Average — CMS composite of the measures below.
The next survey window likely opens around March 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 West Allen during CMS and state inspections, most recent first.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident with hemiplegia and a left above‑knee amputation, measuring 6'6" and 252 lbs, was transferred with a Hoyer lift using a single type of blue sling that lacked a legible size label and showed signs of age. The care plan and MD orders required a Hoyer lift with two staff but did not specify sling size, and there was no documented IDT assessment for sling sizing. During a bed‑to‑chair transfer performed by an LPN and a CNA, the straps were attached to the last black rings to accommodate the resident’s size; the left bottom strap ring broke while the resident was suspended, causing a fall, brief loss of consciousness, and subsequent hospital diagnosis of multiple neck, lower back, and pelvic fractures, followed by death. Staff reported that all residents used the same size sling, no one was assigned to monitor sling age or defects, and rehab did not determine sling size, despite manufacturer, FDA, and facility policy requirements to select sling size based on patient measurements, maintain readable tags, and remove deteriorated slings from service.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed environmental risks and insufficient oversight, resulting in unsafe conditions for residents.
Surveyors observed multiple failures in food safety and sanitation, including unsecured staff medications in the kitchen, expired and unlabeled food items in refrigerators and freezers, dirty equipment and surfaces, and food debris on floors and shelving. Staff interviews confirmed that these practices did not align with facility policies for food storage and cleanliness.
A resident with diabetes and dementia experienced pain due to excessively long toenails after the podiatrist missed scheduled visits and staff failed to identify or address the issue during routine care and assessments, despite facility policy requiring assistance with grooming for dependent individuals.
A resident with a history of mental health diagnoses gained unauthorized access to multiple staff-only areas by using keypad codes and possessed smoking materials and a lock picking kit, despite care plans and facility policy requiring supervision and staff control of such items. Staff were aware of the resident's actions but did not intervene, and documentation failed to reflect these incidents.
A resident with dementia, malnutrition, and dysphagia experienced significant weight loss due to the facility's failure to provide required eating assistance, offer meal replacements or supplements, and report weight changes to the physician as outlined in the care plan and facility policy. Staff interviews confirmed that care interventions were not implemented and documentation was incomplete.
Multiple areas of the facility, including the dining room, hallway, and a resident room, were found with unaddressed damage such as unpainted ceiling patches, gouged drywall, heavy dust accumulation, and a loose trim piece with exposed nails. Maintenance issues were often reported verbally instead of through the required written work order process, and no recent work requests for these damages were documented.
The facility did not ensure proper disposal of garbage and refuse, as all three dumpsters were repeatedly found with open lids, overfilled contents, and surrounding litter. Staff from multiple departments were identified as responsible for maintaining closed dumpsters and a clean area, in accordance with facility policy.
A resident with dementia and other medical conditions was observed with a full mustache, indicating a failure by the facility to provide necessary grooming services. The resident's care plan and Kardex did not include assistance with facial hair grooming or document the resident's preferences, despite the need for substantial assistance with personal care. Interviews revealed that the staff was unaware of this omission, and the facility's policy required services to be provided according to the resident's MDS assessment.
