Majestic Care Of Deming Park

Based on interview and record review, the facility failed to report an allegation of resident-to-resident abuse to the Indiana Department of Health in a timely manner for 2 of 4 residents reviewed for abuse (Resident B and C).

This deficient practice was corrected by 11/3/25 prior to the start of the survey and was therefore Past Noncompliance.

Findings include: A Facility Reported Incident form, submitted by the Interim Administrator on 10/30/25, indicated, on 10/8/25 at 8:45 a.m., Resident B was sitting in the back west hallway with a female resident sitting close by, when Resident C came down the hall and yelled at Resident B to leave her alone.

Resident B then yelled at Resident C in response.

The residents were immediately separated.

During an interview on 11/12/25 at 2:04 p.m., the Social Services Director (SSD) indicated the morning of 10/8/25, she heard yelling down the hallway. As she turned the corner to where the noise was coming from, she observed multiple staff members separating Resident B and Resident C.

She spoke with all residents involved and then went to the former Administrator and reported the incident.

The former Administrator indicated to her that she wanted to reach out to someone prior to the SSD entering a progress note regarding the incident.

She indicated to the SSD she would let her know when to proceed with documentation.

The SSD indicated she noticed later, the former Administrator had left the facility for the day.

She proceeded to enter the progress notes regarding the incident at that time.

She had thought the incident had been reported to the Indiana Department of Health, as Resident B had threatened Resident C.

A progress note, dated 10/8/25 at 3:23 p.m., entered by the SSD, indicated she had heard yelling down the hall.

When she arrived, Resident B was being moved by a staff member away from another resident.

When Resident B was asked what had happened, he indicated Resident C had told him not to touch the female resident, and Resident B responded he would lay him out and fuck him up.

The SSD had reported the incident to the Administrator. A current facility policy, revised 6/5/25, titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, provided by the Director of Nursing on 11/12/25 at 3:38 p.m., included the following: .E.

Initial Reporting .2) Department of Health. a) If abuse is alleged or Serious Bodily Injury. If any form of abuse is alleged (e.g., physical verbal, etc.) ., the Administrator or his/her designee will notify the Department of Health immediately, but not later than 2 hours after the allegation is made.

This deficient practice was corrected by 11/3/25 prior to the start of the survey and was therefore Past Noncompliance.

The facility implemented a systemic plan that included staff education, skin assessments, and wound care plan audits, and ongoing monitoring was in place.

This tag relates to Intake 2657794. 3.1-28(c)

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.

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