Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Majestic Care Of Carmel during CMS and state inspections, most recent first.
Failure to Notify Ombudsman of Hospital Transfers: The facility did not ensure the SLTCO was notified after two residents were transferred to the hospital and later returned. One resident had a femur fracture, dementia, and anxiety, and another had hypotension, dementia, and a traumatic subdural hemorrhage. The SSD stated both were treated as bed holds rather than discharges, so they were not included on the discharge list for Ombudsman notification.
PASARR was not updated after new psychotropic meds were started for two residents. One resident with major depressive disorder was prescribed sertraline for depression, and another resident with anxiety disorder, bipolar disorder, and schizophrenia was prescribed Ativan for anxiety after increased anxiousness, paranoia, and tearfulness were noted. The facility’s records did not show the required updated PASARR screening for either resident.
Failure to Follow Medication Hold Parameters: The facility did not follow prescriber orders for medication hold parameters for three residents. An LPN and the DON confirmed that metoprolol and lisinopril were administered even when systolic BP readings were below the ordered threshold of 120 for residents with diagnoses including HTN, dementia, Parkinson's disease, COPD, atrial fibrillation, and depression. The MARs showed multiple doses were given despite the hold instructions, and facility policy stated medications are administered in accordance with prescriber orders.
A resident with a wound VAC to the left thigh/hip and orders for PRN tramadol had repeated painful dressing changes, but staff did not document pain assessments or consistently give pain medication before the treatments. The resident was observed anxious and in visible distress during dressing changes, stated the procedure was extremely painful, and said she had repeatedly told staff about it. MAR review showed tramadol was rarely given before wound care, and the DON acknowledged the resident should have been pre-medicated before each dressing change.
Incomplete MAR and TAR Documentation: The facility failed to keep MARs and TARs complete and accurately documented for multiple residents. Missing entries included several scheduled meds, a skin evaluation, and required shift-based monitoring for hyperglycemia/hypoglycemia and medication side effects. An LPN and a Clinical Support nurse stated documentation should be completed and signed off as ordered, and the facility policy stated documentation in the medical record shall be complete.
The facility failed to maintain infection control standards, with catheter tubing observed touching the ground for two residents and improper storage of oral care products for several others. Additionally, clean laundry was not handled appropriately, with clothing hung on handrails and towels transported on open carts. The facility's policies lacked specific measures to prevent these issues.
A resident with Parkinson's disease and hand contractures was unable to use a standard call light, leading to distress and unmet needs. Despite having a care plan for a touch pad call light, it was removed, leaving the resident unable to call for assistance. An LPN was unaware of the removal, highlighting a failure in accommodating the resident's needs.
The facility failed to update PASARR Level 1 requests for three residents when changes in medications and diagnoses occurred. One resident was prescribed Nuplazid for Parkinson's without a new PASARR request. Another resident had multiple medication changes, including risperidone and klonopin, without an updated PASARR. A third resident with major depressive disorder was prescribed Trazodone and Fluoxetine, but the PASARR did not reflect these changes. The facility's policy required updates for new mental health diagnoses or medications, which was not followed.
A facility failed to develop a comprehensive care plan for a resident with mental health conditions and antipsychotic medication use. Despite the resident's diagnoses and a physician's order for risperidone, the care plans did not include these mental health needs. Interviews with the MDS Coordinator confirmed the oversight, which violated the facility's policy requiring timely development of comprehensive care plans.
The facility failed to follow physician orders and document care for three residents. A resident received blood pressure medication despite low systolic readings, contrary to hold parameters. Another resident's vital signs and Foley catheter care were not consistently documented. A third resident's monitoring for medication side effects and blood sugar levels was frequently undocumented. The DON confirmed these documentation lapses.
