Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Jefferson Pointe during CMS and state inspections, most recent first.
A resident with dementia and obstructive hydrocephalus vomited a very dark substance, but the chart lacked a documented assessment and did not show timely NP notification. An abdominal x-ray showed ileus, yet the critical result was not documented as reported, the ordered repeat x-ray was not completed, and bowel assessments were not documented. The resident later declined with SOB, low O2 saturation, and an irregular pulse, was sent to the hospital, and was found to have a sigmoid colon perforation, septic shock, and respiratory failure.
Two residents experienced significant weight loss, but the facility did not document timely weight-loss interventions or physician notification. One resident with dehydration, UTI, AKI, and severe sepsis lost weight over several weeks, and staff records did not show the ordered fortified cereal was actually provided or that the MD was notified before the RD later recommended supplements. Another resident with severe dementia, psychosis, depression, and alcohol dependence also had substantial weight loss, with no documentation of follow-up actions or physician notification despite the facility policy requiring notification for abnormal weight changes.
Failure to document controlled pain medications: Multiple residents with serious chronic conditions, including ESRD, DM, heart disease, respiratory failure, and fibromyalgia, had opioid doses signed out from controlled substance counts but not charted on the MAR or in progress notes. The missing documentation involved oxycodone, hydrocodone/APAP, and hydromorphone, and LPNs stated that if a dose is not documented on the MAR there is no way to know it was given.
Failure to provide and document nonpharmacological pain interventions before PRN analgesics were given to four residents. A resident with heart disease, lung disease, and depression, another with necrotizing fasciitis, ESRD, and depression, a third with respiratory failure, diabetes, and fibromyalgia, and a fourth with respiratory disease, diabetes, and ESRD all received PRN opioids without charted use of measures such as repositioning, relaxation, massage, or other comfort interventions. The ED and Regional Nurse Consultant confirmed the residents did not have nonpharmacological interventions before the PRN pain meds were administered.
A resident reported being struck in the face by another resident while sitting on their bed, resulting in bruising and swelling around one eye and a scratch under the other. Progress notes and frequent checks documented the visible injuries and their gradual healing, but no neurological checks or neurological assessment were completed, as confirmed by regional leadership. This omission occurred despite a facility head injury policy requiring neurological evaluation and neuro checks after any known, suspected, or verbalized head injury.
A resident with ESRD, DM, and heart disease died, but hydromorphone 4 mg tablets were still signed out on the controlled count sheet after death. The LPN whose initials appeared on the entries did not work that day, and the entries were not questioned until 5 days later. Several nurses counted the medication, but it was not destroyed in a timely manner after the resident's death.
A resident with schizophrenia, dementia, and a hip fracture was readmitted with an unstageable sacral/coccygeal pressure ulcer and had physician orders for Dakins solution cleansing, Therahoney application, and Mepilex dressing every shift. Review of the MAR showed the ordered wound treatments were not documented as completed on multiple days, and both a QMA and an LPN confirmed that missing initials indicated the treatments were not performed, contrary to facility policy requiring care to be provided as ordered by the physician.
A cognitively intact resident with DM, anxiety, and depression was exploited when a CNA asked to borrow $400 for bills and then did not repay it. The resident reported the CNA avoided him afterward, and the Administrator confirmed the allegation after reviewing the resident’s cash withdrawals and the CNA’s written note about needing money.
The facility did not ensure daily nurse staffing information was accurately posted in a visible location, as required by policy. Outdated postings were observed, and staff interviews revealed confusion about who was responsible for updating the information, potentially affecting all residents.
Surveyors observed unsanitary kitchen conditions, including food debris, spills, and improper storage, as well as a lack of hand hygiene by dietary staff and incomplete cleaning documentation. All residents consumed food prepared in this environment, and facility policy requirements for cleanliness and sanitation were not followed.
A CNA was observed loudly requesting supplies from other staff in a manner that compromised a resident's dignity, rather than using discreet communication methods. The resident involved had Alzheimer's disease, and facility policy requires respectful and private interactions with residents.
A resident with diabetes and morbid obesity did not receive prescribed Ozempic due to pharmacy supply issues. The facility failed to document the reasons for missed doses or notify the physician and family. Despite attempts to offer alternatives, the resident and physician refused, and the facility eventually obtained the medication.
A facility failed to ensure a resident was treated with respect and dignity when a CNA gestured offensively during a disagreement. The resident, who had no cognitive impairment, was extremely angry but not scared. The CNA, employed for 26 years with no prior issues, was terminated following the incident.
