Below average — CMS composite of the measures below.
A standard survey is most likely before 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 South Bend during CMS and state inspections, most recent first.
The facility failed to ensure safe and sanitary food service by not consistently monitoring and documenting food temperatures before meals were served. Over an extended period, Service Line Checklist logs showed frequent missing or incomplete temperature records for beverages, main entrées, alternate entrées, meats, vegetables, fruits, starches, and desserts, with some meals lacking any recorded temperatures. Multiple residents reported that meals, especially breakfast, were often served cold, that hot food was never very hot, and that posted menus were not consistently followed. These practices did not align with the facility’s Food Production policy, which required safe food handling and specified minimum internal cooking temperatures for various food items.
A resident with severe cognitive impairment, behavioral disturbances, and multiple neurocognitive diagnoses experienced significant weight loss over several months while on a regular diet with monthly weights ordered. Care plans identified behavioral refusal of vital signs, potential nutritional risk, a prior weight refusal, and significant recent weight loss, with interventions to document intake and notify the physician of abnormal findings. Weight records showed a marked decline in body weight, meal intake records contained multiple missing entries and several meals with 0–25% intake, and a later ER record documented further weight loss. Despite facility policies requiring notification of the physician and resident representative for significant or abnormal weight changes, interviews with the DON and a family member confirmed there was no documentation or evidence that the physician or family were notified of the resident’s weight refusals or significant weight loss.
Repeated late medication administration and missed ordered treatments. Multiple residents with complex conditions such as DM, CHF, COPD, CKD, AFib, Parkinson’s disease, and psychiatric diagnoses had scheduled meds given hours late, including insulin, antihypertensives, anticoagulants, pain meds, bowel meds, and other routine therapies, with no charted explanation for the delays. The record also showed a resident without ordered TED hose, a resident without an ordered blood sugar check and sliding scale insulin on one evening, and a resident who missed a scheduled IV antibiotic dose. Staff and the DON stated meds should be signed off when given and orders, including parameters, should be followed as written.
A facility failed to ensure staff had the competency to administer meds timely and as ordered for multiple residents. Records showed repeated late insulin administration, one missed daily antibiotic dose, and several doses given hours after ordered times. The DON and staff stated meds should be signed off when given, but some staff documented them later in the shift, and the facility could not produce competency records for several nurses, QMAs, and the SSD.
A resident with severely impaired cognition who used a manual wheelchair had an Activity Care Plan that did not reflect current preferences from the MDS. The plan listed general activity interests and only included verbal reminders, with no intervention to physically assist the resident to activities or to invite the resident to animal or pet-related activities. The DON stated the resident could not take herself to activity programs, and the facility policy required resident-specific interventions and interdisciplinary review and revision of the comprehensive care plan.
Failure to Provide Personalized Activity Programs: Two residents did not receive activity programming tailored to their preferences and abilities. One resident with multiple neurologic and psychiatric diagnoses was repeatedly observed alone while preferred group activities were occurring, despite records showing music, pets, group activities, and going outside were important to her. Another resident with severely impaired cognition was observed wandering, sitting without meaningful engagement, and spending time in bed; although she had preferences for music, animals, cards, and TV, her sensory box was not accessible and she attended only one group activity.
Sanitary Food Service During Lunch Meal Observation: During lunch meal service, a CNA was observed serving food with her thumb over the rim of the plate for 2 residents in the dining hall. When interviewed, the CNA stated she always held plates from the bottom. The facility policy provided by the Regional President of Operations stated the facility would utilize a systemic approach to ensure safety throughout the resident's environment.
The facility failed to maintain aseptic technique and enhanced barrier precautions during PICC care for a resident with multiple chronic conditions, including vascular dementia and IV antibiotic therapy, when an RN did not don a gown before flushing the line and attempted to use a contaminated cap. The facility also failed to keep oxygen equipment clean for another resident with COPD and ESRD, as the oxygen concentrator filter had heavy dust buildup and the nasal cannula was not maintained on the weekly schedule ordered by the physician.
The facility failed to conduct quarterly care plan conferences for four residents, as required. One resident's family reported no conference for the current year, while another resident had not had a meeting since January. Two other residents also missed required conferences, despite facility policy mandating interdisciplinary team involvement in care planning.
The facility failed to maintain sanitary food storage and preparation practices. During a kitchen tour, several food items in the walk-in cooler were found without proper labeling, such as cheese cups and salad bowls, lacking 'made on' or 'use by' dates. Additionally, expired spices were found in the dry storage area. The Dietary Manager acknowledged these lapses, which did not comply with the facility's policy requiring labeling of refrigerated foods held for more than 24 hours.
A facility failed to provide a resident with a necessary assistive device, specifically a wheelchair, resulting in the resident remaining in bed without mobility assistance. Despite the resident's medical conditions, including hemiplegia and an acquired absence of the right leg, staff interviews revealed a lack of process for obtaining a wheelchair. The Director of Rehab acknowledged the oversight, and the facility lacked a policy for accommodating residents' needs.
A facility failed to provide a SNF-ABN to a resident who was discharged from Medicare skilled services but remained in the facility. Although a NOMNC was issued, the SNF-ABN, which informs beneficiaries about potential non-coverage by Medicare, was not provided. The facility's policy lacked guidance on when to issue the SNF-ABN.
The facility failed to provide two residents with the required Notice of Transfer/Discharge when they were hospitalized multiple times. Both residents had intact cognition and various medical conditions, but there was no documentation of the notices being given. The Executive Director confirmed the absence of such documentation, despite the facility's policy requiring it.
The facility failed to provide two residents with a copy of the Bed Hold Policy during their hospitalizations, despite both having intact cognition. The Executive Director confirmed the absence of documentation for both residents, contrary to the facility's policy requiring written notice within 24 hours of an emergency transfer.
