Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Majestic Care Of North Vernon during CMS and state inspections, most recent first.
A resident with non-Alzheimer’s dementia and moderate cognitive impairment alleged that another resident hit her shoulder and reported this to nursing and social services staff. An RN heard the resident yell that she had been hit, briefly checked her shoulder without a full skin assessment, and did not notify the Administrator or DON. The Social Services Director documented a soft file investigation after the resident reported being hit while holding her shoulder, but did not report the allegation to facility leadership or the Department of Health. The Administrator stated he was not informed until several days later, despite facility policy requiring care team members to immediately report all such allegations to the Administrator and the Department of Health.
Surveyors found that the facility failed to dispose of Ozempic pens for two residents after discharge, contrary to facility policy and pharmaceutical waste requirements. The DON stated refrigerated meds were kept in the Unit C med room and that Ozempic was no longer stored in her office, but surveyors observed three Ozempic pens in a small refrigerator in the DON’s office, labeled for two residents who were no longer in the facility. Record review showed both residents were cognitively intact, had DM and anxiety, and had Ozempic orders that had been discontinued, with pharmacy records indicating remaining doses and no documented disposal. The DON later acknowledged that these medications should have been discarded earlier.
Medications and vaccines, including Ozempic, Prevnar 20, and RSV vaccine, were found stored in a miniature refrigerator in the DON’s office together with personal food and drink items, contrary to facility policy requiring all medications to be stored in the pharmacy and/or medication rooms under appropriate conditions for sanitation, segregation, and security. The DON acknowledged forgetting the medications were in the refrigerator and stated that resident medications should not be stored with personal food.
Surveyors found that water temperatures in several resident and common area bathrooms exceeded safe limits, with some readings as high as 134.5°F. The Women's Visitor Restroom, accessible to residents and the public, had water that was hot to the touch. Temperature logs showed inconsistent monitoring, and interviews with the Administrator and DON revealed no prior reports of burns or concerns related to hot water.
A resident with a right arm contracture and multiple comorbidities suffered a fracture after a contracted x-ray technician attempted to reposition her arm without adequate staff assistance, despite the resident's pain and inability to move the limb. The technician did not follow required procedures for seeking help from facility staff, and the resident's pain increased following the incident, with later imaging confirming fractures that required orthopedic intervention.
A resident with moderate cognitive impairment was denied cornbread and milk by an LPN after being told not to stand up while the LPN retrieved the items. When the resident stood up, the LPN discarded the food and drink, failing to treat the resident with respect and dignity as required by facility policy. The incident was witnessed by a CNA and reported by the resident's relative.
A CNA failed to follow hand hygiene protocols while serving meals, including touching her face and handling food items without sanitizing hands between actions. In the kitchen, an aide prepared drinks without a beard net, and expired or unlabeled food items were found in the refrigerators, all in violation of facility policies.
Surveyors identified infection control deficiencies involving improper wound care technique by an LPN, who failed to change gloves after touching contaminated items and did not rinse a wound as ordered, as well as multiple instances where residents' indwelling urinary catheter bags were observed dragging on or resting directly on the floor. These lapses occurred despite facility policies requiring proper hand hygiene and catheter care, and were confirmed through staff interviews and resident record reviews.
Staff left medications unattended at the bedside for two residents who had not been assessed or approved for self-administration. Both residents were cognitively intact but had not been cleared to self-administer, and facility policy prohibits leaving medications unless a resident is assessed as safe. The DON confirmed that no residents were currently approved for self-administration, and both residents' records indicated they required assistance with medication administration.
A resident with multiple diagnoses, including a history of UTIs and an indwelling catheter, received daily prophylactic Cephalexin per physician order, but the care plan was not updated to reflect this ongoing antibiotic regimen. The DON confirmed the omission, which was not in accordance with facility policy requiring comprehensive care plans to include all services provided.
