Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Mccordsville during CMS and state inspections, most recent first.
A resident with a history of knee replacement, dementia, and weakness required two-person assistance for transfers using a stand-up lift, as outlined in the care plan and facility policy. On the day of the incident, at least one transfer was performed by a single CNA without the required second staff member present. After these transfers, the resident was found to have swelling, pain, and an acute displaced distal femur fracture, with the injury determined to have occurred during a transfer.
A resident with a hearing deficit and a care plan requiring daily assistance with hearing aid placement was repeatedly observed without hearing aids and reported difficulty hearing. There was no documentation of refusal, and the required support for hearing aid use was not provided as outlined in the care plan.
A resident with multiple medical conditions did not receive timely follow-up for recommended dental extractions and cleanings. Despite documented dental needs and a care plan requiring coordination, there was no evidence of completed follow-up services or proper documentation. Communication lapses between the facility, dental provider, and physician contributed to the deficiency, and staff failed to document or act on dental recommendations as required by facility policy.
The facility did not have an RN on duty for 8 consecutive hours on six days in April and May 2024, potentially affecting all 32 residents. The DON confirmed the absence of required RN coverage on these days, failing to meet staffing regulations.
A facility failed to properly store a medicated cream for a resident and ensure medication carts were free of expired insulin for four residents. A medicated cream was found on an open shelf in a resident's room, confirmed by an LPN. Observations of medication carts revealed expired insulin bottles for four residents, despite monthly pharmacy audits and night shift staff checks.
The facility failed to provide adequate care for a resident dependent on staff for daily activities, including not meeting her preferences for showers and hair shampooing. Improper perineal care was also observed. Another resident with fragile skin did not receive recommended protective measures, leading to multiple skin tears. Facility policies on skin management and perineal care were not followed, and assistive devices were not provided as needed.
The facility failed to use padded side rails for two residents with seizure disorders and did not follow the manufacturer's guidelines for a Hoyer lift during a transfer for a resident with a history of stroke. Observations showed the absence of padded side rails, and improper use of the Hoyer lift led to resident discomfort. Staff interviews confirmed these deficiencies, indicating non-compliance with facility policies.
A resident with psychotic disorder, major depression, and dementia received an excessive dosage of Risperdal due to an error in the facility's electronic health record. The intended dosage was 0.5 mg twice daily, but the resident received it three times daily from February 10 to February 15, 2024. The error was not communicated to the resident's family member, who expressed concerns about the medication regimen. The DON acknowledged the oversight, which was contrary to the facility's policy on psychotropic medication use.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a suprapubic catheter. Despite a care plan and physician order requiring the use of gown and gloves during high contact care, two CNAs only used gloves while providing care. One CNA admitted forgetting to use the gown. The facility's policy mandates EBP for residents with indwelling devices.
Failure to Provide Two-Person Assistance During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan and facility policy requiring two-person assistance for transfers using a stand-up lift for a resident with a history of left total knee replacement, dementia, mood disorder, and depression. The resident's care plan specified two-person assistance due to weakness and combative behaviors, and the facility's policy mandated two staff for mechanical lift transfers. On the day of the incident, the resident was transferred multiple times, including from bed to wheelchair, wheelchair to shower chair, and back, with at least one transfer observed to be performed by a single CNA without the required second staff member present. Interviews confirmed that only one staff member was present during at least one transfer, despite the resident's need for two-person assistance for safety. Following these transfers, the resident was found to have swelling, pain, and an acute displaced distal femur fracture, as confirmed by x-ray. The incident investigation determined the injury occurred during a transfer, and staff interviews revealed inconsistencies regarding who assisted with each transfer. The failure to provide adequate supervision and follow established transfer protocols directly led to the resident's injury.
Failure to Assist Resident with Hearing Aid Placement
Penalty
Summary
A deficiency was identified when a resident with a documented hearing deficit and a care plan requiring daily assistance with hearing aid placement was repeatedly observed without hearing aids in place. On multiple occasions, the resident indicated difficulty hearing and expressed the need for her hearing aids. Despite these observations, there was no documentation that the resident had refused to wear the hearing aids, and the Director of Nursing confirmed that such documentation could not be found. The resident's care plan specified daily assistance with hearing aid placement and removal at bedtime, as well as ensuring the devices were in working order. The resident was assessed as cognitively intact and had diagnoses including schizophrenia, hypertension, anxiety, age-related physical debility, and vascular dementia. The facility's policy required assistance with functional communication systems as part of activities of daily living (ADLs), but the required support for hearing aid use was not provided or documented as refused.