The facility did not have a dedicated Infection Preventionist (IP), with the Director of Nursing (DON) performing both roles. The Executive Director confirmed the IP role was not separate, and no other staff held infection prevention certification. The facility's records lacked an employee titled as an IP, despite policies requiring a program to prevent communicable diseases.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to ensure the State Long-Term Care Ombudsman was notified after residents were discharged to the hospital for 2 of 3 residents reviewed for hospitalization. Resident 13 had diagnoses including fracture of the right femur, dementia, and anxiety, and the clinical record showed the resident was discharged to the hospital after a fall and later readmitted to the facility. However, the Admission/Discharge To/From Report for the month of June did not list Resident 13 as a discharged resident. Resident 6 had diagnoses including hypotension, dementia, and traumatic subdural hemorrhage, and the clinical record showed the resident was discharged to the hospital and later readmitted on two separate occasions. The Admission/Discharge To/From Report for February did not list Resident 6 as discharged, and the June report also did not include Resident 6. During interview, the SSD stated Resident 13 and Resident 6 were not included on the discharged residents list for June and indicated both were bed holds and not discharges, so neither were included on the discharge list for the Ombudsman to be notified. The facility policy stated a copy of the notice would be sent to the Office of the State Long-Term Care Ombudsman, and the facility document stated CMS requires notification of the majority of residents' transfers and discharges, including emergency transfers to an acute care facility when the resident is expected to return.
PASARR Not Updated After New Psychotropic Medications
Penalty
Summary
The facility failed to ensure PASARR was completed after new psychotropic medications were prescribed for 2 residents reviewed for PASARR. Resident 35 had diagnoses including major depressive disorder, insomnia, and heart failure. A PASARR Level II outcome dated 10/26/22 stated the resident had no mental health medications and that if there was a significant change in physical or mental health, a new Level II evaluation would be needed, with an updated Level I screening submitted to determine whether further PASARR evaluation was necessary. A physician order dated 7/1/25 prescribed Sertraline HCL 25 mg, 3 tablets daily for depression, but no additional PASARR was found in the electronic medical record. Resident 13 had diagnoses including anxiety disorder, bipolar disorder, and schizophrenia. A PASARR Level I outcome dated 9/27/24 stated the resident was not currently prescribed and had not been prescribed any medication for anxiety within the past six months, and that an updated Level I must be submitted if a status change occurred. A psychiatric visit note dated 5/6/25 indicated Ativan would be prescribed after staff reported increased anxiousness, paranoia, and tearfulness, and a physician order the same day prescribed Ativan 0.5 mg twice daily for anxiety. A care plan dated 5/7/25 identified the resident as at risk for adverse side effects related to antianxiety medications, but an updated Level I PASARR including Ativan was not found in the electronic health record.
Failure to Follow Medication Hold Parameters
Penalty
Summary
The facility failed to follow physician orders for medication hold parameters for three residents reviewed for quality of care. Resident 13 had diagnoses including hypertension, anxiety disorder, and dementia, and had an order for metoprolol succinate ER 25 mg daily with instructions to hold the medication if systolic blood pressure was below 120. The MAR showed metoprolol was administered on multiple occasions when systolic blood pressure readings were below that ordered parameter, including readings of 93, 117, 110, 114, 114, and 110. During interview, an LPN stated the MAR check mark meant the medication was administered, and the DON acknowledged the medication had been given below the ordered hold parameter. Resident 2 had diagnoses including hypertension, insomnia, and Parkinson's disease, and had an order for lisinopril 10 mg daily with instructions to hold if systolic blood pressure was below 120. The MAR showed lisinopril was administered when systolic blood pressure was 109, 115, and 107. Resident 4 had diagnoses including dislocation of internal left hip prosthesis, COPD, atrial fibrillation, osteoarthritis, and depression, and had orders for metoprolol 25 mg twice daily with instructions to hold for systolic blood pressure less than 120. The MAR showed metoprolol was administered on multiple occasions with systolic blood pressure readings below 120, including 112, 117, 119, 117, 110, 114, 109, 116, and 112. The DON stated the medication should not have been given below the physician's ordered hold parameter, and the facility policy stated medications are administered in accordance with prescriber orders.
Failure to Provide Pain Medication Before Painful Wound VAC Dressing Changes
Penalty
Summary
The facility failed to ensure Resident 4 was assessed and provided pain management before physician-ordered wound treatment. Resident 4 had diagnoses including dislocation of the internal left hip prosthesis, COPD, atrial fibrillation, osteoarthritis, and depression, and her care plan identified her as at risk for pain related to the surgical incision. She had a wound VAC to the left thigh/hip area with orders for dressing changes on Monday, Wednesday, and Friday, and an order for tramadol 50 mg every 8 hours as needed for pain. During observation, Resident 4 was in bed awaiting wound VAC dressing changes and appeared anxious, with a tight jaw, clenched teeth, grimacing, and repeated verbal expressions of pain during the treatment. She stated the dressing changes were extremely painful and that she had repeatedly told staff about the pain. Record review showed tramadol was not given before most wound VAC dressing changes in May, was given only 3 times in June despite 30 dressing changes, and was not administered before any July dressing changes before the observed treatment. Progress notes from May through July lacked documentation of pain assessments before wound care or documentation that pain medication was offered prior to the dressing changes. The DON stated he knew the dressing changes were painful and that Resident 4 should have been pre-medicated before every dressing change.