Three residents received cardiac medications despite physician orders specifying hold parameters based on blood pressure readings. In multiple instances, medications such as Midodrine and Losartan were administered when residents' systolic blood pressure readings were outside the prescribed limits. Documentation and staff interviews confirmed that these medications were given contrary to both physician orders and facility policy.
A resident with an indwelling urinary catheter and a history of stroke, diabetes, and renal insufficiency was observed on multiple occasions with the catheter drainage bag resting on the floor, contrary to facility policy and professional standards. The resident was receiving prophylactic antibiotics for recurrent UTIs, and staff confirmed that catheter components should not touch the floor.
A nurse crushed and administered a Potassium Chloride Extended-Release tablet to a resident despite a physician's order specifying the tablet should not be crushed, but instead placed in applesauce to dissolve. The DON confirmed that staff should not crush medications with 'do not crush' instructions, in accordance with facility policy.
Surveyors found that multiple medication carts contained undated or improperly labeled medications, including insulins and inhalers, for several residents. An LPN and the DON confirmed that medications such as insulin and inhalers should be dated upon opening and stored according to policy, but this was not consistently done, resulting in a deficiency in medication management.
A facility failed to notify a physician of a change in condition for a resident with severe cognitive impairment and multiple diagnoses. The resident was lethargic and later found unresponsive without a pulse, but there was no documentation of physician notification. The facility's policy required such notification, which was not followed.
A facility failed to report an allegation of verbal abuse in a timely manner. An LPN was reported to have been verbally abusive to a resident, but the incident was not reported to the Department of Health until several days later. The investigation was conducted over the phone and lacked interviews with the resident or other residents, leading to a deficiency.
A facility failed to properly investigate an abuse allegation involving a resident and an LPN. Staff reported the LPN was verbally abusive, but the DON did not conduct a thorough investigation, relying on phone communication and failing to interview the resident or other residents. The investigation did not adhere to the facility's policy, leading to a noted deficiency.
The facility failed to maintain proper storage in resident snack refrigerators, with an ice pack used by a resident found unlabeled in the C-Hall freezer, and another ice pack stored next to ice cream in the A-Hall freezer. Additionally, an opened, unlabeled pudding cup was found in the D-Hall refrigerator. The DON confirmed that these items should be labeled and stored according to facility policies.
The facility failed to maintain a homelike environment due to persistent strong urine odors in the B-Hall secured unit, affecting the hallway, dining room, and common areas. Staff interviews revealed challenges in managing the odor, with maintenance and housekeeping efforts proving insufficient. The facility's policy on resident rights emphasizes a clean and comfortable environment, which was not upheld.
Failure to Timely Report Resident Abuse Allegation to Required Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report and properly document a resident’s allegation of abuse to required facility leadership and external authorities. A resident with non-Alzheimer’s dementia and moderate cognitive impairment (Resident C) reported that another resident (Resident F) hit her left shoulder. She stated she informed a nurse and another staff member at the front of the building, and the nurse told her she would be okay. An RN heard a resident yell, “He hit me,” and found Resident C in front of the nurse’s station. The RN took Resident C back to her room, visually checked her shoulder, found no marks, did not complete a full skin assessment, and did not notify the Administrator or DON of the allegation. An LPN reported that in situations where a resident claims to be hit by another resident, she would verbally report to the Administrator and DON, and that floor staff do not document such occurrences, leaving documentation to management. The Administrator stated he was not informed of the incident until several days after it occurred. The Social Services Director reported that Resident C came to her holding her left shoulder and stating she had been hit by Resident F. The Social Services Director interviewed staff and created a “soft file” investigation document dated 03/20/2026, but did not report the allegation to the Administrator or DON. Review of the facility’s abuse policy, revised 06/05/2025, showed that care team members are required to immediately report all such allegations to the Administrator and to the Department of Health in accordance with the policy’s procedures. Despite multiple staff being informed of the allegation, the required immediate reporting to facility leadership and the Department of Health did not occur, and the Administrator only became aware of the allegation days later, at which point he had just begun his own investigation.