The facility failed to ensure proper labeling of open dates for medications on one of three medication carts reviewed, affecting three residents. Medications for a resident with lung disease, another with chronic kidney disease, and a third with cognitive impairment were found without open dates, despite facility policy requiring such labeling.
Failure to Assess Change in Condition and Complete Ordered Follow-up X-ray
Penalty
Summary
The facility failed to ensure a resident with dementia and obstructive hydrocephalus was adequately assessed and that provider orders were followed after a change in condition. The resident vomited a very dark colored substance, but there was no documented assessment of the resident or the vomitus, and no documentation that the NP was notified at that time. An abdominal x-ray was ordered for the resident after the vomiting episode, and the x-ray showed considerable distention of the colon due to a non-specific ileus, but there was no documentation that the critical result was reported to the NP when received. The NP later documented that the resident had been seen for abnormal abdominal x-rays and that treatment for ileus included Lactulose, Reglan, clear liquids for 24 hours, extra fluids, and a repeat abdominal x-ray. The record did not show that the repeat abdominal x-ray ordered for the morning of 5/15/26 was completed. There was also no documentation of bowel assessments between 5/14/26 and 5/18/26, including bowel sounds, abdominal distention, abdominal pain, or increased fluid intake, and there was no record that the ordered repeat labs were received or documented. On 5/18/26, the resident was observed with shortness of breath, difficulty being aroused, oxygen saturation of 65%, and an irregular pulse. The NP indicated the resident was declining rapidly and ordered transfer to the hospital because the resident was full code. In the emergency room, the resident was unresponsive, profoundly hypotensive, had a distended abdomen, and was diagnosed with pneumoperitoneum, respiratory failure, and septic shock. He was taken emergently to surgery where a sigmoid colon perforation was found, and he later died in the ICU.
Failure to Monitor and Report Significant Weight Loss
Penalty
Summary
The facility failed to ensure appropriate weight management interventions were implemented for two residents with documented weight loss, including follow-up for the weight changes and notification of the physician regarding significant loss. Resident 11 had diagnoses including dehydration, UTI, acute kidney failure, and severe sepsis without septic shock. Her weights showed a drop from 110 pounds to 103 pounds, then to 102.2 pounds, for a total loss of 8.8 pounds or 7.26% in one month. The record contained no documentation that the severe weight loss was identified or that interventions were put into place between the initial loss and the dietitian review on 3/11/26. Resident 11’s care plan identified nutritional risk and included interventions for RD review, weights as ordered or indicated, and notification of the MD for significant weight changes. Although the physician order included fortified cereal at breakfast, the meal ticket reviewed later did not show fortified cereal, and staff interviews indicated the resident did not receive cereal with breakfast. The dietitian later noted the cause of the weight loss was unknown, the BMI was underweight, and recommended Ensure Plus HP daily, but no physician order for that supplement was located and no documentation showed the MD had been notified before the unit manager called on 3/18/26. Resident 50 had diagnoses including psychotic disorder with delusions, severe dementia, depression, and alcohol dependence. His weights declined from 176 pounds to 157.2 pounds, a loss of 10.68%. His care plan also identified nutritional risk and required RD evaluation, weights as ordered or indicated, and notification of the MD for significant weight changes. The record contained no additional documentation of weight-loss interventions or physician notification, and nursing interviews confirmed staff could not locate documentation that the physician had been notified of the resident’s weight loss. The cited policy required the nurse to notify the physician/NP/PA and the resident or representative when abnormal weight changes occurred, with notification attempted within 24 hours unless there was an emergency.
