Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Majestic Care Of Fort Wayne during CMS and state inspections, most recent first.
A resident with multiple psychiatric and medical conditions was mistakenly given a double dose of Clozaril, leading to lethargy and eventual hospitalization. The error was discovered after the resident received two doses of 150 mg within an hour, instead of the prescribed 150 mg twice daily. Despite monitoring and medical intervention, the resident's condition worsened, resulting in unresponsiveness and hospitalization.
A resident with bipolar disorder and COPD was given two doses of Clozaril 150 mg in one day due to a medication administration error. The error involved a QMA trainee who was instructed by an LPN to administer the medication despite issues with the MAR. The DON was informed, and the physician advised monitoring the resident's vitals due to adverse reactions.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that Resident K was free from significant medication errors, which resulted in a change of condition and subsequent hospitalization. Resident K, who had multiple diagnoses including schizoaffective disorder, bipolar type, and moderate dementia with psychotic disturbance, was prescribed Clozaril to manage his behavioral symptoms. On the day of the incident, the resident was erroneously administered two doses of Clozaril 150 mg within an hour, totaling 300 mg, instead of the prescribed 150 mg twice daily. This error occurred shortly after the medication was delivered to the facility. Following the administration of the double dose, Resident K was observed to be lethargic and was taken to his room to rest. The staff discovered the medication error and promptly notified the psychiatric nurse practitioner, who advised monitoring the resident's vital signs closely. Despite these measures, Resident K's condition deteriorated, and he was found unresponsive later that evening. CPR was initiated, and the resident was transported to the hospital, where he remained unresponsive and on a ventilator. The psychiatrist confirmed that there was no antidote for the overdose and recommended monitoring vital signs and administering intravenous fluids if necessary. The Clozaril information indicated that the medication could cause severe side effects, including low blood pressure, slow heart rate, and cardiac arrest, especially during the initial titration period. The overdose led to Resident K experiencing symptoms consistent with Clozaril overdose, such as sedation and respiratory failure, ultimately resulting in his hospitalization.
Medication Administration Error for Resident
Penalty
Summary
The facility failed to ensure safe medication administration for Resident E, resulting in a medication error. Resident E, who has diagnoses including bipolar disorder and chronic obstructive pulmonary disease, was given a dose of Clozaril 150 mg during the day shift. Shortly after, on the second shift, a second dose of 150 mg was administered. This error occurred despite the physician's order indicating that Clozaril should be given as a one-time dose of 150 mg. The incident was self-reported to the Indiana State Department of Health. Interviews and record reviews revealed that a Qualified Medication Aide (QMA) trainee was involved in the administration process. The QMA trainee asked a Licensed Practical Nurse (LPN) if the medication should be given when the order was yellow in the medication administration record (MAR). The LPN instructed the trainee to administer the medication. The QMA trainee, who was being trained by another QMA, administered the medication but was unable to sign it out in the MAR. Subsequently, the trainee was informed that Resident E had received a second dose of Clozaril 150 mg. The Director of Nursing (DON) was notified of the error and contacted the physician, who advised monitoring Resident E's vital signs every 1-2 hours due to the adverse reactions of lethargy and drowsiness. The facility's plan of action included in-servicing nursing staff on safe medication administration and reviewing all residents' MARs for missed documentation. The facility also conducted audits to ensure physician orders were correctly entered and medications were administered properly.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fort Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lutheran Life Villages | 1.8 mi | ★★★★★ | 23 | 0 |
| Englewood Health & Rehabilitation Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Majestic Care Of Jefferson Pointe | 4.8 mi | ★★★★★ | 18 | 1 |
| Life Care Center Of Fort Wayne | 5.1 mi | ★★★★★ | 9 | 0 |
| Sage Bluff Health And Rehab Center | 5.3 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.