Failure to Dispose of Discharged Residents’ Ozempic as Required
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmaceutical services when medications belonging to two discharged residents were found stored in the DON’s office refrigerator instead of being disposed of. During an interview and observation, the DON initially stated that refrigerated medications were kept in the Unit C medication room refrigerator and that Ozempic was no longer stored in her office. However, surveyors observed a miniature refrigerator in the DON’s office containing three Ozempic pens: two labeled for one resident and one for another, both of whom the DON confirmed had been discharged. Facility policy on medication storage required routine inspection by the consultant pharmacist for discontinued medications, and the hazardous waste policy required management of all pharmaceutical waste as hazardous in accordance with applicable regulations. Record review showed that one resident, cognitively intact and diagnosed with diabetes mellitus and anxiety, had Ozempic orders that were discontinued on two separate occasions, with documentation indicating remaining doses at the time of last administration and no documentation of disposal. This resident had a discharge-return not anticipated assessment completed, and the Ozempic order was discontinued on the date of discharge. The second resident, also cognitively intact with diabetes mellitus and anxiety, had an Ozempic order discontinued while still in the facility and later passed away; pharmacy records indicated remaining doses after the last administration. During a subsequent interview, the DON acknowledged that the Ozempic medications for both residents should have been discarded earlier, confirming that the medications were not disposed of after discharge as required by policy and regulatory expectations.
Improper Storage of Medications and Vaccines in DON Office Refrigerator
Penalty
Summary
Surveyors observed that medications and vaccines were improperly stored in the DON’s office in a miniature refrigerator that also contained personal food and drink items. During the observation, the refrigerator held Ozempic, two single-dose vials of Prevnar 20 (pneumococcal 20-valent vaccine), and two single-dose vials of RSV vaccine alongside an unopened individually wrapped sandwich, a half-full dressing bottle, four unopened 12-ounce cans of lemonade, a three-quarters full bottle of water, and a personal water bottle. In an interview, the DON stated she had forgotten that the medications were in her refrigerator and acknowledged that resident medications should never be stored with personal food items. Review of the facility’s Medication Storage policy, last reviewed on 12/12/2023, indicated that all medications housed on the premises were to be stored in the pharmacy and/or medication rooms to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security, which was not followed in this instance. This citation relates to Intake 2791258 and 410 IAC 16.2-3.1-25(o).
Unsafe Water Temperatures in Resident and Common Area Bathrooms
Penalty
Summary
The facility failed to maintain safe water temperatures in 5 out of 9 resident bathrooms and 1 out of 2 common area bathrooms. During observations, water temperatures in these areas were found to be significantly above the recommended maximum, with readings ranging from 122.5 to 134.5 degrees Fahrenheit. The Women's Visitor Restroom, accessible to residents and the public, had water that was hot to the touch and could not be held under the hand. The Maintenance Director confirmed that the restroom had its own on-demand water heater, which had been tampered with despite a warning tape placed over the temperature dial. The restroom was generally unlocked and accessible except when in use. Temperature logs for September and October showed that water temperatures were within the acceptable range on certain dates, but there were gaps in the logs and no other dated records were provided. Interviews with the Administrator and DON indicated that there had been no reported burns or concerns related to hot water temperatures prior to the survey. The facility's policy required water temperatures to be maintained within the state's allowable range, but this was not consistently achieved in the areas observed.