A facility failed to develop a person-centered care plan for a resident with diabetes and congestive heart failure, who had a physician's order for a 2000 ml daily fluid restriction. The care plan did not specify how much fluid each shift and department were allotted, despite the resident being at risk for fluid imbalance. The Unit Manager acknowledged the omission.
The facility failed to provide adequate personal hygiene and oral care for two residents. One resident did not receive scheduled showers, resulting in poor nail hygiene, while another had significant oral hygiene issues due to insufficient assistance. Despite care plans requiring regular hygiene support, documentation and staff interviews revealed lapses in care provision and adherence to facility policies.
The facility failed to follow Physician's orders for G-tube care for two residents. One resident's G-tube was not flushed as required, with discrepancies in staff documentation. Another resident's G-tube system was not changed daily, and labeling was incomplete. Staff interviews confirmed these deficiencies.
The facility exceeded the acceptable medication error rate, with errors involving two residents. One resident did not receive Fluticasone Propionate due to unavailability, while another resident's Albuterol inhalers lacked opened dates, leading the nurse to withhold administration. The DON confirmed the availability of Albuterol in the emergency kit and outlined procedures for obtaining medications. These issues resulted in an 8% medication error rate.
The facility failed to maintain proper infection control practices, including unsanitized glucometer storage, improper glove use during catheter care, and inadequate storage of a bipap mask. A QMA did not sanitize a glucometer after use, and staff did not change gloves appropriately during catheter care for a resident with a urinary tract infection. Additionally, a resident's bipap mask was improperly stored, and there was confusion about cleaning responsibilities. Existing policies were not adhered to, leading to these deficiencies.
The facility failed to maintain a safe environment by not monitoring personal refrigerator temperatures and disposing of expired food for three residents. Observations showed unrecorded temperatures and expired food items in residents' refrigerators. Interviews revealed confusion among staff about responsibilities, with the facility's policy not being followed.
The facility failed to arrange alternative dialysis services for residents after the closure of its in-house dialysis center, resulting in missed treatments and hospitalizations. Despite advance notice of the closure, the facility did not secure outpatient dialysis or provide adequate monitoring for residents, leading to critical health issues for some.
A facility failed to ensure proper medication administration standards were followed when an LPN left a resident's medications unattended on a bedside table. The resident, who was alert and oriented, was not informed of the medication's presence, leading to them often ending up on the floor. The facility's policy required observation of medication ingestion, which was not followed.
The facility failed to provide necessary transfer documentation, including notification of transfer, appeal rights, and bed hold policy, for three residents transferred to a hospital for dialysis. The residents, with diagnoses such as ESRD and heart failure, were sent without physician orders or proper documentation, as confirmed by the Unit Manager and Regional Nurse Consultant.
A resident with a Full Code status was found unresponsive, but staff failed to immediately initiate CPR, leading to the resident's death. Despite the resident's medical history and requests for ER transfer due to discomfort, there was a delay in response as staff did not promptly verify the code status or start CPR, highlighting a deficiency in emergency procedures.
The facility failed to maintain adequate staffing of licensed nurses on the Skilled/Rehabilitation Unit, affecting resident care. A resident with complex medical needs experienced an unwitnessed fall, and required neurological assessments were not completed. The resident was later found unresponsive and passed away. Staffing schedules and PPD calculations were below required levels, and interviews revealed challenges in managing workloads due to insufficient staffing.
The facility failed to maintain cleanliness in a shower room on the South Unit, affecting 55 residents. Observations revealed wipes, brief packages, smears of substances, used towels, a wet sheet, and trash in the room. Interviews indicated unclear responsibilities for cleaning, with no specific policy in place. The 'Routine Cleaning' policy did not address shower room cleaning responsibilities.
The facility failed to administer medications and treatments as ordered for several residents, including missed blood sugar checks, insulin injections, and wound care treatments. Residents with conditions such as diabetes and pressure ulcers did not receive consistent care, and facility policies on medication administration were not adhered to.
The facility did not report a resident-to-resident physical altercation to local law enforcement within 24 hours, as required by their policy. The incident involved two residents who sustained forehead bruising. Despite immediate separation and assessments, the facility's administrator and DON did not believe reporting was necessary due to the lack of serious injuries. The facility's policy, however, mandates reporting such incidents to law enforcement, regardless of injury severity.
A facility failed to thoroughly investigate a resident-to-resident altercation resulting in bruising. Two residents were involved in a physical altercation while waiting to smoke, leading to forehead bruising. The facility separated the residents and conducted assessments but did not interview staff or witnesses, contrary to their abuse prevention policy. The Administrator and DON did not see the need for further investigation due to the absence of injuries, resulting in a deficiency citation.
Failure to Monitor and Document Food Temperatures Resulting in Cold Meals
Penalty
Summary
The deficiency involves the facility’s failure to ensure food was served under safe and sanitary conditions by not consistently monitoring and documenting food temperatures before serving. Resident grievances and Resident Council minutes documented repeated complaints that meals, particularly breakfast, were often served cold and that food was not served on time, resulting in hot foods arriving cold. Specific grievances noted that food was served cold every day and that residents did not want their food served cold. A detailed review of the Service Line Checklist logs over an extended period showed pervasive gaps in temperature monitoring and documentation for multiple meals. Numerous entries listed temperatures without identifying the food items, and many days lacked temperature recordings for beverages, main entrées, alternate entrées, meats, vegetables, fruits, starches, and desserts. On some days, there were no food temperatures recorded at all for certain meals. These omissions occurred repeatedly across breakfast, lunch, and dinner, indicating that the facility did not consistently follow its own procedures for checking and recording food temperatures. Interviews with several residents corroborated the documentation issues, as they reported that meals were frequently cold when served and that the posted menus were not consistently followed. One resident stated that meals were frequently cold and that the kitchen did not follow the posted menus. Another resident reported that the meals were not very good, the menu was not closely followed, biscuits and gravy were served too often, and hot food was never very hot. A third resident indicated that the kitchen did not always follow the menu and that hot food was not always hot. The facility’s policy on Food Production required safe food handling practices and specified minimum internal cooking temperatures for various meats and casseroles, but the observed practices and documentation did not demonstrate adherence to these standards.
