Majestic Care of South Bend

In the surveyor’s words

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

• Immediate jeopardy, patternF698Aug 23, 2024

  Based on interview and record review, the facility failed to ensure residents who required dialysis services continued to receive those services in accordance with physician orders when the facility-based dialysis center closed on 8/12/2024 for 6 of 7 residents reviewed for dialysis services. (Resident D, E, F, R, S and V) This deficient practice resulted in Resident D and Resident E missing two dialysis treatments and required transfer to an acute care hospital for treatment of critical laboratory results and emergency dialysis treatments. […]

• Immediate jeopardy, isolatedF678Jul 15, 2024

  Based on record review and interview, the facility failed to immediately initiate Cardiopulmonary Resuscitation (CPR) in accordance with the resident's advanced directives for 1 of 3 residents reviewed for facility discharge. (Resident D) This deficient practice resulted in CPR not being provided immediately when staff found the unresponsive resident and the resident died . The Immediate Jeopardy began, on [DATE] at 5:25 P.M., when staff identified Resident D was unresponsive and failed to immediately initiate CPR. The Administrator and the Interim Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on [DATE] at 12:46 P.M. […]

• Immediate jeopardy, isolatedF689Oct 12, 2023

  Based on interview and record review the facility failed to supervise a resident, with severe cognitive deficits and wandering behaviors, from exiting the facility resulting in the elopement of Resident J. The immediate jeopardy began on 10/3/23 when the facility failed to ensure supervision was provided to Resident J, who was deemed high risk for an elopement, had a diagnosis of Alzheimer's disease and displayed exit seeking behaviors. As a result, the resident was able to exit the facility unattended. The Interim Administrator, Director of Nursing Services, and Regional Nurses were notified of the immediate jeopardy, at 12:21 P.M. on 10/11/23. […]

• Actual harm, isolatedF684Oct 19, 2021

  Based on record review and interview, the facility failed to ensure treatments were performed as ordered for 2 of 3 residents reviewed for dressing changes. This resulted in infection, hospitalization , and subsequent amputation for 1 of 3 residents reviewed. (Residents B and G) Findings include: 1. During a interview, on 10/16/21 at 1:00 P.M., Resident B indicated he was a recent [CONDITION(S)] because the previous owners of the facility did not ensure their staff changed his dressings as they were ordered. The clinical record for Resident B was reviewed on 10/18/21 at 10:00 A.M Resident B was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Jan 16, 2026

  Based on interview, and record review, the facility failed to ensure foods were served under safe and sanitary conditions related to monitoring food temperatures before serving. This deficient practice had the potential to affect 69 of 70 residents who were served meals from the facility kitchen. Finding includes:On 1/7/25 at 10:45 A.M., facility Grievances from 10/1/25 to 1/7/25 were reviewed. On 12/16/25 the Resident Council had submitted a grievance that indicated Residents did not want their food served cold. A grievance, dated 12/20/25, indicated the food was served cold every day. […]