Majestic Care of Jefferson Pointe

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684May 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure a resident was adequately assessed and provider orders were followed after a change in condition for 1 of 3 residents reviewed. The facility failed to ensure bowel assessments were performed and an abdominal X-ray was completed as ordered. This resulted in the facility sending the resident to the hospital with a perforated bowel (Resident C).The Immediate Jeopardy began on 5/15/26 when the facility failed to assess Resident C's change of condition and complete an order for a follow-up x-ray. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on May 19, 2026, at 4:12 P.M. […]

• Actual harm, isolatedF692Mar 23, 2026

  Based on interview and record review, the facility failed to ensure appropriate weight management interventions were implemented, including follow-up for identified weight loss and notification of the physician regarding significant weight changes for 2 of 3 residents reviewed (Resident 11 and Resident 50). This resulted in severe unintended resident weight loss for Resident 11 and Resident 50. Findings include:1. Resident 11's record was reviewed on 3/17/2026 at 11:55 AM. Diagnoses included dehydration, urinary tract infection (UTI), acute kidney failure and severe sepsis without septic shock.A review of Resident 11's weights indicated on 2/10/26, Resident 11 weighed 110 pounds. On 2/16/2026, Resident 11 weighed 110.0 pounds. […]

• Actual harm, isolatedF760Feb 14, 2024

  Based on interview and record review the facility failed to ensure residents were free from significant medication errors for 2 of 4 residents reviewed for medication errors. The deficient practice resulted in Resident B experiencing altered mental status that required emergent treatment at the facility for opioid overdose and hospitalization for chest pain. The deficient practice resulted in Resident C experiencing altered mental status with lethargy that required hospitalization . (Resident B, Resident C). 1. An Indiana Department of Health (IDOH) facility-reported incident report was provided by the Administrator on 2/13/24 at 1:00 P.M. […]

• Actual harm, isolatedF684May 5, 2022

  Based on interview and record review, the facility failed to notify the physician and family when a resident had a significant change in condition and weight loss which resulted in hospitalization for 1 of 3 residents reviewed (Resident B). Findings include: On 5/5/22 at 2:47 P.M., Resident B's record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS (Minimum Data Set) assessment, dated 1/14/22, indicated the resident had a BIMS (Brief Interview Mental Status) score of 7-severely impaired cognition. […]

• No harm, potential for more than minimal, widespreadF732Apr 10, 2025

  Based on observation, and interview, the facility failed to ensure the daily report of nursing staff directly responsible for resident care was accurately posted. This had the potential to effect 74 of 74 residents. Findings include: During an observation, on 4/6/25 at 9:01 AM, next to the front desk on the wall, visible to all. There was a plastic slot with several daily staffing postings inside. The date of the visible sheet was 4/3/25. The daily posting behind was dated for 4/2/25. The third one was dated 3/28/25. The last one was dated 3/6/25. […]