Failure to Notify Physician and Family of Significant Weight Loss and Weight Refusals
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and responsible party of repeated refusals to be weighed and of significant, documented weight loss. The resident, who had Alzheimer’s disease, neurocognitive disorder with behavioral disturbance, delusional disorder, insomnia, and muscle weakness, was admitted with an initial weight of 178 lbs. A quarterly MDS dated 10/22/25 showed the resident weighed 170 lbs, had severe cognitive impairment, exhibited negative behaviors, wandered daily, and was receiving antipsychotic and antianxiety medications. A discharge MDS dated 11/26/25 documented inattention, disorganized thinking, multiple behavioral symptoms including rejection of care, and a weight of 156 lbs. Physician’s orders included a regular diet and monthly weights starting 7/23/25. The care plan identified behavioral symptoms including refusal of vital signs, with interventions to reapproach the resident and notify the physician and psychiatric services for increased behavioral symptoms. Another care plan, dated 10/19/25, identified potential nutritional risk related to diagnoses, a weight refusal in October, and significant weight loss of 14.7% over the prior 90 days, with interventions to document food and fluid intake and notify the physician of abnormal findings. Weight records showed a decline from 178 lbs in late July to 170 lbs in early September, then to 152 lbs on 11/6/25 and 156 lbs on 11/11/25, reflecting approximately 14% loss in less than five months; an ER record on 11/26/25 documented a weight of 146 lbs, over 17% loss in five months. Meal intake documentation between 10/1/25 and 11/26/25 showed multiple missing entries for breakfasts, lunches, and suppers, and several recorded intakes of 0–25% at various meals. A nutrition review on 8/1/25 noted good intake (76–100% of most meals) and made no dietary recommendations. A dietary note on 11/21/25 recorded that no weights had been entered for 30 days, that the resident had lost 26 lbs in 90 days (14.6% loss from 170 to 152 lbs), and that the resident’s BMI was 29.5, with no recommendations made and a plan to continue monitoring. During interview, the DON confirmed there was no documentation that the physician or responsible party had been notified of the significant weight loss or weight refusals, and the family member reported they were never informed of the resident’s significant weight loss. Facility policies on weight monitoring and change in condition required notification of the physician and family/guardian for verified significant weight changes and abnormal weights, and documentation of such notifications, which did not occur in this case.
Repeated Late Medication Administration and Missed Ordered Treatments
Penalty
Summary
The facility failed to administer medications as ordered for multiple residents, and the record review showed repeated delays in giving scheduled medications, including insulin, antihypertensives, anticoagulants, pain medications, bowel medications, and other routine drugs. For one resident with heart failure, type 2 diabetes mellitus, anxiety, depression, and COPD, the MAR showed numerous medications given hours late on many occasions, including insulin lispro, insulin glargine, amlodipine, Eliquis, Tradjenta, gabapentin, Jardiance, carvedilol, torsemide, ferrous sulfate, and tamsulosin. The resident stated medications were often late and that insulin was not being given with meals. The record lacked documentation explaining why the medications were not administered on time. Another resident with bladder and prostate cancer, diabetes, anxiety, and hypertension had multiple late administrations of oxycodone, Creon, nifedipine, pantoprazole, thiamine, multivitamins, Lokelma, and Novolog sliding scale insulin. The record again lacked documentation for the delays. A resident with Alzheimer’s disease, insomnia, and osteoarthritis had repeated late administrations of quetiapine, risperidone, levothyroxine, and meloxicam, with no documentation explaining the late doses. A resident with cellulitis, CHF, esophageal varices, atrial fibrillation, and type 2 diabetes mellitus also had repeated late administration of furosemide, insulin lispro, omeprazole, escitalopram, bupropion, apixaban, metoprolol, and potassium chloride, and the record lacked any explanation for the delays. Additional residents were affected by similar failures. A resident with alcoholic cirrhosis, CKD, anxiety, PTSD, and chronic pain had late administration of sennosides-docusate, lamotrigine, ergocalciferol, doxepin, apixaban, aspirin, doxycycline, and eye drops, with no documentation for the delays. Another resident with bradycardia, COPD, Parkinson’s disease, ESRD, diabetes, depression, and atrial fibrillation had late administration of pregabalin, oxcarbazepine, docusate, hydrocodone-acetaminophen, sevelamer, midodrine, carbidopa-levodopa, omeprazole, cephalexin, aspirin, lorazepam, and fluticasone furoate-vilanterol, again without documentation explaining why the medications were not given on time. The DON and QMAs stated medications should be signed off when given and that orders, including parameters such as blood pressure checks, should be followed as written. The report also included a resident who was observed without TED hose despite an order to wear them in the morning and remove them in the evening, a resident whose ordered blood sugar check and sliding scale insulin were not completed on one evening, and a resident who did not receive a scheduled IV ertapenem dose.
Late Medication Administration and Missing Competency Documentation
Penalty
Summary
Nursing staff failed to administer medications timely and/or as ordered for 8 of 8 residents reviewed, including residents receiving insulin before meals and one resident ordered ertapenem daily. For Resident 1, the record showed multiple insulin doses given well after the ordered meal times, including breakfast and lunch insulin administered together at 1:30 P.M. on one date, breakfast insulin given at 11:30 A.M. on another, and lunch insulin given at 3:05 P.M. and 2:24 P.M. on later dates. The record also showed that between 7/15/2025 and 8/15/2025, Resident 1 received medications at least 90 minutes late on 24 of the last 60 shifts. Resident 3 also had repeated late insulin administration, including breakfast insulin at 11:05 A.M., 12:27 P.M., and 10:49 A.M., and lunch insulin at 1:56 P.M., 5:56 P.M., 1:50 P.M., 5:09 P.M., and 1:54 P.M. The record indicated Resident 3 received medications at least 90 minutes late on 22 of the last 60 shifts. Resident 4 had insulin ordered for 8:00 P.M., but one dose was documented as given at 3:12 A.M. the next day and another at 4:53 A.M. the next day; Resident 4 also had an order for daily ertapenem and did not receive the dose on 8/15/2025. Resident 4 received medications at least 90 minutes late on 28 of the last 60 shifts. Additional record reviews showed similar patterns for Resident 8, Resident 29, and Resident 51, with late medication administration documented on 29, 17, and 28 of the last 60 shifts, respectively. The DON stated medications were considered late if administered one hour after the ordered time and indicated medications should be signed off as soon as they were given. RN 3 stated she administered medications timely but signed them off later in the shift, and other staff gave similar statements. The facility could not provide medication administration competency documents for several staff members, including RN 3, the SSD, and multiple QMAs, while the facility policies stated that medications should be administered according to physician orders and that competency documentation should be maintained in personnel files.
