests 58 of 58 residents residing in the facility ate their meals from the kitchen. Findings include: During an observation of the kitchen on 11-7-2021 at 11:35 a.m., food was observed on the floor in the area to the left of the stove between the stove and the steamer. Ants were observed on the food on the floor and were observed crawling back to the wall behind the steamer. The kitchen manager indicated they were sprayed for ants recently and she did not know the ants were in the kitchen. An interview with the Kitchen Manager on 11-10-2021 at 11:28 a.m., indicated all 58 residents eat from the facility kitchen. […]