Majestic Care Of New Haven
MAJESTIC CARE OF NEW HAVEN in NEW HAVEN, IN — inspection on January 9, 2026.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
(injury/decline/room, etc.) that affect the resident.
residents reviewed. (Resident 2)Findings include: Resident 2's record review began on 1/4/26 at
obstructive pulmonary disease, and heart disease.A progress note, dated 10/26/25 at 10:15PM, indicated the resident was sent to ER for chest pain not relieved by Nitroglycerin tablet sublingual and per resident request. EMS was called.There were no progress notes to indicate Resident 2's emergency contact was notified of their trip to the Emergency Room.
There was no note in the record to indicate Resident 2 did not want his emergency contact notified. Resident 2 was his own responsible party with his brother named as emergency contact.Resident 2's care plan indicated family was involved with the resident in the last 14 days yet did not indicate Resident 2 did not want brother involved in care or contacted in case of an emergency:Resident 2 indicated it was very important to choose what clothes he wore, to take care of his belongings, to choose the way he bathes, to have snacks available, to choose his own bedtime, and to have family or friends involved in his care plan. A review of Resident 2's care plans indicated there was no entries to address Resident 2 not wanting his emergency contact notified in case of an emergency. In an interview, on 1/7/26 at 10:24AM, the DON indicated Resident 2 did not wish for his brother to be notified.
The DON indicated the wishes were in his care plan. In an interview, on 1/7/26 at 2:15PM, the Regional Nurse Consultant indicated Resident 2's brother was not notified due to Resident 2 being his own responsible party. A current policy and procedure were provided by DON on 1/8/26 at 11:31AM.
The policy was titled Use and Disclosure of PHI for Facility Directories, Care Involvement, and Notification purposes dated 8/27/25 last revision date of 10/1/25.
Involvement in Care and Notification a. We may disclose PHI directly relevant to a person's involvement in resident's/patient's care or payment, or to notify individuals of the patient's location, condition, or death. 3.1-5(a)
155207 01/09/2026
Majestic Care of New Haven 1201 Daly Drive New Haven, IN 46774
Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.A review of the
defined as any use of oral, written or gestured language that willfully includes disparaging and
regardless of their age, ability to comprehend or disability.This citation is related to Intake 2710550.3.1-27(b)
155207 01/09/2026
Majestic Care of New Haven 1201 Daly Drive New Haven, IN 46774
1/4/2026.
Diagnoses included pain in the right leg, other specified arthritis (unspecified site), primary
systemic lupus erythematosus (unspecified).A review of physician orders, dated 11/10/2025 at 11:15 AM, indicated to give oxycodone-Acetaminophen Oral Tablet 7.5-325 MG 1 tablet by mouth every 8 hours as needed for severe pain greater then 7 on the pain scale.
The order had a discontinued date of 12/18/2025.A review of physician orders dated 12/18/2025 at 12:30 PM indicated to give oxycodone-Acetaminophen Oral Tablet 7.5-325 MG 1 tablet by mouth every 8 hours as needed for severe pain greater than 7 on the pain scale.A review of Resident 11's current Care Plan indicated the resident was at risk of pain due to arthritis, lupus, and sciatica, with a goal date of 2/16/2026.
Interventions included offering nonpharmacological interventions such as position changes, relaxation, a quiet environment, back rubs, and diversional activities.A review of Resident 11's Medication Administration Record (MAR), dated December 2025, indicated oxycodone-Acetaminophen Oral Tablet 7.5-325 MG was administered when the resident's pain level was less than 7 on the following dates: on 12/5/2025, Resident 11 reported a pain level of 4; on 12/7/2025, Resident 11 reported a pain level of 6; on 12/16/2025, Resident 11 reported a pain level of 6; and on 12/27/2025, Resident 11 reported a pain level of 6.A review of Resident 11's progress notes dated 12/5/2025, 12/7/2025, 12/16/2025, and 12/27/2025 was completed. No documentation of nonpharmacological interventions being provided was located in the notes.