Failure to Document Controlled Pain Medications
Penalty
Summary
The facility failed to ensure resident pain medications were secured and properly documented to prevent misappropriation for 4 of 16 residents reviewed. For Resident 2, who had diagnoses including necrotizing fasciitis, end stage renal disease, and heart disease, the physician ordered oxycodone 10 mg every 6 hours for pain management. A review of the March MAR and controlled count sheet showed 14 oxycodone tablets were taken from the resident’s controlled substance supply on multiple dates and times, but there was no documentation on the MAR or in progress notes that the doses were administered. For Resident 53, who had end stage renal disease, diabetes, and heart disease, the physician ordered hydrocodone/APAP 5/325 mg every 8 hours as needed for pain. Comparison of the March controlled count sheets with the March MAR showed 8 doses were removed from the resident’s controlled substance supply without documentation in the MAR or progress notes that they were given. For Resident 64, who had respiratory failure, diabetes, and fibromyalgia, the physician ordered hydromorphone 8 mg every 4 hours as needed for chronic pain. The March MAR and controlled substance count sheet showed 9 hydromorphone tablets were removed from the resident’s supply without documentation that they were administered. For Resident 92, who had end stage renal disease, diabetes, and heart disease, orders were in place for hydromorphone 4 mg tablets for pain across January and February 2026. The controlled count sheets compared with the MARs showed 45 Dilaudid tablets were signed out but not documented on the MAR or in progress notes. During interviews, an LPN stated that when medication is given it must be documented on the MAR and that if it is not documented there is no way to know it was given. Another LPN stated that when a medication is not documented on the MAR, there is no way to determine the medication had been given.
Failure to Document and Provide Nonpharmacological Pain Interventions
Penalty
Summary
The facility failed to provide nonpharmacological interventions before administering as-needed pain medication for 4 of 4 residents reviewed. Resident 1, who had diagnoses including heart disease, lung disease, and depression, received oxycodone-acetaminophen multiple times, but the MAR and progress notes did not document any nonpharmacological measures such as repositioning, relaxation, a quiet environment, back rubs, or diversional activity before the medication was given. The resident stated the facility only provided medication for pain management and denied receiving massages, ice, or other nonpharmacological interventions before PRN pain medication. Resident 2, with diagnoses including necrotizing fasciitis, end stage renal disease, and depression, received oxycodone 10 mg PRN on several occasions. The MAR contained an area for documenting nonpharmacological nursing measures offered before PRN pain medication, but that section was blank, and the progress notes did not show any nonpharmacological interventions on the dates and times the medication was administered. Resident 64, who had respiratory failure, diabetes, and fibromyalgia, received hydromorphone 8 mg PRN repeatedly, and the MAR and progress notes likewise lacked documentation of any nonpharmacological interventions before administration. Resident 92, with diagnoses including respiratory disease, diabetes, and end stage renal disease, received hydromorphone 4 mg PRN multiple times before the order expired. The February 2026 MAR and progress notes did not indicate any nonpharmacological interventions on the dates and times the medication was given. In interview, the Executive Director and Regional Nurse Consultant stated that these four residents did not have nonpharmacological interventions prior to PRN pain medication administration. The facility policy titled Pain Management stated that nonpharmacological interventions may include environmental comfort measures, loosening constrictive items, splinting, cold or warm applications, massage, turning and repositioning, exercise, and cognitive or behavioral interventions.
Failure to Perform Neurological Evaluation After Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to complete a neurological evaluation after a resident sustained a blow to the eye from another resident. A progress note dated 3/10/2026 at 10:19 PM documented that Resident 55 was sitting on their bed and reported that another resident hit him near his eye. On assessment, staff noted bruising to the left eye and a scratch under the right eye. A subsequent progress note dated 3/11/2026 at 5:18 PM documented that the IDT met to review the incident, confirming that Resident 55 had been in his room sitting on his bed when a nurse was called because another resident had made contact with his face. Ongoing 15-minute checks documented on 3/13/2026, 3/15/2026, 3/16/2026, 3/18/2026, and 3/19/2026 indicated that Resident 55 was resting in bed and that the bruising and swelling to the left eye continued to heal over time. However, in interviews, the Regional Vice President of Operations and the Regional Nurse Consultant both stated that the facility did not complete neurological checks or a neurological assessment following this incident. This was inconsistent with the facility’s current “Head Injury” policy, dated 1/2/2024, which required assessment following a known, suspected, or verbalized head injury, including a neurological evaluation for changes in physical function, behavior, cognition, level of consciousness, dizziness, nausea, irritability, slurred speech, or slow responses, and performance of neuro checks as indicated or specified by the physician.
Delayed Destruction of Controlled Medication After Resident Death
Penalty
Summary
The facility failed to destroy a deceased resident's controlled substance in a timely manner for one of one resident reviewed. Resident 92 had diagnoses including end stage renal disease, diabetes, and heart disease, and progress notes showed the resident's respiration had ceased at 10:53 AM on the reported date. Despite the resident being deceased, the controlled count sheet for hydromorphone (Dilaudid) 4 mg tablets showed a tablet signed out at 1:00 PM, 5:00 PM, and 9:00 PM that same day. The LPN whose initials appeared on those entries did not work that date, according to her time card, and the entries were not questioned until five days later. The medications were counted by several nurses but were not destroyed timely after the resident's death. In interview, the Regional Nurse Consultant stated the medications should have been destroyed in a timely manner.
