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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? |
|---|---|---|---|---|
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-07-15 | 2024-09-12 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2024-07-15 | 2024-08-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-15 | 2024-08-08 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-07-15 | 2024-08-08 | Y |
| 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 |
| 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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