The facility failed to identify triggers for two residents with histories of trauma and mental health issues, leading to potential re-traumatization. Resident 3, with severe mental health diagnoses and past trauma, was observed in distress without appropriate interventions. Similarly, Resident 16, with PTSD and depression, displayed behaviors like wandering and refusal of care, but their care plan lacked specific stressor identification. The facility did not follow its policy to identify and address triggers in care plans.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Improper Sling Selection and Use Leads to Fatal Mechanical Lift Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff used a correctly sized, properly labeled, and intact mechanical lift sling when transferring a resident, and to have an effective process for sling sizing and condition assessment. A resident with hemiplegia affecting the left side and a left above-knee amputation required transfers with a Hoyer (mechanical) lift and assistance of two staff. The resident’s MDS documented a height of 78 inches (6 feet 6 inches) and weight of 252 pounds. The resident’s care plan and physician orders specified use of a Hoyer lift with two staff for transfers but did not identify the size of sling to be used. There was no documentation of an interdisciplinary assessment to determine appropriate sling size prior to using the lift, and no physician orders specifying sling size. During a transfer from bed to chair, an LPN and a CNA used a blue sling with four straps and color‑coded rings. The CNA reported that the sling straps were inspected before use and did not appear worn, though she described the sling as old. The straps were attached to the lift bar using the last black ring on each strap to accommodate the resident’s size. While the resident was suspended in the lift and being moved backward, the black ring on the left bottom (leg) strap broke in the middle, causing the resident to fall from the sling, strike his head on a bed frame, and land on the floor. The resident briefly lost consciousness, then became lethargic and complained of pain in the head, back, and hips. Vital signs were obtained and the NP was notified, who ordered transfer to the hospital. Hospital CT scans later showed multiple fractures of the lower back, pelvis, and neck, and the resident died at the hospital. Subsequent observation of the sling in the Administrator’s office showed a blue sling with pilling along the edges, a torn black ring on the left bottom strap, and a worn, torn label with no legible writing. There were no visible tags identifying sling size or directions for use. Facility documentation for the sling model indicated that a large universal sling was generally intended for patients 225–325 pounds and 5 feet 5 inches to 6 feet 1 inch tall, and that sling size and fit could vary based on weight and girth, with physician consultation recommended for sling selection. Staff interviews revealed that, prior to the incident, all slings in use were the same size, residents did not have specific sling sizes assigned, and staff did not know who was responsible for monitoring slings for age or defects. The Rehabilitation Director stated that rehab evaluated residents for need of mechanical lifts but did not determine sling size, and that staff were expected to follow sling label directions, even though the sling involved had an illegible tag. External guidance from the FDA and a sling manufacturer emphasized the need to select sling size based on patient measurements and manufacturer recommendations, and to remove slings from service if tags were missing, faded, or illegible, or if deterioration was present. The facility’s own policy required availability of varying sling sizes, correct resident measurement per manufacturer instructions, and removal of damaged or unsafe slings from service, which was not carried out in this case.
Removal Plan
- Removed all lift pads from service
- Assessed residents utilizing lifts for proper fit according to manufacturer's guidelines
- Replaced all slings with properly sized slings
- Added sling sizing to care plans and care guidance for CNAs
- Developed a replacement schedule for slings according to manufacturer's instructions
- Reeducated staff on how to identify deterioration of sling pads before use
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Failure to Maintain Food Safety and Sanitation Standards in Kitchen and Pantry
Penalty
Summary
The facility failed to store and serve food and drinks in a manner that maintained food safety for all 78 residents who consumed food and drinks from the kitchen. During a continuous observation of the kitchen, surveyors found three unsecured medication bottles, including a prescription for Xarelto, in an open basket on a counter. Moisture and white debris were observed in several bowls being prepared for pudding service. The dishwasher unit had dead bugs and particles on its surface, and a ceiling vent above the freezer was coated with a thick layer of dark gray, fuzzy substance. The wall behind the freezer showed discoloration, and the pantry floor and shelving had food debris, including cereal, granules, sugar, salt packets, and onion peels. Several food items in the refrigerators and freezers were found to be expired, unlabeled, or undated, including milk, juice, and various packaged foods. The interior of the ice machine had a reddish brown substance, and non-food items such as a plastic spoon, candy wrapper, blue glove, and a linen pillowcase were found on the floor and atop the freezer. Interviews with staff confirmed that expired and unlabeled food items should not have been present in the refrigerators, and that staff medications should have been secured in lockers. Review of facility policies indicated requirements for proper cleaning schedules, food storage, and labeling of food brought in by family or visitors. Cleaning logs showed that staff were responsible for ensuring dishes, utensils, and surfaces were cleaned and sanitized, and that the dish machine and dry storage areas were maintained. Despite these policies and logs, the observations revealed multiple failures in maintaining food safety and cleanliness standards in the kitchen and pantry areas.