Failure to Complete Ordered Wound Care for Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to complete ordered wound care treatments for a resident with multiple pressure ulcers. Resident E had diagnoses including schizophrenia, dementia, anxiety disorder, and a hip fracture, and a significant change MDS showed moderately impaired cognition with delusions. A care plan documented that the resident was readmitted with an unstageable pressure ulcer to the sacrum/coccyx, with interventions specifying that wound treatment was to be provided as ordered. A physician order directed that Dakins 0.125% solution be applied to the coccyx every shift, with cleansing using Dakins-dampened Kerlix, application of Therahoney to the sacrum, and coverage with a Mepilex dressing. Review of the January MAR showed that the ordered coccyx wound treatment lacked completion initials on three separate dates, indicating the treatment was not completed as ordered. A QMA confirmed that if medications or treatments were not initialed on the MAR, it meant they had not been completed. An LPN similarly stated that medications and treatments were to be completed as ordered by the physician and initialed on the MAR or TAR, and that a lack of documentation indicated the treatment had not been done. The facility’s policy provided by the Administrator stated that care and services were to be provided as ordered by the physician, which was not followed in this case.
Resident Money Borrowed by CNA
Penalty
Summary
The facility failed to ensure a cognitively intact resident was free from exploitation related to personal funds. The resident had diagnoses of diabetes, anxiety, and depression, and a quarterly MDS assessment dated 10/21/25 indicated he was cognitively intact and able to make decisions. A Report of Concern dated 10/12/25 stated the resident reported that a CNA had asked to borrow money about 1 month earlier, saying she was short on funds and needed money to pay bills. The resident loaned the CNA $400 with the understanding it would be repaid, but afterward the CNA avoided him and did not return any money. The investigation found the CNA was placed on suspension and refused to participate while suspended. An undated written note from the CNA to the resident stated she had just gotten her paycheck, that it would not cover bills due that day, and that services could be disconnected; the note also indicated $400 had been loaned to her. The Administrator stated the allegation was confirmed after reviewing the resident’s cash withdrawals showing he had withdrawn $400 about 1 month before the reported incident. The Administrator also stated the resident did not want to report the matter, but the CNA did not pay him back and appeared to be avoiding him.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily report of nursing staff directly responsible for resident care was accurately posted in a visible and accessible location. During an observation, several daily staffing postings were found in a plastic slot near the front desk, but the most recent visible posting was dated several days prior, with others even older. Multiple staff members were observed passing by the postings without updating them. Interviews with the Maintenance Director, Medical Records manager, and the scheduler revealed confusion and lack of clarity regarding who was responsible for updating the daily staffing postings, with no specific staff member identified as accountable when the scheduler was absent. The facility's policy required that the number of licensed nurses and unlicensed nursing personnel responsible for direct resident care be posted daily, within two hours of each shift's start, in a prominent and accessible location. However, the observed postings were outdated, and staff interviews indicated inconsistent practices and unclear delegation of responsibility for maintaining the postings. This failure had the potential to affect all 74 residents in the facility.
Failure to Maintain Sanitary Kitchen Conditions and Proper Food Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by multiple observations of unclean equipment, improper hand hygiene, and inadequate labeling and storage of food items. During inspections, surveyors noted food debris in the handwashing sink, a broken paper towel dispenser with no towels available, and spills of colored liquids and food debris on the kitchen floor. The dry storage area contained an open cardboard box, and the walk-in refrigerator had an opened can of mustard covered only with plastic wrap, as well as unlabeled and undated containers of brown liquid and expired fruit. The walk-in freezer floor was covered with ice, vegetables, cardboard, and other debris. The stove and grill trap contained unidentifiable hot liquid, tiles were missing from the wall behind the stove, and the dishwashing station had pans and plates stored upside down, exposing them to potential contamination. Additionally, a garbage can was missing its lid. Further, the Dietary Manager was observed preparing food for residents with special diets without wearing gloves and wiping her hands on her pants, indicating a lack of proper hand hygiene. Review of cleaning schedules over several weeks revealed that most cleaning tasks were not documented as completed, with many days showing no initials to indicate that cleaning had occurred. Facility policy requires all food preparation and service areas to be maintained in a clean and sanitary condition, with routine cleaning schedules and proper trash containment, but these standards were not met. All 74 residents in the facility consumed food prepared in this kitchen.
