Majestic Care: Failed to Notify Families of Transfers - IN
The incident at Majestic Care of West Allen illustrates how communication breakdowns can leave families in the dark about medical emergencies involving their loved ones with dementia and other cognitive conditions.
Resident 2 had been struggling. Progress notes from March 1st showed the person developed altered mental status, fever, and weakness around 6:50 AM. Staff notified the physician but made no other calls. The notes specifically stated that Resident 2 was "their own responsible party and no other notification was completed."
Two hours later, the resident had improved slightly but remained below their normal mental baseline.
By 2:26 PM that same day, the situation had deteriorated. Resident 2 was transferred to the hospital by ambulance for fever, abdominal pain and distention. Again, staff noted that no power of attorney or family notification was completed because they considered the resident their own responsible party.
The decision ignored a crucial document in the resident's file. On February 3rd, just weeks before the emergency, Resident 2 had signed an Indiana Durable Power of Attorney designating an agent to make healthcare decisions. The legal document specifically referenced Indiana Code 30-5-5-17, which governs healthcare consent and refusal.
Federal inspectors found that staff had the power of attorney paperwork but failed to use it when the resident's condition required emergency hospitalization.
The facility's own assessment data supported the need for family involvement. A quarterly evaluation completed March 17th showed Resident 2 scored 10 on the Brief Interview for Mental Status, indicating moderate cognitive impairment. The assessment noted difficulty recalling the current month and problems with short-term memory.
Despite these documented cognitive limitations, staff treated the resident as capable of making independent decisions about hospital transfers and family notification.
A second resident experienced similar communication failures. Resident 85, who had been diagnosed with dementia and a serious bone infection called osteomyelitis, was also transferred to a hospital on March 9th. Transfer documentation noted that this resident "required a proxy for decision making," yet there's no indication families were contacted about the hospitalization.
The facility's written policy, dated January 2024, clearly outlined requirements for hospital transfers. According to the director of nursing, the policy mandated that staff provide written notice specifying bed-hold duration and explaining how residents could return to the next available bed. The policy also required keeping signed copies of bed-hold notices in resident files.
But having the right paperwork didn't translate to proper family communication.
For Resident 2, transfer documentation failed to include the bed-hold policy initially. An untimed notice dated March 1st showed the resident eventually signed acknowledgment of the bed-hold policy, but the timing remained unclear.
Resident 85's case showed better documentation compliance. Transfer forms indicated copies of both the transfer paperwork and bed-hold policy were sent with the resident to the hospital.
The inspection findings highlight a gap between policy and practice that can have serious consequences for families. When residents with cognitive impairment face medical emergencies, family members may be the only ones who can provide crucial medical history, medication information, or insight into the person's preferences and typical condition.
The facility is disputing the citation, but the documentation tells a clear story. Two residents with significant cognitive limitations were hospitalized during medical emergencies, and their families weren't told.
For Resident 2, the failure was particularly striking given the existence of a power of attorney document specifically designed to ensure someone could make healthcare decisions when the person's cognitive abilities were compromised.
The cases occurred within eight days of each other in early March, suggesting the communication problems weren't isolated incidents but part of a broader pattern in how staff handled family notification during medical emergencies.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Majestic Care of West Allen from 2026-04-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 12, 2026 · Our methodology
MAJESTIC CARE OF WEST ALLEN in FORT WAYNE, IN was cited for violations during a health inspection on April 16, 2026.
Resident 2 had been struggling.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at MAJESTIC CARE OF WEST ALLEN?
- Resident 2 had been struggling.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in FORT WAYNE, IN, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from MAJESTIC CARE OF WEST ALLEN or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 155322.
- Has this facility had violations before?
- To check MAJESTIC CARE OF WEST ALLEN's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.