Incomplete MAR and TAR Documentation
Penalty
Summary
The facility failed to ensure the Medication Administration Records (MARs) and Treatment Administration Records (TARs) were complete and accurately documented for 3 of 5 residents reviewed. For Resident 37, whose diagnoses included COPD, hypertension, and bipolar disorder, the June 2025 MAR and TAR were missing documentation for multiple medications administered on 6/10/25 at 6:00 p.m., including Aricept 5 mg, Ativan 0.5 mg, melatonin 5 mg, carvedilol 25 mg, gabapentin 100 mg, and Namenda 5 mg. The record was also missing a completed skin evaluation for the evening shift on 6/11/25. An LPN stated that MAR/TAR entries should be signed after medications or treatments were administered and that staff should have signed off as they were completed. For Resident 2, whose diagnoses included hypertension, insomnia, and Parkinson's disease, the June and July 2025 MARs and TARs were missing documentation for several administered medications, including melatonin, carboxymethylcellulose sodium eye drops, galantamine hydrobromide, Namenda, lisinopril, and Sinemet on specified dates and times. For Resident 41, whose diagnoses included type 2 diabetes, depression, and congestive heart failure, physician orders required monitoring for signs and symptoms of hyperglycemia and hypoglycemia, diuretic side effects, and anticoagulant side effects every shift. The TARs for May, June, and July 2025 were missing documentation for these required monitoring tasks on multiple day, evening, and night shifts. An LPN stated medication monitoring should be signed off every shift, and a Clinical Support nurse stated staff should observe side effects as ordered and document 3 times per day. The facility policy stated documentation in the medical record shall be complete.
Infection Control Deficiencies in Catheter and Oral Care Management
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by multiple observations of catheter tubing touching the ground for two residents. Resident 34's catheter tubing was observed touching the floor on two separate occasions, and the Director of Nursing acknowledged the issue. Resident 302's catheter tubing was also seen dragging on the ground while being wheeled to therapy. Both residents had diagnoses that included chronic kidney disease and dementia, and their care plans indicated a risk for infection related to indwelling catheters. Additionally, the facility did not ensure proper storage of oral care products for several residents. Toothbrushes were found unlabeled, uncovered, and in contact with unsanitary surfaces in the bathrooms of multiple residents. Furthermore, clean laundry and linen were not handled appropriately, with observations of clean clothing hung on handrails and clean towels transported on open carts. The facility's infection control policies did not include specific measures to prevent catheter tubing from touching the ground.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The facility failed to provide a resident with a call light that he was physically capable of activating, which led to a deficiency in accommodating the resident's needs. The resident, who had contracted hands with all fingers flat against his palms and was unable to grip or use his thumbs, was observed in the dining room and later in his room with a standard small push button call light clipped to his pant leg. Despite multiple attempts, the resident was unable to activate the call system due to his physical limitations, causing him visible distress and frustration. The resident, who had a low voice volume due to Parkinson's disease, indicated that he used to have a soft touch pad call button, which was removed by staff because he occasionally rolled over on it in bed. The resident's clinical record revealed diagnoses including Parkinson's disease, depression, anxiety, psychotic disorder with delusions, muscle wasting and atrophy in both hands and upper arms, and repeated falls. A care plan initiated earlier in the year acknowledged the resident's impaired physical mobility and the need for a touch pad call light, which was only reinstated after the resident was observed struggling with the standard call light. An LPN interviewed was aware that the resident previously had a soft touch pad call light and was unsure why it had been removed, indicating a lapse in ensuring the resident's needs were continuously met as per the facility's policy on accommodation of needs.