Failure to Ensure Safe X-Ray Positioning Results in Resident Arm Fracture
Penalty
Summary
A resident with a history of stroke, contracture of the right arm, diabetes, hypertension, neurogenic bladder, arthritis, aphasia, and osteoporosis experienced significant pain and ultimately a fracture following an x-ray procedure performed by a contracted x-ray technician. The resident was cognitively intact but had physical impairments and required complete assistance for activities of daily living. The x-ray was ordered due to redness, swelling, and pain in both elbows, and the resident was being treated for possible cellulitis at the time. During the x-ray procedure, the technician attempted to reposition the resident's contracted right arm without adequate assistance from facility staff, despite the resident's inability to move the arm due to the contracture. The resident cried out in pain during the procedure, which was heard by a registered nurse who intervened and stopped the technician from further manipulating the arm. The technician stated that she could not obtain the necessary images without straightening the arm, but did not request or wait for staff assistance as required by the x-ray company's own procedures. Facility staff were not present in the room during the initial attempt, and the technician did not seek help despite the resident's obvious physical limitations and pain. Following the incident, the resident continued to experience increased pain in the right arm, which was not relieved by Tylenol and later required stronger pain management. Subsequent x-rays revealed fractures in the right arm, and the resident was referred to an orthopedic physician for casting. Interviews with facility staff and review of the x-ray company's procedures confirmed that facility staff assistance was required for repositioning residents with significant physical limitations, but this protocol was not followed during the incident.
Resident Denied Food and Drink as Punishment by LPN
Penalty
Summary
A deficiency occurred when a resident, who was moderately cognitively impaired and had diagnoses including hypertension, arthritis, and gastroesophageal reflux disease, was not treated with respect and dignity by a staff member. The incident began when the resident requested her cornbread, which had been saved from lunch, to be microwaved. An LPN agreed to do so and instructed the resident not to stand up while she was gone. Upon returning, the LPN observed the resident standing and, as a result, refused to give her the cornbread and milk, discarding both items in the trash. This action was witnessed by a CNA, who reported the event to her superiors. The resident later recounted the same sequence of events to the Social Service Director, and a facility document corroborated the details of the incident. The facility's policy on dignity requires that all residents be treated with respect and that their rights be protected and promoted. However, in this case, the LPN's actions—specifically, withholding food and drink as a consequence for the resident's movement and discarding the items—demonstrated a failure to uphold these standards. The incident was reported by both staff and the resident's relative, and documentation confirmed the resident's account of being denied food and drink in a manner that did not maintain her dignity.
Deficiencies in Hand Hygiene, Food Storage, and Staff Attire
Penalty
Summary
A Certified Nurse Aide (CNA) was observed during meal service in the D-Hall Dining Room engaging in multiple lapses in hand hygiene. The CNA pushed a chair, touched her nose, face, and ear, and then proceeded to serve a meal tray to a resident without performing hand hygiene between these actions. She handled the resident's plate, napkin, silverware, and food items directly before the resident began eating. The CNA later used hand sanitizer before serving another tray, but facility policy required the use of hand sanitizer after each tray and prohibited staff from touching themselves before serving meals. The CNA confirmed during an interview that these procedures were not followed as required. In the kitchen, an Activity Aide was observed preparing drinks without a beard net, despite having a long beard that was not restrained, contrary to facility policy. Additionally, the kitchen refrigerators contained several food items that were either undated, expired, or not properly labeled, including tuna salad, Dijon pork, milk, and tomato juice. The Assistant Dietary Manager confirmed that these items should have been labeled and discarded according to facility policy, and that the staff member's beard should have been covered while in the kitchen.