Care Plan Not Updated to Reflect Resident’s Current Activity Needs
Penalty
Summary
The facility failed to revise the comprehensive care plan to reflect Resident 29’s current status. An admission MDS showed the resident had severely impaired cognition, used a manual wheelchair for mobility and locomotion, and had activity preferences that were very important to him, including listening to music and being around animals and pets. However, the Activity Care Plan, initiated on 7/27/2025, listed preferences such as playing cards, watching reality shows, and enjoying rock and roll music, and the only intervention was to verbally remind the resident of the time and place of the activity. There was no intervention to physically assist and take the resident to desired activities and no intervention to invite the resident to activities involving animals or pet visits. The DON stated the resident was not able to take herself to any of the activity programs, and the facility policy required resident-specific interventions reflecting the resident’s needs and preferences and review and revision of the comprehensive care plan after each comprehensive and quarterly MDS assessment.
Failure to Provide Personalized Activity Programs
Penalty
Summary
The facility failed to provide personalized activity programs for 2 of 3 residents reviewed for activities. Resident 10 was observed seated alone in her room watching television while bingo was being held in the dining hall, and she was again observed seated by herself in her room during the bingo activity. The Activities Director stated that activity interventions depended on a resident’s likes and abilities and identified that Resident 10 liked being around people, listening to music, and playing bingo. Resident 10 also stated that she liked to drink and go outside. Her record showed diagnoses including hemiparesis and hemiplegia following a subarachnoid hemorrhage, malignant neoplasm of the left kidney, COPD, aphasia following cerebral infarction, vascular dementia, schizophrenia, hypertension, depression, and dysphagia. Her Significant Change MDS indicated she was rarely or never understood, dependent on staff for all ADLs, and that music, pets, group activities, and going outside were important to her. Her activity care plan included assistance/escort to activity functions, and the activity record showed only limited participation in preferred activities during June and July 2025. Resident 29 was observed wandering the unit in her wheelchair without noted purpose, sitting in the dining room without meaningful engagement, picking at her clothes at the nurses’ desk without participating in any activity, and later in bed. CNA staff stated she sometimes slept late into the day and was up all evening. The Activities Director stated Resident 29 had a sensory box in her room that she used on occasion, occasionally attended activities as a passive observer, and liked the facility cat, which staff sometimes brought to the activity room. However, when her room was observed, the sensory box was not present where she could access it. Her MDS showed severely impaired cognition and activity preferences that were very important to her included listening to music and being around animals and pets. Her activity care plan listed preferences such as playing cards, watching reality shows, and rock and roll music, with interventions to verbally remind her of the time and place of activities and that she could leave at any time. Activity documentation indicated she had been engaged in independent activities daily for the month and had attended only one group activity during the current month.
Sanitary Food Service During Lunch Meal Observation
Penalty
Summary
The facility failed to serve food in a sanitary manner in 1 of 1 dining rooms observed during the lunch meal service. During continuous observation on 8/12/2025 from 12:16 P.M. through 12:28 P.M., CNA 11 was observed serving food with her thumb over the rim of the plate for 2 of 2 residents in the dining hall. During an interview on 8/12/2025 at 12:29 P.M., CNA 11 stated she always held plates from the bottom. On 8/13/2025 at 11:30 A.M., the Regional President of Operations provided the facility policy titled, Meal Supervision, dated 12/12/2023, which indicated the facility would utilize a systemic approach to ensure safety throughout the resident's environment.
Infection Control Failures During PICC Care and Oxygen Equipment Maintenance
Penalty
Summary
The facility failed to ensure aseptic technique and enhanced barrier precautions were maintained during PICC line care for one resident. Resident 4 had diagnoses including urinary tract infection, diabetes mellitus with neuropathy, giant cell arteritis, a prosthetic heart valve, dissection of the aorta, vascular dementia, depression, anxiety, abnormal coagulation profile, and chronic pain syndrome, and was assessed as moderately cognitively impaired. The resident was sent to an acute care center for PICC placement for IV antibiotics, and the physician ordered PICC dressing changes every 7 days. However, the PICC dressing date was not legible during observation, and the record showed the dressing change was not documented until 14 days after the line was placed. During a later observation of PICC flushing, an RN did not don a gown before the procedure until prompted and attempted to apply a contaminated cap to the PICC line end until the issue was stopped. The facility also failed to ensure oxygen equipment was cleaned for one resident. Resident 7 had diagnoses including COPD, end stage renal failure, major depressive disorder, and generalized anxiety disorder. The physician ordered weekly nasal cannula changes and weekly cleaning of the oxygen filter, but during observation the oxygen concentrator filter had a heavy buildup of dust and the nasal cannula was dated earlier than expected based on the weekly schedule. The DON acknowledged the nasal cannula should have been changed weekly and that the oxygen concentrator filter should not have had a buildup of dust.
