Majestic Care of West Allen

In the surveyor’s words

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

• Immediate jeopardy, patternF600Feb 25, 2022

  Based on observation, interview, and record review the facility failed to protect residents in the secured unit from abuse related to a resident with physically and sexually aggressive behaviors. This resulted in physical and sexual abuse for in 5 of 5 residents reviewed for abuse. (Resident B, Resident C, Resident D, Resident E and Resident F) The immediate jeopardy began on 10-5-21 when the facility failed to put interventions and supervision in place to prevent abuse. The Executive Director, Director of Nursing Services, and Clinical Nursing Consultant were notified of the immediate jeopardy at 12:30 P.M. on 2-24-22. […]

• Immediate jeopardy, patternF740Feb 25, 2022

  Based on observation, interview and record review, the facility failed to provide behavioral services for a resident with physical and sexual aggressive behaviors. (Resident B) This resulted in a failure to protect 4 of 4 residents from unwanted physical and sexual contact. (Resident C, Resident D, Resident E and Resident F) The immediate jeopardy began on 10-5-21 when the facility failed to put interventions and supervision in place to address aggressive behavior. The Executive Director, Director of Nursing Services, and Clinical Nursing Consultant were notified of the immediate jeopardy at 12:30 P.M. on 2-24-22. […]

• Immediate jeopardy, isolatedF689Mar 9, 2026

  Based on observation, interview and record review, the facility failed to ensure staff used the correctly sized sling, in good working condition, when transferring a resident with a mechanical lift for 1 of 3 residents reviewed for assistive device use (Resident G). This failure resulted in the resident falling from the lift when a strap on the sling broke causing the resident to fall sustaining multiple fractures of neck, lower back, and pelvis. This resulted in Resident G's death. The immediate jeopardy began on [DATE] when the facility failed to ensure a lift sling was properly sized and in good working condition. […]

• Actual harm, isolatedF692May 8, 2025

  Based on interview and record review the facility failed to ensure care plan interventions were implemented, weight losses were reported and addressed timely. This resulted in a significant weight loss of 6.6% in 30 days for 1 of 3 residents reviewed (Resident 37). Findings include: During an observation on 5/4/25 at 11:58 AM, Resident 37 was observed eating lunch independently. He was slow at consuming his meal and tired easily during eating. Resident 37's record was reviewed on 5/5/25 at 1:12 PM. Diagnoses included unspecified dementia, moderate protein-calorie malnutrition, and gastro-esophageal reflux. Resident 37's current Admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively impaired. […]

• Actual harm, isolatedF557Jul 16, 2021

  Based on observation, interview and record review, the facility failed to ensure 11 of 85 residents residing in the facility received their clothing back from the laundry in a timely manner. This resulted in residents missing therapy, being embarrassed and ashamed of how they looked or smelled. (Resident 4, Resident 16, Resident 17, Resident 23, Resident 28, Resident 35, Resident 39, Resident 40, Resident 52, Resident 61, and Resident 74) 1. Resident 61 was interviewed on 7/15/21 at 8:31 AM. During the interview Resident 61 indicated his family provided him with 10 pairs of pants and he did not have any of them now. Resident 61 indicated his missing clothing made him angry and he wanted to slap the [expletive] out of someone for stealing from him. […]