Failure to Provide Toenail Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary toenail care for a resident who was unable to perform this activity independently. The resident, who had diagnoses of type 2 diabetes without complications and dementia, reported that her toenails had become very long and caused her pain while walking. She stated that the podiatrist, who usually trimmed her toenails, had not visited for an extended period due to scheduling issues. The resident had communicated her concerns to the Social Service Director. Observation confirmed that the resident's toenails were excessively long, with irregular edges and thickening, and a callous was present on her foot. Record review showed no documentation of hygiene care refusal or mention of long toenails in recent skin evaluations. The Regional Nurse Consultant acknowledged that the resident's nails were excessively long and should have been trimmed, noting that both nurse aides and nurses are responsible for identifying and addressing such issues during daily care and weekly skin checks. The last podiatry visit was in February, and the scheduled April visit did not occur. Facility policy requires that residents unable to perform activities of daily living receive necessary services to maintain good grooming, which was not met in this case.
Failure to Secure Staff Areas and Control Smoking Materials
Penalty
Summary
The facility failed to ensure that staff-only areas remained secure and that smoking materials were properly controlled for one resident. During observations and interviews, a resident demonstrated knowledge of and access to multiple keypad-protected areas, including the conference room, dementia unit, housekeeping closet, shower room, and pantry, where cleaning products were present. The resident also reported knowing the codes for doors leading to the smoking area and exterior exits. Staff confirmed that the resident quickly learned new codes whenever they were changed. The resident was observed possessing lighters and a lock picking kit, and staff present did not intervene or confiscate the smoking materials. The resident also reported vaping in his room despite being told not to and storing smoking materials in his room safe. The resident's care plan required supervision while smoking and specified that smoking materials should be kept by facility staff. However, the resident frequently smoked and vaped unsupervised and maintained possession of smoking materials. Documentation did not reflect incidents of unsupervised smoking, possession of smoking materials, or unauthorized entry into restricted areas, except for a note indicating the resident had attempted to pick locks and was placed on direct supervision. Facility policy required that residents who smoke be supervised and that smoking materials be stored by staff, but these procedures were not consistently followed for this resident, who had diagnoses including schizoaffective disorder, antisocial personality disorder, ADHD, and anxiety disorder.
Failure to Implement Nutritional Interventions and Timely Reporting of Weight Loss
Penalty
Summary
The facility failed to implement care plan interventions and address significant weight loss for a resident with multiple risk factors, including dementia, protein-calorie malnutrition, and dysphagia. Despite care plans indicating the need for eating assistance and prompt notification of significant weight changes to the physician, the resident experienced a 6.6% weight loss over 30 days. Documentation showed repeated low meal intake, frequent meal refusals, and missing records for several meals. There was no evidence that meal replacements or supplements were offered or recorded, and no additional weights or reweights were documented as required by facility policy. Interviews with staff revealed that the resident did not receive eating assistance as outlined in the care plan, and that significant weight changes were not reported to the physician or family in a timely manner. The facility's policy required weekly weights for new admissions, reweights for variances of three pounds or more, and physician notification for weight losses of 5% or more in 30 days. These procedures were not followed, and progress notes lacked documentation of reweights or reporting of the weight loss. The deficiency was identified for one resident out of three reviewed.
