Majestic Care of North Vernon

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Nov 12, 2021

  Based on interview, observation, and record review, the facility failed to provide emergency basic life support of rescue breathing, immediately when needed, for a resident after staff witnessed the resident go unresponsive with no breathing and failed to have the necessary equipment available for staff to perform rescue breathing. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 1:50 p.m. While staff members were providing Resident B with a bed bath, the resident became unresponsive with no breathing. Staff members went to provide CPR (a medical intervention used to restore circulatory and respiratory function that has ceased), and neither of the two facility crash carts had an Adult Bag Valve Mask (BVM) or face shield. […]

• Actual harm, isolatedF776Oct 16, 2025

  Based on observation, record review, and interview, the facility failed to meet the needs of a resident related to image acquisition by a contracted x-ray staff member. The resident's arm was improperly positioned and she cried out for 1 of 3 residents reviewed for diagnostic services. The resident's arm resulted with a fracture. (Resident B)Findings include:During an observation, on 10/15/2025 at 9:12 A.M., Resident B was lying in bed, her eyes were closed. There were no signs of distress. The resident had a red cast on her right arm that went from her hand up past her elbow. The clinical record for Resident B was reviewed on 10/15/2025 at 9:23 A.M. An Annual Minimum Data Set (MDS) assessment, dated 08/21/25, indicated the resident was cognitively intact. […]

• Actual harm, isolatedF686May 15, 2023

  Based on observation, interview, and record review, the facility failed to prevent pressure ulcers that resulted in the development of Stage 3 pressure ulcers (Residents 16 and 103) and follow a physician's order (Resident 91) for 3 of 7 residents reviewed for pressure ulcers. Findings include: 1. During an observation of Resident 16's wound on 05/11/23 at 9:43 A.M., the Wound NP (Nurse Practitioner) cleansed the wound to the left heel. The area had slightly macerated skin. The wound bed was pink with no drainage. The wound measured 0.4 cm (centimeters) x (by) 0.4 cm. The Wound NP indicated she expected the wound to be macerated due to the treatment she had in place. The clinical record for Resident 16 was reviewed on 05/10/23 at 1:52 P.M. […]

• Actual harm, isolatedF686May 13, 2021

  Based on observation, interview, and record review, the facility failed to prevent pressure ulcers, complete assessments, correctly stage, and follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Residents 59, 39, and 91). Findings include: 1. The clinical record for Resident 59 was reviewed on 05/13/21 at 12:56 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 03/26/21, indicated the resident was cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was at risk for pressure ulcers, and had an unhealed stage 2 pressure wound. The resident had 3 venous/arterial ulcers, and open [CONDITION(S)] to the foot. […]

• No harm, potential for more than minimal, widespreadF803Jun 29, 2022

  Based on observation, interview, and record review, the facility failed to provide palatable meals, provide menus, and follow menus related to food service. This deficient practice had the potential to affect 94 of 96 resident residing in the facility. Findings include: A meal test tray was observed on 06/24/22 at 12:59 P.M., with the DM (Dietary Manager). The meal contained a fish sandwich, potato wedges, and green beans. There were no condiments on the sandwich or on the tray. The pureed green beans had strings and 1/4 chunks of dark green beans. The pureed fish was warm, wet tuna. The tuna had a poor flavor. The DM indicated there were 9 residents on a pureed diet. The pureed green beans should not be chunky. She had two boxes of breaded fish fillets for the fish sandwiches. […]