Failure to Maintain Resident Dignity During Staff Communication
Penalty
Summary
During an observation in the men's memory unit dining room, a Certified Nursing Assistant (CNA) was heard yelling from a resident's room, requesting supplies such as a brief, pants, linens, and towels from other staff members. The CNA expressed concern about not wanting the resident to walk down the hall, prioritizing safety over dignity. In a subsequent interview, the CNA acknowledged that yelling down the hall was a dignity issue and admitted not considering the use of the call light or other discreet means to request assistance. The resident involved had a diagnosis of Alzheimer's disease. Facility policy requires staff to speak respectfully to residents and maintain resident privacy, which was not followed in this instance.
Medication Availability and Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were available and administered as prescribed by the physician for a resident. The resident, who had diagnoses of diabetes and morbid obesity, was prescribed Ozempic for weight loss. The medication was supposed to be administered weekly starting in August, with increasing dosages over time. However, the Medication Administration Record (MAR) indicated that the medication was not given on specific dates in August and November. There was no documentation in the progress notes explaining why the medication was not administered, nor was there any record of notifying the physician or the resident's family about the missed doses. Interviews with staff revealed that the facility experienced supply issues with obtaining Ozempic from the pharmacy. The Director of Nursing confirmed that the endocrinologist wanted the resident to be on Ozempic exclusively, but the medication was difficult to obtain. Although alternative medications were suggested by the pharmacy, they were refused by the resident and physician. Eventually, the facility received a multi-dose pen and began administering the medication as prescribed. However, the Director of Nursing was unable to provide documentation of the pharmacy's supply issues.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity. An incident occurred between Resident F and a Certified Nurses Aide (CNA 6), where CNA 6 was observed having a disagreement with Resident F. During the disagreement, Resident F was on the phone with a family member and mentioned something about CNA 6. In response, CNA 6 put their middle finger up and gestured toward the resident. Resident F, who had no cognitive impairment, indicated that she was not scared but was extremely angry and hung up the phone on her niece. The incident was confirmed by the Executive Director, who noted that CNA 6 had been employed for 26 years with no prior incidents or issues and was well-liked. However, the employee was terminated following the incident. Resident F's medical history included Chronic Obstructive Pulmonary Disease with acute exacerbation. The facility's policy on Resident's Rights, dated October 2019, was reviewed and indicated that all care team members should recognize the rights of residents at all times to enable dignity, respect, and proper delivery of care. The incident was related to a complaint and was found to be a deficiency in the facility's adherence to this policy.
Failure to Properly Label Medications
Penalty
Summary
The facility failed to ensure proper labeling of open dates for medications on one of three medication carts reviewed, affecting three residents. During an observation, it was noted that the East Hall medication cart had three opened medications without an open date: cough syrup for Resident 9, polyethylene glycol powder for Resident 14, and milk of magnesia for Resident 92. The Qualified Medical Assistant (QMA) indicated that all medications should be labeled with an open date and a discard or expiration date. However, the medications in question were not labeled accordingly, and the QMA labeled them with the date 5/15/24 during the observation. Resident 9 had a diagnosis of lung disease and muscle weakness, and their Medication Administration Record (MAR) indicated that the cough syrup had not been administered in May 2024. Resident 14, diagnosed with chronic kidney disease and constipation, had an order for polyethylene glycol powder dated 4/29/23, which was last administered on 5/22/24. Resident 92, diagnosed with adult failure to thrive and cognitive impairment, had an order for milk of magnesia dated 4/26/24, but the medication had not been administered from May 1 to May 22, 2024. The Regional Nurse Consultant acknowledged ongoing issues with medication labeling during cart audits from February to April 2024, and the facility's policy on medication storage did not specify the labeling requirements for multiple-use packaging.
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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) |
|---|---|---|---|---|
| Sage Bluff Health And Rehab Center | 1.6 mi | ★★★★★ | 6 | 0 |
| Coventry Meadows | 1.7 mi | ★★★★★ | 8 | 0 |
| Englewood Health & Rehabilitation Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Fort Wayne | 4.6 mi | ★★★★★ | 9 | 0 |
| Majestic Care Of Fort Wayne | 4.8 mi | ★★★★★ | 2 | 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.