Failure to Update PASARR for Residents with Medication and Diagnosis Changes
Penalty
Summary
The facility failed to ensure that a new Pre-Admission Screening and Resident Review (PASARR) Level 1 request was submitted when changes in medications and diagnoses occurred for three residents. For Resident 35, the clinical record indicated a diagnosis of general anxiety disorder, recurrent depressive disorder, Parkinson's disease, and other conditions. Despite a new physician's order for Nuplazid, an atypical antipsychotic medication, no new PASARR Level 1 request was made. The Director of Nursing confirmed that a PASARR Level 1 had not been requested for the new medication order. Resident 40's clinical record showed diagnoses of Parkinson's disease, depression, anxiety, and a psychotic disorder with delusions. Despite multiple changes in medications, including the addition of risperidone and klonopin, no additional PASARR was conducted. Similarly, Resident 46 had a diagnosis of major depressive disorder and was prescribed Trazodone and Fluoxetine HCL, yet the PASARR Level 1 outcome did not reflect these mental health diagnoses or medications. The Minimum Data Set Coordinator acknowledged that the diagnoses and medications were not included in the PASARR. The facility's policy required Level 1 assessments to be reviewed with any new mental health diagnoses or related medications, which was not adhered to in these cases.
Failure to Develop Comprehensive Care Plan for Mental Health and Medication
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with mental health conditions and the use of antipsychotic medications. The resident, who had been in the facility for 31 days, had diagnoses including bipolar type schizoaffective disorder, bipolar disorder, metabolic encephalopathy, intellectual disabilities, and type 2 diabetes mellitus. Despite a physician's order for risperidone, an antipsychotic medication, the care plans did not include the mental health diagnoses or the use of the medication. Interviews with the MDS Coordinator revealed that the mental health diagnoses and medications should have been included in the care plan. The facility's policy requires a comprehensive care plan to be developed within 7 days after the completion of the comprehensive MDS assessment, which was not adhered to in this case. The resident's care plan was not updated to reflect their mental health needs and medication regimen, leading to a deficiency in meeting the resident's comprehensive care requirements.
Failure to Follow Physician Orders and Document Care
Penalty
Summary
The facility failed to adhere to physician-ordered hold parameters for medication administration and did not document treatments in the Treatment Administration Record (TAR) for three residents. For Resident B, the facility administered hydralazine, a blood pressure medication, multiple times despite the resident's systolic blood pressure being below the physician-ordered hold parameter of 160. This occurred six times in the morning, two times in the afternoon, and fifteen times in the evening. Interviews with RN 5 and the Director of Nursing (DON) confirmed that the medication was administered outside the prescribed parameters. For Resident 34, the facility did not document vital signs and Foley catheter care as ordered by the physician. The TAR showed multiple instances where vital signs were not recorded across various shifts on different days. Similarly, Foley catheter care was not documented for several shifts on multiple days. This lack of documentation indicates a failure to follow the physician's orders for regular monitoring and care. Resident 46's records revealed a lack of documentation for monitoring side effects of anticoagulant and antidepressant medications, as well as for signs of hypoglycemia and hyperglycemia. The TAR showed numerous instances where these observations were not recorded across different shifts. Additionally, monitoring for side effects of diuretic medication was also not documented on several occasions. The DON acknowledged the missing documentation in the TARs, highlighting a significant lapse in the facility's adherence to physician orders and documentation policies.
Lack of Dedicated Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) who could fulfill the role at least part-time, as required. Instead, the Director of Nursing (DON) was performing the duties of both the DON and the IP. During interviews, the Executive Director (ED) confirmed that the IP role was not a separate position and that no other employees held an infection prevention certification. The DON also confirmed that he was solely responsible for infection prevention tracking and duties, in addition to his responsibilities as the DON. The facility's employee records did not list an employee with the title of Infection Preventionist, indicating a lack of compliance with the requirement to have a dedicated IP. The facility's policies on infection control and the infection prevention and control program outlined the need for a program designed to prevent the development and transmission of communicable diseases, but these policies were not effectively implemented due to the absence of a dedicated IP.
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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 Carmel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wellbrooke Of Carmel | 0.7 mi | ★★★★★ | 10 | 0 |
| Barrington Of Carmel, The | 1.2 mi | ★★★★★ | 0 | 0 |
| Restoracy Of Carmel | 1.7 mi | ★★★★★ | 8 | 0 |
| Carmel Health & Living Community | 2 mi | ★★★★★ | 17 | 0 |
| Retreat At The Stratford, The | 2.6 mi | ★★★★★ | 6 | 0 |
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