Majestic Care Of Jefferson Pointe

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

permission.An NP progress note, dated 10/6/25, indicated the NP was accompanied by LPN 2 during his visit. Resident H turned conversation towards LPN 2 and began to raise his voice, making accusations against the nurse. He accused LPN 2 of hitting him which he had reported to the state Department of Health. The exam was deferred with the resident due to his body language, verbal behaviors, and resident recording visit. The NP and LPN 2 exited the room.LPN 2 continued to provide care to Resident H on 9/27, 9/29, 9/30, 10/4, 10/6, and 10/7/25 following the resident's meeting with the Ombudsman, Administrator, and DON on 9/24/25, when he requested LPN 2 not care for him or come into his room.On 10/16/25 at 10:35 A.M., the Administrator and DON were interviewed. The Administrator indicated he had been present

during the meeting with the Ombudsman on 9/24/25 but couldn't recall the resident requesting LPN 2 not be assigned to care for him. The DON indicated she had been in and out of the room during the meeting but while in the resident's room, hadn't heard him say he hadn't wanted the nurse to care for him. When asked about the resident relocating to another facility and having someone from the other facility assess him, both indicated the resident had verbalized in the past, he wanted out of their building and would go anywhere to get away from the facility.A current policy, titled Resident Rights was provided by the Administrator on 10/16/25 at 11:00 A.M. The policy indicated residents had the right to be informed of and participate in his/her treatment including the development and implementation of his/her person-centered plan of care. Residents had the right to participate in the planning process, the right to request revisions to

the person-centered plan, the right to establish goals and outcomes of care, and the right to be informed in advance of changes to the plan of care.This Citation relates to Intake 2633029.3.1-3(n)(3)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Majestic Care of Jefferson Pointe

5700 Wilkie Dr Fort Wayne, IN 46804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on interview and record review, the facility failed to ensure an allegation of physical abuse was reported timely for 1 of 3 residents reviewed for abuse (Resident H). Findings include:A report, dated 9/23/25 at 6:53 p.m., indicated Resident H alleged Licensed Practical Nurse (LPN) 2 struck him on his hand

after the resident allegedly kicked LPN 2. A Certified Nurse Aide had been present during the incident and indicated they witnessed Resident H kick LPN 2 but hadn't seen LPN 2 strike the resident on the hand. A nurse progress note, dated 9/20/25 at 10:44 p.m., indicated Resident H became upset with LPN 2 over a physician order he hadn't agreed with. The resident became verbally aggressive and allegedly kicked LPN 2

in the face. Staff left the room to allow Resident H to calm down. After staff left the room, a police officer showed up at the facility after a 911 call, placed by Resident H, who alleged LPN 2 had struck him on the hand.On 10/16/25 at 10:35 A.M., the Administrator was interviewed. He indicated he had been notified of

the incident on 9/20/25 (unknown time) but had not reported the incident until 9/23/25. He indicated he should have reported the incident within 24 hours after determining the resident had no injury or within 2 hours of the incident if an injury had occurred.A current facility policy, titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation was provided by the Administrator on 10/14/25 at 10:00 A.M., which indicated: All incidents and allegations of abuse, neglect, exploitation, mistreatment and misappropriation of resident and injuries of unknown source were to be reported immediately to the Administrator.If any form of abuse is alleged or serious bodily injury has occurred related to the allegation, the Administrator was to notify the Indiana Department of Health immediately but no later than 2 hours.All other allegations were to be reported immediately but no later that 24 hours from the time the incident/allegation was made known to staff.This Citation relates to Intake 2633029.3.1-28(c)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Majestic Care of Jefferson Pointe

5700 Wilkie Dr Fort Wayne, IN 46804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

shift as scheduled on 9/20/25. There was no documentation to indicate the Administrator had been notified of the incident on 9/20/25. LPN 2 continued to provide care to Resident H on 9/20, 9/21, 9/27, 9/29, 9/30, 10/4, 10/6, and 10/7/25. On 10/16/25 at 10:35 A.M., the Administrator was interviewed. He indicated he had been notified of the incident on 9/20/25 (unknown time) but had not reported the incident immediately. He indicated he had gotten Resident H's statement and statements by LPN 2 and CNA 3. He indicated CNA 3 was present and witnessed the resident kick the nurse in the face but had not seen the nurse hit the resident's hand. The investigation had been concluded at the time because there was a witness to the incident. When asked, the Administrator couldn't recall the resident asking to not have LPN 2 care for him.

There had been no further interviews completed with other residents or staff to determine if there had been any other concerns with care provided by LPN 2. A current facility policy, titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation was provided by the Administrator on 10/14/25 at 10:00 A.M., which indicated: When notified of an allegation of abuse, staff were to report and protect the resident from further harm. The nurse was responsible for performing an initial assessment of the resident which included

a full body assessment for possible injuries. If staff were involved in the allegation of abuse, the staff member was to be removed from the facility and suspended pending outcome of the investigation. Social Services were to be notified of the incident, so appropriate interventions are put in place for the residents psychosocial needs. The physician was to be notified of the allegation/incident and documentation completed in the nurse notes to include results of the full body assessment, notification to physician and family (if appropriate) and any treatment provided as a result of the incident.This Citation relates to Intake 2633029.3.1-28(d)

Event ID:

Facility ID:

If continuation sheet