Cycle 1
Health 2024-12-19 · Fire 2024-12-19
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fort Wayne, IN
Majestic Care Of Fort Wayne
4-star overall rating with 4-star inspections
7519 Winchester Rd, Fort Wayne, IN
(260) 747-7435
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Majestic Care
Operator or chain grouping
Approved since
1990-05-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 3 overall / 2 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.38
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.05
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.00
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.56
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.28
CMS adjusted RN staffing hours
Adjusted total hours
2.28
CMS adjusted total nurse staffing hours
Case-mix index
1.83
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,369
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.86
Composite VBP score used to determine payment impact.
Payment multiplier
0.9833
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.77
Baseline 70.49% · Performance 46.43% · Measure score 4.77 · Achievement 4.22 · Improvement 4.77
Adjusted total nurse staffing
0
Baseline 2.29 hours · Performance 2.15 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 4 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 44.44% |
8.2%
36.2 pts better
|
Numerator 28 · Denominator 63 |
| Staff flu vaccination coverage | 16.67% |
42%
25.3 pts worse
|
Numerator 8 · Denominator 48 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
93.6%
4.5 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 97.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.6% |
95.4%
2.8 pts worse
|
95.5%
2.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.8%
1.4 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.0% · Q3 5.8% · Q4 7.4% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 98.5% |
24.6%
73.9 pts worse
|
11.4%
87.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 100.0% · Q3 100.0% · Q4 98.5% · 4Q avg 98.5% |
| Percentage of long-stay residents who lose too much weight | 8.3% |
5.6%
2.7 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 6.5% · Q3 18.5% · Q4 3.1% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.9% |
23.5%
13.4 pts worse
|
19.6%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.3% · Q2 40.3% · Q3 32.3% · Q4 35.9% · 4Q avg 36.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 55.1% |
14.8%
40.3 pts worse
|
16.7%
38.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.2% · Q2 56.0% · Q3 47.6% · Q4 50.0% · 4Q avg 55.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.7% |
13.3%
7.6 pts better
|
16.3%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 8.1% · Q3 4.6% · Q4 2.3% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.8% |
11.7%
6.9 pts better
|
14.9%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 3.3% · Q3 3.1% · Q4 3.1% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.4%
0.4 pts worse
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.6% |
24.2%
2.4 pts worse
|
19.8%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 31.3% · Q3 19.3% · Q4 27.1% · 4Q avg 26.6% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.1%
1.8 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.4% · Q3 2.2% · Q4 2.3% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.4% |
81.6%
10.2 pts worse
|
81.7%
10.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 71.4% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-09 · Fire 2023-01-09
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-01-09
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-02-25
F · Potential for more than minimal harm
2023-01-09
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-02-25
F · Potential for more than minimal harm
2023-01-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-25
E · Potential for more than minimal harm
2023-01-09
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-02-25
E · Potential for more than minimal harm
2023-01-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-02-25
E · Potential for more than minimal harm
2023-01-09
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2023-02-25
E · Potential for more than minimal harm
2023-01-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-25
C · Minimal harm
2023-01-09
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-02-25
Inspection history
Recent health citations
G · Actual harm
2024-07-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-06
D · Potential for more than minimal harm
2024-06-21
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-06-06
D · Potential for more than minimal harm
2024-01-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-26
D · Potential for more than minimal harm
2024-01-11
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-01-26
C · Minimal harm
2024-01-11
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-08-28
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-06-26
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-01-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-01-20
Penalties and ownership
What sits behind the stars
Ownership
Daviess County Hospital
5% Or Greater Direct Ownership Interest · Organization
Alexander, James
Operational/Managerial Control · Individual
Chamberlain, Margaret
Operational/Managerial Control · Individual
Daviess County Hospital
Operational/Managerial Control · Organization
Fuller, Greggory
Operational/Managerial Control · Individual
Ltc Consulting Services LLC
Operational/Managerial Control · Organization
Majestic Care Of Fort Wayne LLC
Operational/Managerial Control · Organization
Majestic Management LLC
Operational/Managerial Control · Organization
Marx, David
Operational/Managerial Control · Individual
Pruitt, Paul
Operational/Managerial Control · Individual
Reddy, Subhash
Operational/Managerial Control · Individual
Rewa, Angela
Operational/Managerial Control · Individual
Russell, Robert
Operational/Managerial Control · Individual
Settles, April
Operational/Managerial Control · Individual
Shatrov, Anzhelika
Operational/Managerial Control · Individual
Steiner, Deron
Operational/Managerial Control · Individual
Wolfe, Eric
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Lutheran Life Villages
Fort Wayne, IN
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Englewood Health & Rehabilitation Center
Fort Wayne, IN
5-star overall rating with 4-star inspections with 1 recent health deficiencies
#3
Majestic Care Of Jefferson Pointe
Fort Wayne, IN
1-star overall rating with 2-star inspections with 7 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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