Failure to Conduct Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to ensure that care plan conferences were conducted quarterly for four residents, leading to a deficiency in care planning. Resident 13's family reported that no care plan conference had been held for the current year, and a record review confirmed the last conference was in April 2023. Resident 26 reported not having a care plan meeting, and the Social Service Director acknowledged that a conference should have occurred in June or July 2024. Resident 8 also indicated not attending a care conference, with records showing the last meeting in January 2024, despite a quarterly assessment in July 2024 indicating intact cognition and participation in planning. Resident 59 expressed uncertainty about being invited to a care conference, and records showed a significant gap between meetings from September 2023 to September 2024. The Unit Manager confirmed that required care conferences had not been conducted for Residents 8 and 59. The facility's policy, dated December 2023, mandates that comprehensive care plans be prepared by an interdisciplinary team, including the resident and their representative, to the extent practicable. This policy was not adhered to, resulting in the identified deficiency.
Deficiency in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to store and prepare food in a sanitary manner, as observed during a kitchen tour. In the walk-in cooler, several food items were found without proper labeling, including eight single-serve cheese cups, a half bag of salad mix, a bag of celery, and seven bowls of salad. These items lacked 'made on' or 'use by' dates, which are necessary to ensure food safety and compliance with the facility's policy. The Dietary Manager (DM) acknowledged that these items should have been labeled with the appropriate dates. Additionally, in the dry storage area, several spices were found to be expired or lacking an 'opened on' date. These included whole celery seed, poultry seasoning, cayenne pepper, and a brand of sprinkles. The DM and District Dietary Manager (DDM) confirmed that spices should not be used past their expiration dates, although the facility did not have a specific policy regarding spices. The facility's existing policy on food preparation requires that refrigerated, ready-to-eat foods held for more than 24 hours be labeled with a prepared date and a use by date, which was not adhered to in this instance.
Failure to Provide Assistive Device for Resident
Penalty
Summary
The facility failed to provide a dependent resident, identified as Resident 3, with an assistive device, specifically a wheelchair, which was necessary for the resident to get out of bed. The deficiency was identified through observations and interviews conducted over several days. During a family interview, the responsible party for Resident 3 expressed concern that the resident did not have a wheelchair and was always in bed during visits. Observations confirmed that Resident 3 was consistently in bed without a wheelchair present in the room. The resident's medical history included hemiplegia, vascular dementia, and an acquired absence of the right leg below the knee, indicating a need for assistance with mobility. Interviews with facility staff revealed that Resident 3 had not been provided with a wheelchair due to a lack of process for obtaining one. A Qualified Medication Aide (QMA) mentioned having previously obtained a wheelchair from the therapy department for Resident 3, but it was returned after use. The Director of Rehab acknowledged that Resident 3 should have had a chair and noted that some residents preferred to stay in bed, although there was no documentation of Resident 3 refusing to get out of bed. The facility lacked a policy related to accommodating residents' needs, contributing to the oversight in providing necessary assistive devices for Resident 3.
Failure to Provide SNF-ABN to Resident Post-Medicare Discharge
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility-Advanced Beneficiary Notice (SNF-ABN) to a resident who was discharged from Medicare skilled services but remained in the facility. During a review of Beneficiary Notification forms, it was found that a Notice of Medicare Non-Coverage (NOMNC) was given to the resident, indicating the end of Medicare coverage. However, the SNF-ABN, which informs beneficiaries that Medicare may not pay for certain services or items, was not provided. Interviews with the Social Services Director and a review of the facility's policy confirmed that the SNF-ABN was not issued, and the policy did not specify when this form should be provided.
Failure to Provide Transfer Notices to Residents
Penalty
Summary
The facility failed to provide timely notification to two residents, or their representatives, regarding their transfer to a hospital, as required by regulations. Resident 8, who had intact cognition and diagnoses including type 2 diabetes mellitus with neuropathy, bladder cancer, anxiety, and depression, was hospitalized on three occasions. However, there was no documentation that the facility provided a Notice of Transfer/Discharge for any of these hospitalizations. The Executive Director confirmed the absence of such documentation during an interview. Similarly, Resident 59, who also had intact cognition and diagnoses including end-stage renal disease, chronic obstructive pulmonary disease, and type 1 diabetes with neuropathy, was hospitalized four times. The facility again failed to provide the required Notice of Transfer/Discharge for any of these hospitalizations. The Executive Director acknowledged the lack of documentation for Resident 59 as well. The facility's policy, which mandates providing a notice of transfer and the facility's bed hold policy to the resident and representative, was not followed in these cases.
Failure to Provide Bed Hold Policy to Hospitalized Residents
Penalty
Summary
The facility failed to provide two residents, who were hospitalized, with a copy of the Bed Hold Policy, as required. Resident 8, who had diagnoses including type 2 diabetes mellitus with neuropathy, bladder cancer, anxiety, and depression, was hospitalized on three occasions. Despite having intact cognition, there was no documentation that Resident 8 received the Bed Hold Policy during any of these hospitalizations. The Executive Director confirmed the absence of such documentation. Similarly, Resident 59, with diagnoses including end-stage renal disease, chronic obstructive pulmonary disease, and type 1 diabetes with neuropathy, was hospitalized multiple times. Although Resident 59's cognition was also intact, there was no record of the Bed Hold Policy being provided during any of these hospitalizations. The Executive Director acknowledged the lack of documentation for Resident 59 as well. The facility's current policy, dated December 12, 2023, mandates that written notice of the Bed Hold Policy be provided within 24 hours of an emergency transfer.
Failure to Develop Person-Centered Fluid Restriction Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan regarding fluid needs for a resident with type 2 diabetes mellitus with neuropathy and congestive heart failure. The resident had a physician's order for a 2000 ml daily fluid restriction due to edema and congestive heart failure, and was prescribed Furosemide for hypertensive heart disease and congestive heart failure. The current care plan, initiated in September 2022, identified the resident as at risk for fluid imbalance related to acute kidney failure and diuretic use. However, the care plan lacked specific instructions on how much fluid each shift and department were allotted to maintain the ordered fluid restrictions. During an interview, the Unit Manager acknowledged that the fluid restriction should have been detailed in the care plan to specify the amount of fluids per shift and department.