Infection Control Failures in Wound Care and Catheter Management
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices involving wound care and indwelling urinary catheter management for four residents. During a wound dressing change for a resident with a severe cognitive impairment and a history of stroke, hypertension, and neurogenic bladder, an LPN donned gloves and then touched potentially contaminated items, such as her pocket and treatment cart keys, before handling wound care supplies. The LPN did not change gloves after these contacts, failed to rinse the wound thoroughly after applying Hibiclens as ordered, and touched sterile gauze pads with contaminated gloves. The facility's hand hygiene policy required handwashing or use of alcohol-based hand rub after contact with objects in the resident's vicinity, which was not followed. For three other residents with indwelling urinary catheters, surveyors observed that the catheter drainage bags were either dragging on the floor or resting directly on the bare floor in multiple locations and at different times. One resident's catheter bag was seen dragging on the floor while she was in the dining room and being transported through hallways. Another resident's catheter bag was observed with two to three inches in direct contact with the floor while he was in bed, and a third resident's catheter bag was repeatedly seen with about one inch resting on the floor while she sat in her recliner. Staff interviews confirmed that catheter bags should not be in contact with the floor, and the facility's policy required appropriate care in accordance with professional standards. The clinical records for the affected residents indicated significant medical histories, including diabetes, acute neurological disorders, stroke, benign prostatic hyperplasia, and neurogenic bladder. Observations and interviews confirmed that staff did not adhere to established infection control protocols for both wound care and catheter management, as required by facility policy and professional standards.
Medications Left Unattended for Residents Not Assessed for Self-Administration
Penalty
Summary
Facility staff left medications unattended at the bedside of two residents who had not been assessed or approved for self-administration of medications. In one instance, a resident was observed sitting on her bed with three medication cups containing various pills left on her bedside table. The resident confirmed the medications were hers and that the nurse had left them for her to take, with no staff present in or near the room. Review of her clinical record showed she was cognitively intact but had diagnoses including hypertension, heart failure, dementia, anxiety, and depression. The DON confirmed that the resident did not have a self-administration assessment and was not considered safe to self-administer medications. Facility policy prohibits leaving medications unattended unless a resident has been assessed as safe to self-administer. In another case, a resident was found reclining on her bed with a medication cup containing a half tablet and a capsule on her overbed table. The resident stated that sometimes staff left medications at her bedside and sometimes supervised her taking them, depending on whether the staff member was familiar with her. No staff were present in the immediate area at the time. Her clinical record indicated she was cognitively intact with diagnoses including stroke, anxiety, depression, and respiratory failure. The DON stated that there were no residents in the facility currently approved to self-administer medications, and the resident's assessment indicated she required assistance with medication administration.
Failure to Update Care Plan for Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to revise the care plan for a resident who was receiving a prophylactic antibiotic for recurrent urinary tract infections (UTIs). The resident, who was moderately cognitively impaired and had diagnoses including stroke, diabetes, renal insufficiency, and an indwelling urinary catheter, had a physician's order for daily Cephalexin starting from 02/13/25. Review of the resident's medication administration records confirmed that the antibiotic was administered daily over several months. Despite the ongoing use of the prophylactic antibiotic, the resident's comprehensive care plan did not include any information regarding this medication regimen. The Director of Nursing confirmed that the care plan should have been updated to reflect the prophylactic antibiotic use, as ordered by the resident's urologist. Facility policy requires that the comprehensive care plan describe all services provided to maintain the resident's highest practicable well-being, but this was not done in this case.
Failure to Follow Physician Orders for Cardiac Medication Hold Parameters
Penalty
Summary
The facility failed to follow physician's orders regarding hold parameters for cardiac medications for three residents. For one resident with a history of stroke, hypertension, and coronary artery disease, the physician's order specified that Midodrine should be held if the systolic blood pressure exceeded 120. However, the medication was administered multiple times when the resident's systolic blood pressure was above this threshold, as documented in the Electronic Medication Administration Record (EMAR). Another resident, diagnosed with diabetes, hypertension, neurogenic bladder, and aphasia, had a physician's order for Losartan to be held if the systolic blood pressure was less than 120 or the heart rate was less than 60. Despite this, the EMAR showed that the medication was given on several occasions when the resident's systolic blood pressure was below 120. This pattern was observed over several months, indicating a repeated failure to adhere to the specified hold parameters. A third resident, with multiple diagnoses including amputation, anemia, hypertension, and diabetes, also had a physician's order for Midodrine to be held if the systolic blood pressure was greater than 120. The EMAR revealed that the medication was administered on numerous occasions when the resident's systolic blood pressure exceeded the prescribed limit. During an interview, an LPN stated that medications with hold parameters should not be administered if vital signs are outside the specified range, and the facility's policy confirmed this requirement. Despite this, the records demonstrated that staff did not consistently follow these orders.