During an interview, on 1/7/2026 at 12:00 PM, the Director of Nursing (DON) indicated she could not find a reason why the oxycodone was administered for pain less than 7.
The DON indicated the medication should not have been administered.A review of a current policy provided by the DON on 1/8/2026 at 10:06 AM indicated, Pharmacological interventions will follow a systematic approach for selecting medication and doses to treat pain.
The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain.3.1-37(a)
155207 01/09/2026
Majestic Care of New Haven 1201 Daly Drive New Haven, IN 46774
reviewed on 01/04/2026 at 10:34 AM.
Diagnoses included end stage renal disease and dependence on
section did not include vital signs and was incomplete on 01/05/2026, 12/30/2025, 12/28/2025, 12/26/2025, 12/23/2025, 12/21/2025, 12/19/2025, 12/17/2025, and 12/10/2025.
During an interview, on 01/07/2026 at 10:10 AM, Resident 7 indicated he took a folder to dialysis and inside it contained his medications and the dialysis communication form. Resident 7 indicated the facility did not always complete the form.
During an interview, on 01/07/2026, the Director of Nursing (DON) indicated the facility did not complete the pre-dialysis section on the communication form as the facility had its own assessments.
The DON indicated the assessment contained the same information and was sent with the resident to dialysis.
The DON indicated the facility did not have a dialysis folder and instead sent a packet with the resident to each appointment.
The DON indicated she did not have a way to demonstrate the facility sent the assessment, as the facility did not maintain a folder and sent the information in a packet.
During an interview, on 01/08/2026 at 9:33 AM, the Dialysis Center Registered Nurse (RN) indicated Resident 7 routinely came to dialysis with a folder.
The Dialysis Center RN indicated the facility often sent the dialysis communication sheet blank.
The Dialysis Center RN indicated the section the facility was supposed to complete was often not filled out.
The Dialysis Center RN indicated the facility did not send a separate facility assessment with the resident.A current policy dated July 2020, provided by the DON, indicated, Continued assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at an off-site dialysis center.
Collaboration with the dialysis facility's plan of care.
Appropriate paperwork as required by the off-site dialysis center will be sent with the resident.3.1-37(a)
155207 01/09/2026
Majestic Care of New Haven 1201 Daly Drive New Haven, IN 46774
Based on observation and record review the facility failed to ensure only current medications and
include: During an observation on 01/04/2026 at 11:08 AM, a bottle of medication was observed with the liquid level approximately 1.5 inches from the top of the bottle.
The medication label had NOT OPEN in capital letters written in black marker.
There was no open date on the bottle.
Licensed Practical Nurse (LPN) 2 opened the lid.
The inner seal was punctured with red liquid on the puncture and around inner part of lid.
The multiple dose bottle was opened and some of the medication used.
The medication was labeled with Resident 47's information.
The medication was Guaifenesin liquid 100mg/5ml.
The medication pharmacy label was dated 5/25/25 as being dispensed.Resident 47's record was reviewed on 1/4/26 at 11:22AM. Resident 47 did not have an active order for Guaifenesin liquid 100mg/5ml. In an interview, on 1/4/26 at 11:30 AM, the Director of Nursing (DON) indicated Resident 47 should have had an order for the medication but did not have one currently. A policy and procedure titled, Medication Storage provided by DON on 1/8/26 at 1:49PM, did not indicate what labeling practices should be.A policy and procedure titled, Labeling of Medication, review date 1/27/2025, was provided by the DON on 1/8/26 at 2:12PM.