Deficiencies in Personal Hygiene and Oral Care
Penalty
Summary
The facility failed to ensure proper personal hygiene and shower assistance for residents, as evidenced by the case of Resident 3. Despite being scheduled for showers twice a week, documentation revealed that Resident 3 had not received a shower from 9/1/2024 to 10/1/2024, with no records of refusal or behaviors that would justify the lack of care. Observations noted long, dirty fingernails, and interviews with staff indicated that while some morning care was provided, comprehensive bathing and nail care were neglected. The care plan for Resident 3 included interventions for bathing and nail care, but these were not consistently implemented, and the documentation did not reflect any refusals of care. Similarly, Resident 24 was observed with significant oral hygiene issues, including a thick white substance on her bottom teeth. Despite requiring assistance with oral care due to severe cognitive impairment and physical limitations, documentation showed that oral care was only offered once daily on several occasions, contrary to the care plan's directive for twice-daily oral care. Interviews with staff confirmed that Resident 24 needed encouragement and manual assistance for oral hygiene, which was not adequately provided, leading to visible plaque build-up. The facility's policies on routine nail care and oral care were not adhered to, as evidenced by the lack of regular nail inspections and oral hygiene assistance. The Director of Nursing acknowledged the absence of documentation for bathing and oral care refusals, indicating a failure to offer and document necessary care consistently. The facility's failure to follow its policies and care plans resulted in deficiencies in the provision of essential daily living activities for the residents involved.
Failure to Follow G-Tube Care Protocols
Penalty
Summary
The facility failed to adhere to the Physician's orders regarding the care of gastrointestinal tubes (G-tubes) for two residents. Resident 222 reported that his G-tube, which was not being used for nutrition or medications, was supposed to be flushed twice daily but had only been flushed once since his admission. Observations confirmed the absence of medical equipment for flushing in his room, and documentation discrepancies were noted in the Treatment Administration Record (TAR). Interviews with staff revealed inconsistencies in the reported completion of G-tube flushes, with one LPN admitting to mistakenly documenting a flush that was not performed. For Resident 7, the facility failed to change the G-tube tubing and syringe every 24 hours as per the Physician's orders. Observations showed that the tube feeding formula and clear liquid bags were not labeled correctly, and a syringe was found with an outdated label. An RN acknowledged the discrepancies in labeling and the failure to change the system daily. The facility's policies on documentation and enteral feeding were provided, indicating the expected standards of practice, but these were not followed in the cases of Residents 222 and 7.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by observations during a medication pass involving two residents. For Resident 28, the medication Fluticasone Propionate was not available for administration, and the nurse indicated she would contact the pharmacy to obtain it. This resident had diagnoses including chronic pain syndrome and allergies, with a physician's order for Fluticasone Propionate dated several months prior. The absence of this medication during the scheduled administration contributed to the facility's medication error rate. For Resident 35, the nurse found two inhalers in the medication drawer without opened dates and decided not to administer the medication, opting instead to notify the pharmacy for a new one. This resident had a diagnosis of chronic obstructive pulmonary disease, with a physician's order for Albuterol Sulfate. The Director of Nursing later indicated that Albuterol was available in the emergency kit, and if not, the nurse should notify the pharmacy. The facility's policy on medication administration, which includes procedures for obtaining medications not readily available, was provided by the DON. These incidents resulted in a medication error rate of 8 percent, exceeding the acceptable threshold.
Infection Control Deficiencies in Equipment Storage and Care Practices
Penalty
Summary
The facility failed to ensure proper infection control practices in several areas, including the storage of respiratory equipment, catheter care, and blood sugar monitoring. During an observation, a Qualified Medication Aide (QMA) did not sanitize a glucometer after use and placed it unsanitized on top of supplies. The QMA was unsure about the correct procedure for cleaning the glucometer. Additionally, during catheter care for a resident with a urinary tract infection and other conditions, staff did not change gloves after cleaning stool and before placing a clean bed pad and brief on the resident, despite the use of enhanced barrier precautions. Furthermore, a resident's bipap mask was observed to be improperly stored on the bed and floor without a protective bag, and with a brown substance on the inside seal. Staff interviews revealed confusion about responsibilities for cleaning and storing the bipap mask, and no policy was provided regarding its storage. The facility's existing policies on blood glucose monitoring and glucometer disinfection were not followed, contributing to the deficiencies observed.
Failure to Monitor Refrigerator Temperatures and Expired Food
Penalty
Summary
The facility failed to maintain a safe and sanitary environment by not properly monitoring personal refrigerator temperatures and disposing of expired food for three residents. Observations revealed that the temperature logs for Residents 21 and 44's personal refrigerators were not recorded for any dates in August, while Resident 45's log for July had only a few recorded temperatures. Additionally, Resident 45's refrigerator contained several expired food items, including a pre-made salad, honey ham lunch meat, chocolate pudding cups, and a squeeze bottle of Miracle Whip. Interviews with various staff members, including the Social Services Director, Interim Executive Director, Maintenance Director, Environment Services Director, and Unit Manager, highlighted inconsistencies and confusion regarding the responsibility for checking refrigerator temperatures and removing expired food. The facility's policy indicated that maintenance staff should record temperatures weekly, but this was not being followed. The Magic Makers system, which assigned management staff to check on residents and their refrigerators, was not effectively implemented, leading to the oversight of expired food and unrecorded temperatures.