Improper Placement of Urinary Catheter Drainage Bag
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter, who was receiving prophylactic antibiotics for recurrent urinary tract infections, was observed with improper catheter drainage bag placement on multiple occasions. On one occasion, the drainage bag was seen hanging on the side of the bed with about two inches of the bag resting on the bare floor. On another occasion, the drainage bag was observed hanging under the resident's wheelchair, with about an inch of the bag touching the floor. In both instances, the urine in the tubing was noted to be dark yellow with sediment. The resident involved had a history of stroke, diabetes, and renal insufficiency, and was assessed as moderately cognitively impaired. Facility staff, including the Corporate Clinical Support Nurse, confirmed that no part of an indwelling catheter should be in contact with the floor. The facility's policy on indwelling catheters also required adherence to professional standards of practice, which were not followed in these observed instances.
Failure to Follow 'Do Not Crush' Medication Order
Penalty
Summary
A registered nurse prepared and administered medications to a resident, including Potassium Chloride Extended-Release 10 MEQ, by crushing all the medications together and mixing them with applesauce before administration. The physician's order for the Potassium Chloride specifically instructed that the tablet was not to be crushed, but rather placed in applesauce and allowed to dissolve. The nurse did not follow these instructions and crushed the tablet. The Director of Nursing confirmed that medications with 'do not crush' instructions should not be crushed. Facility policy also required staff to administer medications as ordered and not to crush medications labeled with 'do not crush' instructions.
Failure to Properly Label and Store Medications on Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to store and label medications in accordance with professional standards on three of four medication carts. Specifically, on the A-Hall medication cart, an unopened vial of insulin Lispro for one resident was found undated, and two inhalers (Symbicort and Albuterol) for another resident were opened but not dated. On the B-Hall medication cart, a Combivent inhaler for a resident was present and dated, but the report does not specify if the date was appropriate. On the C-Hall medication cart, an opened vial of Humalog insulin for a resident was found undated, with the nurse indicating it had just been labeled with the pharmacy delivery date at the time of observation. During interviews, the DON confirmed that all insulins in the medication cart should be dated, and unopened insulins should be stored in the refrigerator. The DON also stated that inhalers such as Albuterol, Symbicort, and Combivent have specific expiration periods after opening and should be dated accordingly, with undated inhalers being discarded after their expiration. The facility's policy on product expiration dates was provided, confirming these requirements. The failure to date and properly store these medications constituted a deficiency in medication management.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, identified as Resident B, who was severely cognitively impaired with diagnoses including non-Alzheimer's dementia, hypertension, anxiety, and depression. On January 30, 2024, Resident B was documented to have eaten less than a quarter of his meals at both 10:50 A.M. and 1:50 P.M. Later that day, at 4:30 P.M., a progress note by an RN indicated that Resident B was lethargic. However, there was no documentation of the physician being notified of this change in condition. Subsequently, at 7:19 P.M., an LPN documented that Resident B was found unresponsive and without a pulse at 6:05 P.M. During interviews, the RN could not recall the resident or provide additional information beyond her documentation. The Director of Nursing confirmed that there was no documentation of physician notification on January 30, 2024, and the last recorded notification of change for Resident B was on November 7, 2023. The facility's policy required nurses to notify the physician of significant changes in a resident's condition, which was not adhered to in this case.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse in a timely manner for a resident. The incident involved a Licensed Practical Nurse (LPN) who was reported to have been verbally abusive to a resident by yelling and using inappropriate language. The incident was witnessed by other staff members who reported it to the Director of Nursing (DON). Despite the report, the DON did not immediately come to the facility and conducted the investigation over the phone. The investigation was deemed insufficient as it lacked interviews with the resident involved or any other residents in the facility. The facility's policy requires that any allegations of abuse be reported to the Department of Health immediately, but no later than two hours after the allegation is made. However, the incident was not reported to the Indiana Department of Health until several days later. The DON initially determined that abuse had not occurred and allowed the nurse to finish her shift. It was only after consulting with the new Executive Director and Clinical Support Nurse that the incident was reported. The delay in reporting and the inadequate investigation process led to the deficiency.