The policy indicated. 3) Multidose vials/devises should be labeled with date opened and or accessed. 3.1-25(j)(m)and(n)
updated, be reviewed by dietician, and meet the needs of the resident.
following menu tickets for 4 of 4 residents reviewed. (Resident 46, Resident 49, Resident 63 and
Resident 63 and Resident 67 were not served broccoli salad on their lunch trays. A review of the residents' food tickets confirmed both individuals were scheduled to receive the broccoli salad as part of their meal.During a dining observation on 01/05/2026 at 12:02 PM, Resident 67 indicated he did not receive any garlic bread. He further stated that he frequently does not receive items listed on his meal ticket and that no substitutions are provided.A review of the food meal posting, dated 01/05/26, on 01/05/2026 12:08 PM, indicated garlic bread was listed.
The sign was not modified to include a substitute if needed.A review of grievances on 1/8/26 at 12:20 PM indicated the following:A grievance related to Resident 46, dated 12/6/25, indicated she was having trouble with the lunch/dinning staff.
The follow up indicated the dinning staff were not looking at her meal ticket and left food off of her meal tray.A grievance related to Resident 49, dated 10/27/25, indicated the resident was having issues with her meal trays (lunch and dinner).
The findings indicated, dinning staff were not following the meal ticket. In a interview, on 1/6/26 at 1:25 PM, the Regional Nurse Consultant and Regional Dietary Manager, indicated dinning staff should look over the resident's diet and meal tickets to make sure they did not receive an item they should not get. A current facility policy, titled Menus, dated 1/2/24, was provided by the Director of Nursing on 1/8/26 at 10:06 AM.
The policy indicated .
Menus will be followed .Menus will consider the preferences of the resident population .the facility will determine an alternate menu/choices to accommodate resident choices/preference as possible 1.3-20(i)(1) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
155207 01/09/2026
Majestic Care of New Haven 1201 Daly Drive New Haven, IN 46774
on 01/04/2026 at 11:38 AM, dietary staff was temping the food, and the puree broccoli temped at 130
then asked if she should place food back to be reheated. [NAME] 11 indicated, she would be placing food on the burner to cook. A record review of food temperature logs, dated December 2025 indicated the following:On 12/31/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/27/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/25/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/18/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/14/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/13/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/12/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/11/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/8/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.On 12/4/25, there was no temperature record for the breakfast puree, lunch puree, or dinner puree.In a interview, on 1/9/26 at 8:52 AM, the Director of Nursing indicated on these dates there were 4 residents ordered puree diets.A current facility policy, Safe food handling, dated 3/1/25, was provided by the Director of Nursing on 1/8/26 at 10:06 AM.
The policy indicated .Will follow safe food handling to significantly reduced the risk for foodborne illness, thus strengthening the safety of the food provided to our residents/patients 1.3-21 (a)(1)(2)
155207 01/09/2026
Majestic Care of New Haven 1201 Daly Drive New Haven, IN 46774
include: During an observation, on 01/04/2026 at 11:08 AM, a bottle of liquid medication was observed
OPEN in capital letters with black marker.
There was no open date on the bottle.
Licensed Practical Nurse (LPN) 2 opened the lid. A puncture to the inner seal was observed with red liquid on the puncture and around inner part of lid.
The multiple dose bottle was opened and used. Resident 47's record was reviewed on 1/4/26 at 11:22AM.
The medication was discontinued and did not have an active order.
The open bottle of a multiple dose container without an open date prompted a citation of F-F0761.
The [NAME] Report for the facility was reviewed on 1/4/26 at 8:52AM.
The report indicated the facility was cited for F-F0761 Labeling/Store Drugs and Biologicals on the following dates 07/2022, 05/2023, 03/2024 and 1/2025. In an interview, on 1/9/26 at 10:04AM, the Director of Nursing (DON) indicated the facility did not have a current improvement plan for medication storage.
The DON indicated the facility did cart audits Monday through Friday for expired medications, medications without an open date, and for any loose pills in the cart.
The DON indicated they did cart to Medication Administration Record (MAR) audits weekly to ensure there were no medications in the cart that did not belong.
The DON indicated the facility did audits and reported the results in their Quality Assurance Performance Improvement (QAPI) meetings.
155207 01/09/2026
Majestic Care of New Haven 1201 Daly Drive New Haven, IN 46774