Failure to Provide Dialysis Services After In-House Unit Closure
Penalty
Summary
The facility failed to ensure the continuation of dialysis services for residents who required such services after the closure of the facility-based dialysis center. This resulted in six out of seven residents missing their scheduled dialysis treatments. The closure of the dialysis center was communicated to the facility months in advance, but the necessary arrangements for alternative dialysis services were not made in time. As a result, residents who depended on regular dialysis treatments were left without care, leading to critical health issues for some. Resident E, who had a history of end-stage renal disease, congestive heart failure, and respiratory failure, missed two dialysis treatments and was admitted to the hospital with critical lab results indicating fluid overload. Despite being aware of the impending closure of the in-house dialysis unit, the facility did not secure alternative dialysis arrangements or provide adequate monitoring for signs of fluid overload. The resident's family was not informed of any arrangements, and the facility failed to provide transportation to an alternative dialysis center. Similarly, Resident D, who also had end-stage renal disease and other health issues, missed dialysis treatments and was admitted to the hospital with critical lab levels. The facility did not document any efforts to secure outpatient dialysis services for Resident D, and there was no communication with the resident about the lack of arrangements. The facility's inaction and lack of communication led to significant health risks for the residents, who were left without essential medical care.
Failure to Follow Medication Administration Standards
Penalty
Summary
The facility failed to ensure that a Licensed Nurse followed the standards of practice during medication administration for a resident, identified as Resident Q. During a random observation, it was noted that Resident Q had a breakfast tray and a small clear cup containing multiple medications on his bedside table, approximately five feet from his bed. Resident Q indicated he was unaware that the medications were on the table and mentioned that it was not unusual for them to be left in the room. He also stated that his medications often ended up on the floor because he was not informed that they had been left on the bedside table. An agency staffing nurse, identified as LPN 11, confirmed that the medications belonged to Resident Q and had left them on the bedside table after the resident expressed a desire to wait before taking them. LPN 11 believed it was acceptable to leave the medications unattended in the room, as Resident Q was alert and oriented. The medications included Morphine Sulfate, Cetirizine, Ondansetron, Sertraline, Aspirin, Plavix, Divporex, Gabapentin, Thera-M, Escitalopram, Docusate, Quetiapine, and Tamsulosin. The facility's policy on oral medication administration, provided by the Interim Director of Nursing, required that licensed nurses or authorized personnel observe the resident ingest all medications, which was not adhered to in this instance.
Failure to Provide Required Transfer Documentation for Residents
Penalty
Summary
The facility failed to ensure that three residents, who were transferred to a local hospital for dialysis treatments, received the necessary documentation including a statement of notification of the transfer, appeal rights, a copy of the bed hold policy, and the Ombudsman's information. Resident E, who had diagnoses including End Stage Renal Disease (ESRD), congestive heart failure, and respiratory failure, was transferred to the emergency room without any nursing assessments documented for the days leading up to the transfer. There was no physician's order for the transfer, and the required documentation was not provided to Resident E. Resident F, with diagnoses of ESRD, diabetes, and hypertension, was noted to have shortness of breath and an overall decline. The Nurse Practitioner ordered a transfer to the emergency room, but again, there was no documentation provided to the resident regarding the transfer, appeal rights, or bed hold policy. Similarly, Resident D, who had multiple diagnoses including ESRD and heart failure, was sent to the hospital for dialysis without a physician's order or the necessary transfer documentation. The Unit Manager LPN admitted to sending Residents E and D to the hospital without completing the required transfer forms. The Regional Nurse Consultant confirmed the absence of transfer documentation for all three residents. The facility's policy on transfers and discharges, which includes providing a notice of transfer and the facility's bed hold policy, was not followed in these cases.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to immediately initiate Cardiopulmonary Resuscitation (CPR) for a resident, identified as Resident D, who was found unresponsive. Despite having a physician's order and an advanced directive indicating the resident was a Full Code, staff did not promptly begin CPR when the resident was discovered unresponsive. This delay in initiating CPR occurred on the evening when the resident was found by an aide during dinner tray distribution, and the resident subsequently died. Resident D had a complex medical history, including necrotizing fasciitis, insulin-dependent diabetes, end-stage renal disease requiring hemodialysis, and a history of cardiac arrest. The resident had been experiencing persistent hyperkalemia and had refused dialysis treatments, which were critical for her condition. On the day of the incident, the resident had expressed discomfort, including stomach pain and vomiting, and had requested to be sent to the emergency room (ER). However, the request was not acted upon, and the resident's condition was not adequately monitored or documented throughout the day. Interviews with staff revealed a lack of communication and coordination in responding to the resident's needs and emergency situation. The Qualified Medication Aide (QMA) and Registered Nurse (RN) on duty did not promptly verify the resident's code status or initiate CPR. Instead, there was a delay as the QMA sought assistance from the RN, who was stationed on another unit. This delay in response and failure to follow the resident's advanced directive for a Full Code contributed to the resident's death, highlighting a significant deficiency in the facility's emergency response procedures.
Removal Plan
- Nursing staff education/in-service on CPR, basic process with emphasis on immediately implementing CPR, in accordance with resident's advanced directive
- One staff member calling the code, while another staff member dials 911 and another staff member documenting code process
- Mock codes completed for each shift
- Resident code status and Care plans updated
- Ongoing audits to review Progress Notes for a change of condition and/or requests to be sent to ER
Inadequate Staffing Leads to Deficient Care in Skilled/Rehabilitation Unit
Penalty
Summary
The facility failed to ensure adequate staffing of licensed nurses (RN/LPN) on the Skilled/Rehabilitation Unit, which directly affected the care of several residents. Specifically, the facility did not maintain the necessary number of licensed nurses to meet the care needs of residents, as evidenced by the staffing schedules and Per Patient Day (PPD) calculations that fell below the facility's own assessment of required staffing levels. This deficiency was highlighted by the Payroll Based Journal (PBJ) staffing data report, which indicated low staffing levels, particularly on weekends. Resident D, who had complex medical conditions including necrotizing fasciitis, diabetes, and end-stage renal disease, experienced an unwitnessed fall. The required neurological assessments following the fall were not completed as scheduled, and there was a significant gap in progress notes. The resident was later found unresponsive and passed away despite CPR efforts. This incident underscores the impact of insufficient staffing on the ability to provide timely and adequate care. Interviews with residents and staff further revealed issues related to staffing shortages. Residents reported delays in receiving medications and care, while staff described challenges in managing workloads, particularly during meal times and weekends. The facility's scheduling practices did not consistently ensure the presence of a licensed nurse on the Skilled/Rehabilitation Unit, leading to increased responsibilities for other staff members and potential lapses in resident care.