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to appropriately investigate an allegation of abuse involving a resident, identified as Resident C, and a Licensed Practical Nurse (LPN). On the date of the incident, multiple staff members reported that the LPN was verbally abusive towards Resident C, yelling and using inappropriate language. Despite these reports, the Director of Nursing (DON) did not conduct a thorough investigation. The DON was informed of the incident and initiated an investigation via phone without coming to the facility. The investigation lacked interviews with Resident C and other residents, which is contrary to the facility's policy that requires interviewing the resident, the accused, and all witnesses. The DON relied on the Executive Director's assessment that the LPN was merely stern with the resident, and the LPN was allowed to finish her shift. The investigation report showed that only staff members were interviewed, and there was no documentation of interviews with Resident C or other residents who might have been affected. The facility's policy mandates a comprehensive investigation process, including interviews with all involved parties, which was not followed in this case. This failure to conduct a proper investigation led to the deficiency noted in the report.
Improper Storage Practices in Resident Snack Refrigerators
Penalty
Summary
The facility failed to maintain proper storage practices in residents' snack refrigerators, as observed during a survey. In the C-Hall snack refrigerator, an ice pack used by Resident 67 for shoulder pain was found lying in the bottom bin of the freezer, without a label or date. The nurse acknowledged that resident items should be labeled with a name and date. In the A-Hall snack refrigerator, six small tubs of ice cream were stored next to a large blue ice pack belonging to a discharged resident who had used it post-knee replacement surgery. This indicates a lack of adherence to proper storage protocols for resident-specific items. Additionally, the D-Hall snack refrigerator contained an opened, half-full pudding cup that was not labeled. During an interview, the DON confirmed that opened pudding used for medication administration should be labeled and stored correctly. The facility's current policies on refrigerator and freezer maintenance, as well as food brought in by family or visitors, emphasize the importance of safe food handling and proper labeling. However, these policies were not followed, leading to the observed deficiencies.
Persistent Urine Odor in B-Hall Secured Unit
Penalty
Summary
The facility failed to provide a homelike environment due to persistent strong urine odors in the B-Hall secured unit, as observed by surveyors on multiple occasions. The odor was noted in various areas, including the hallway, dining room, and common areas, and was particularly strong during mealtimes. A sticky substance with a foul urine odor was also found on the floor near the jukebox in the common area, causing resistance when walking. Additionally, a resident's room was noted to have a strong urine smell, with the bedding removed and the bed left bare. Interviews with staff revealed ongoing challenges in managing the urine odor. The Head of Maintenance acknowledged efforts to control the smell, including the installation of new ventilation systems, but noted that the system was less effective in the secured unit due to closed doors. A CNA reported issues with residents urinating on the floor, while the housekeeping supervisor indicated difficulties in maintaining cleanliness due to the frequency of urination by certain residents. Despite efforts to mop regularly, the odor persisted, and previous issues with dining room recliners retaining urine odor had been addressed by replacing them. The facility's policy on resident rights emphasizes the importance of a safe, clean, and comfortable environment, which was not upheld in this instance.
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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 North Vernon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seymour Crossing | 12.9 mi | — | 10 | 0 |
| Lutheran Community Home | 14 mi | — | 15 | 0 |
| Covered Bridge Health Campus | 15.5 mi | — | 8 | 0 |
| Hickory Creek At Columbus | 18.7 mi | — | 7 | 0 |
| Four Seasons Retirement Center | 18.9 mi | — | 0 | 0 |
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