Failure to Maintain Safe and Clean Facility Environment
Penalty
Summary
The facility failed to maintain several areas in a safe, clean, and comfortable condition for residents, staff, and the public. Observations revealed multiple deficiencies, including four unpainted areas on the dining room ceiling, a deep gouge and missing drywall at the main doorway corner, and additional drywall damage along the same area. Heavy dust was found on the drop ceiling and metal supports outside a resident room, and rectangular marks were present on walls between rooms and outside the infection control office. In one resident room, a five-foot-long trim piece with four exposed nails was found on the floor under the bed's headboard. A review of maintenance logs showed no written work requests for wall or trim damage in the past six months. Staff interviews indicated that maintenance issues were often reported verbally rather than through the required written work order process. The Maintenance Director confirmed receiving both verbal and written requests, and the Housekeeping Manager stated that paint repairs should be completed the same day they are reported. The facility's policy requires work orders to be filled out and prioritized, but this process was not consistently followed, contributing to the deficiencies observed.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as evidenced by observations on two separate occasions where all three dumpsters on site were not kept closed. The first dumpster was found with its lid fully open, the second had white trash bags propping open the lids, and the third, designated for cardboard, was overfilled with cardboard keeping both lids open. Additionally, plastic and other trash were observed on the ground around the dumpsters and extending into the nearby tree line. During an interview, the Dietary Manager confirmed that housekeeping, dietary, and nursing staff are responsible for ensuring dumpster lids are closed and that no debris is left outside the dumpsters. The facility's current policy requires dumpsters to be kept closed and free of surrounding litter.
Failure to Provide Grooming Services for Resident with Dementia
Penalty
Summary
The facility failed to provide grooming services for the facial hair of a resident with dementia, diabetes, stroke, and hemiplegia, who required substantial assistance with personal care. The resident was observed with a full mustache, and their care plan did not include assistance with grooming facial hair or indicate any preference regarding facial hair maintenance. The resident's care plan and Kardex lacked specific instructions for grooming facial hair, despite the resident's need for assistance with activities of daily living (ADLs). Interviews with the facility's Administrator, Regional Nurse Consultant, and Director of Nursing revealed that the resident often refused personal care, and the staff was unaware that grooming of facial hair was not included in the care plan or Kardex. The Administrator acknowledged that grooming should be offered to all residents, including females, and that the resident's preferences should be documented. The facility's policy indicated that services should be provided according to the resident's MDS assessment, and refusals of personal care by residents with dementia should be investigated.
Failure to Identify Triggers for Trauma-Informed Care
Penalty
Summary
The facility failed to identify triggers to prevent potential re-traumatization for two residents reviewed for mood and behavior. Resident 3, who has a history of severe mental health issues and past trauma, was observed in distress multiple times without appropriate interventions to address her specific triggers. Her care plan and Kardex lacked details on her identified triggers, despite her history of sexual abuse and mental health diagnoses, which include paranoid schizophrenia and major depressive disorder. The care plan did not include strategies to eliminate or reduce these triggers, which could lead to re-traumatization. Resident 16, who also has a history of trauma and mental health issues, was observed displaying behaviors such as wandering and refusal of care. The resident's care plan did not attempt to identify specific stressors or triggers that could lead to these behaviors. Despite having a history of PTSD and depression, the care plan lacked interventions to address these issues, and the Kardex did not reflect the resident's mental health history or behaviors. The facility's policy required the identification of triggers with the potential to re-traumatize trauma survivors and the inclusion of specific interventions in the care plan. However, the facility did not adhere to this policy, as evidenced by the lack of trigger identification and intervention strategies in the care plans of Residents 3 and 16. The Administrator and Social Service Director were unaware of the need for such identification, indicating a gap in the facility's implementation of trauma-informed care.
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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) |
|---|---|---|---|---|
| Coventry Meadows | 5.6 mi | ★★★★★ | 8 | 0 |
| Sage Bluff Health And Rehab Center | 5.6 mi | ★★★★★ | 6 | 0 |
| Majestic Care Of Jefferson Pointe | 6.4 mi | ★★★★★ | 18 | 1 |
| Englewood Health & Rehabilitation Center | 9 mi | ★★★★★ | 0 | 0 |
| Waters Of Columbia City Skilled Nursing Facility | 10 mi | ★★★★★ | 11 | 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.