Failure to Maintain Cleanliness in Shower Room
Penalty
Summary
The facility failed to ensure cleanliness in one of the three shower rooms on the South Unit, potentially affecting all 55 residents residing there. On two separate occasions, surveyors observed an opened package of wipes on the sink, brief packages on a dresser, a moderate-sized smear of a brown substance in front of the toilet, a smear of a white substance on the left assist bar for the toilet, used towels on a cart, a large chair with a wet sheet on it, and trash bags on the floor near the door. These observations were made in the presence of the Unit Manager, who acknowledged that the staff responsible for completing the showers should have removed trash and linens, and housekeeping should have cleaned the floor, toilets, and sink. Interviews with the Unit Manager and Housekeeping Manager revealed a lack of clarity regarding the responsibilities for cleaning the shower rooms. The Housekeeping Manager indicated that housekeepers were supposed to clean the shower room floor first thing in the morning, and CNAs were to contact a housekeeper if further cleaning was needed. However, there was no policy specifying who was responsible for cleaning the shower rooms and when it should be done. The Administrator provided a policy titled 'Routine Cleaning,' which emphasized the importance of routine cleaning and disinfection to maintain a safe and sanitary environment, but it did not address the specific responsibilities for shower room cleaning.
Medication and Treatment Administration Deficiencies
Penalty
Summary
The facility failed to ensure that residents received medications and treatments in accordance with physician orders and facility policy for four of the six residents reviewed. Resident B, who was cognitively intact and had multiple diagnoses including diabetes and pressure ulcers, did not receive scheduled blood sugar checks and insulin injections on several occasions. Additionally, wound care treatments were not documented as completed on specific dates, and the resident expressed concerns about the inconsistency in blood sugar monitoring. Resident L, who was severely cognitively impaired and had a history of stroke and diabetes, also did not receive scheduled blood sugar checks and insulin injections as ordered. Furthermore, the resident missed doses of prescribed medications such as Lexapro and Metformin, as well as nutritional supplements. These omissions were documented in the resident's medication and treatment records, indicating a failure to adhere to physician orders. Resident K, who was cognitively intact and had multiple diagnoses including bipolar disorder and diabetes, experienced similar issues with missed blood sugar checks and insulin injections. Additionally, the resident did not receive a prescribed dose of Zofran and missed a scheduled wound treatment. Resident D, with diagnoses including necrotizing fasciitis and diabetes, did not receive scheduled doses of Heparin and missed blood sugar checks and insulin administration. The facility's policies on medication administration and wound treatment management were not followed, contributing to these deficiencies.
Failure to Report Resident-to-Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to local law enforcement within 24 hours, as required by their policy. The incident involved two residents who were allegedly involved in a physical altercation, resulting in forehead bruising to both individuals. The incident was reported to the Indiana State Department of Health, and it was noted that the residents were separated immediately, and head-to-toe assessments were conducted. The physician, administrator, and family were notified, and Resident B was placed on 15-minute safety checks. However, the facility did not report the incident to local law enforcement, as the administrator and the Director of Nursing (DON) believed that the policy did not require reporting if there were no serious injuries. Resident B's clinical records indicated diagnoses of bipolar disorder, schizoaffective disorder, anxiety, intermittent explosive disorder, and post-traumatic stress disorder. The progress notes detailed that Resident B had head-butted Resident C, resulting in a 1x1 reddened area on Resident B's forehead. Resident C's records showed diagnoses of hemiplegia following a stroke, dementia with behavioral disturbance, anxiety, and chronic obstructive pulmonary disease, with a 1x2 red area on the forehead noted after the incident. Both residents were assessed with no complaints of headache, dizziness, or pain. The facility's abuse prevention policy, dated March 2022, required notification of law enforcement for resident-to-resident abuse incidents, even if they did not result in serious bodily injury, which was not adhered to in this case.
Inadequate Investigation of Resident Altercation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving two residents, Resident B and Resident C, who were allegedly involved in a physical altercation. The incident occurred in the hallway while the residents were waiting to smoke, resulting in bruising on the foreheads of both residents. The facility's response included separating the residents, conducting head-to-toe assessments, notifying the physician, administrator, and family, and placing Resident B on 15-minute safety checks. However, the investigation was deemed insufficient as no staff or resident statements were taken, and potential witnesses were not interviewed. The Administrator and Director of Nursing did not conduct interviews with staff or residents regarding the incident, as they believed it was unnecessary due to the lack of injuries. The Environmental Service Manager, who was thought to be a witness, was not interviewed, and no statements were collected from other residents who were present during the incident. The facility's policy on abuse prevention requires interviews with witnesses and staff involved, but this protocol was not followed. Resident B's clinical records indicated a history of bipolar disorder, schizoaffective disorder, anxiety, intermittent explosive disorder, and PTSD. Resident C's records included diagnoses of hemiplegia following a stroke, dementia with behavioral disturbance, anxiety, and COPD. Both residents were assessed after the incident, and their progress notes documented the altercation and subsequent actions taken. Despite these assessments, the lack of a comprehensive investigation into the incident led to the deficiency cited in the report.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 506 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near South Bend
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holy Cross Rehabilitation And Wellness | 1.3 mi | ★★★★★ | 5 | 0 |
| Wellbrooke Of South Bend | 2.1 mi | ★★★★★ | 19 | 0 |
| Brickyard Healthcare - Fountainview Care Center | 2.5 mi | ★★★★★ | 3 | 0 |
| Healthwin Health & Rehabilitation | 2.5 mi | ★★★★★ | 34 | 0 |
| Holy Cross Village At Notre Dame Inc | 2.7 mi | ★★★★★ | 20 | 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.