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Deficiency Records for Majestic Care of South Bend

A list of the most recent deficiencies for Majestic Care of South Bend. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Majestic Care of South Bend. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-09-11 2024-06-14 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-02-20 2024-03-07 Y
Respond appropriately to all alleged violations. Health 2024-02-20 2024-03-07 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-01-11 2024-01-26 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-01-11 2024-01-26 Y
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2023-09-11 2023-11-10 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-09-11 2023-11-10 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-09-11 2023-11-10 N
Have properly located and lighted "Exit" signs. Fire Safety 2023-09-11 2023-10-26 N
Provide properly protected cooking facilities. Fire Safety 2023-09-11 2023-10-26 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2023-09-11 2023-10-26 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2023-09-11 2023-10-26 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-09-11 2023-10-26 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-09-11 2023-10-26 N
Have restrictions on the use of portable space heaters. Fire Safety 2023-09-11 2023-10-26 N
Have proper medical gas storage and administration areas. Fire Safety 2023-09-11 2023-10-26 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-10-12 2023-10-04 Y
Honor the resident's right to manage his or her financial affairs. Health 2023-08-28 2023-09-30 N
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Health 2023-08-28 2023-09-30 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2023-08-28 2023-09-30 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-08-28 2023-09-30 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2023-08-28 2023-09-30 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-08-28 2023-09-30 N
Assist a resident in gaining access to vision and hearing services. Health 2023-08-28 2023-09-30 N
Provide enough food/fluids to maintain a resident's health. Health 2023-08-28 2023-09-30 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-08-28 2023-09-30 N
Provide care or services that was trauma informed and/or culturally competent. Health 2023-08-28 2023-09-30 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-08-28 2023-09-30 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2023-08-28 2023-09-30 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2023-08-28 2023-09-30 N
Ensure medication error rates are not 5 percent or greater. Health 2023-08-28 2023-09-30 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2023-08-28 2023-09-30 N
Provide or obtain dental services for each resident. Health 2023-08-28 2023-09-30 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-08-28 2023-09-30 N
Provide and implement an infection prevention and control program. Health 2023-08-28 2023-09-30 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2023-08-28 2023-09-30 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-08-28 2023-09-30 Y
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2023-03-13 2023-03-24 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-11-17 2022-12-15 Y
Respond appropriately to all alleged violations. Health 2022-11-17 2022-12-15 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-11-17 2022-12-15 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2022-11-17 2022-12-15 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-09-07 2022-09-24 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2022-09-07 2022-09-24 N
Develop a communication plan. Fire Safety 2022-09-07 2022-09-24 N
Establish emergency prep training and testing. Fire Safety 2022-09-07 2022-09-24 N
Conduct testing and exercise requirements. Fire Safety 2022-09-07 2022-09-24 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2022-09-07 2022-09-24 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-09-07 2022-09-24 N
Install an approved automatic sprinkler system. Fire Safety 2022-09-07 2022-09-24 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2022-09-07 2022-09-24 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-09-07 2022-09-24 N
Ensure proper usage of power strips and extension cords. Fire Safety 2022-09-07 2022-09-24 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-08-05 2022-08-26 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2022-08-05 2022-08-26 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-08-05 2022-08-26 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-08-05 2022-08-26 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2022-08-05 2022-08-26 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2022-08-05 2022-08-26 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-08-05 2022-08-26 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2022-08-05 2022-08-26 N
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2022-08-05 2022-08-26 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-08-05 2022-08-26 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2022-08-05 2022-08-26 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2022-08-05 2022-08-26 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-06-24 2022-07-08 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-06-24 2022-07-08 Y
Respond appropriately to all alleged violations. Health 2022-06-24 2022-07-08 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-01-05 2022-01-26 Y
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2021-10-19 2021-11-12 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-10-19 2021-11-12 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2021-10-19 2021-11-12 Y
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Health 2021-07-02 2021-07-27 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2021-07-02 2021-07-27 N
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2021-07-02 2021-07-27 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2021-07-02 2021-07-27 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-07-02 2021-07-27 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2021-07-02 2021-07-27 N
Plan the resident's discharge to meet the resident's goals and needs. Health 2021-07-02 2021-07-27 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2021-07-02 2021-07-27 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-07-02 2021-07-27 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2021-07-02 2021-07-27 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2021-07-02 2021-07-27 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2021-07-02 2021-07-27 N
Provide routine and 24-hour emergency dental care for each resident. Health 2021-07-02 2021-07-27 N
Provide and implement an infection prevention and control program. Health 2021-07-02 2021-07-27 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2021-07-14 2021-07-27 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2021-07-14 2021-07-27 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2021-07-14 2021-07-27 N
Establish policies and procedures for medical documentation. Fire Safety 2021-07-14 2021-07-27 N
Establish policies and procedures for volunteers. Fire Safety 2021-07-14 2021-07-27 N
Establish roles under a Waiver declared by secretary. Fire Safety 2021-07-14 2021-07-27 N
Develop a communication plan. Fire Safety 2021-07-14 2021-07-27 N
List the names and contact information of those in the facility. Fire Safety 2021-07-14 2021-07-27 N
Establish emergency prep training and testing. Fire Safety 2021-07-14 2021-07-27 N
Establish staff and initial training requirements. Fire Safety 2021-07-14 2021-07-27 N
Conduct testing and exercise requirements. Fire Safety 2021-07-14 2021-07-27 N
Implement emergency and standby power systems. Fire Safety 2021-07-14 2021-07-27 N
Use approved construction type or materials. Fire Safety 2021-07-14 2021-07-27 N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2021-07-14 2021-07-27 N
Have corridors or aisles that are unobstructed and are at least 8 feet in width. Fire Safety 2021-07-14 2021-07-27 N
Have exits that are accessible at all times. Fire Safety 2021-07-14 2021-07-27 N
Have properly located and lighted "Exit" signs. Fire Safety 2021-07-14 2021-07-27 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2021-07-14 2021-07-27 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2021-07-14 2021-07-27 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2021-07-14 2021-07-27 N
Install an approved automatic sprinkler system. Fire Safety 2021-07-14 2021-07-27 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-07-14 2021-07-27 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2021-07-14 2021-07-27 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2021-07-14 2021-07-27 N
Have simulated fire drills held at unexpected times. Fire Safety 2021-07-14 2021-07-27 N
Have a battery powered remote alarm panel in a location accessible by operating personnel. Fire Safety 2021-07-14 2021-07-27 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2021-07-14 2021-07-27 N
Have proper medical gas storage and administration areas. Fire Safety 2021-07-14 2021-07-27 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2021-07-14 Not Fixed N

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