Failure to Follow Up on Dental Recommendations and Document Care
Penalty
Summary
The facility failed to follow up with dental recommendations for a resident who was cognitively intact and had multiple diagnoses, including anxiety, depression, atrial fibrillation, hypertension, and heart failure. The resident reported that a problematic tooth needed extraction, and although she had seen a dentist about a year prior, the extraction was never completed. The care plan indicated the need for coordination of dental care, and dental notes documented recommendations for follow-up exams, cleanings, and extractions. However, there was no evidence in the clinical record that these follow-up dental services were provided within the recommended timeframes. Further review revealed that after an outside dental provider recommended extraction of three teeth, with the resident consenting to the removal of only the broken tooth, no follow-up was documented. The dental provider reported not receiving the necessary medical clearance from the resident's physician, despite multiple attempts, and the facility did not contact the provider after the appointment. Interviews with staff showed a lack of documentation and follow-through on dental recommendations, and conflicting accounts from the resident and staff regarding her consent for the procedure. The facility's policy required assistance with dental appointments and documentation of all actions, which was not followed in this case.
Failure to Maintain RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to maintain compliance with the requirement to have a Registered Nurse (RN) on duty for 8 consecutive hours per day. This deficiency was observed for six days during April and May 2024, potentially affecting all 32 residents residing at the facility. The Director of Nursing (DON) provided daily schedules for the specified period, which revealed the absence of RN coverage for 8 consecutive hours on the dates of April 13, April 14, April 27, April 28, May 11, and May 12. An interview with the DON confirmed the lack of RN hours for the specified days, indicating a failure to meet the regulatory staffing requirements.
Improper Storage of Medications and Expired Insulin Found
Penalty
Summary
The facility failed to properly store a medicated cream for Resident D, who has a history of stroke and was cognitively intact according to an Annual MDS Assessment. During observations, a container of medicated cream with a pharmacy label for Resident D was found stored on an open shelf in the resident's room. This was confirmed by LPN 2, who acknowledged that the cream was currently ordered for Resident D and should not have been stored in the resident's room. The cream was subsequently removed by LPN 2. Additionally, the facility failed to ensure that medication carts did not contain expired insulin for four residents. Observations of two medication carts revealed expired insulin bottles for Residents 1, 2, 4, and 8. LPN 3 and LPN 2 confirmed the presence of expired insulin, with dates consistent with those on the bottles. The Director of Nursing indicated that the pharmacy conducted monthly audits of the medication carts, and the night shift staff also conducted audits. However, the expired insulin was still present during the surveyor's observation.
Deficiencies in Resident Care and Infection Control
Penalty
Summary
The facility failed to provide adequate care and assistance for activities of daily living for Resident D, who was dependent on staff for showering, bathing, and transferring. Despite Resident D's preference for showers and hair shampooing twice a week, the facility did not meet these preferences. Observations revealed that Resident D was given a bed bath instead of a shower, and her hair was not shampooed, leading to her expressing dissatisfaction with her hygiene care. Additionally, during perineal care, improper cleaning techniques were used, which could potentially compromise infection control. Resident 9, who had severe cognitive impairment and was at risk for skin injuries due to thin, fragile skin, did not receive appropriate preventative measures. Despite recommendations for the use of long sleeves or geri sleeves to prevent further skin injuries, these interventions were not implemented. Observations showed Resident 9 wearing short sleeves without any protective sleeves, despite having multiple skin tears documented in their clinical record. The facility's policies on skin management and perineal care were not adequately followed, as evidenced by the lack of preventative measures for Resident 9 and improper perineal cleaning for Resident D. The facility also failed to ensure the availability of assistive devices as needed, as indicated in their policy. These deficiencies were identified during interviews, observations, and record reviews conducted by surveyors.
Failure to Implement Padded Side Rails and Proper Hoyer Lift Use
Penalty
Summary
The facility failed to implement the use of padded side rails for two residents who had care plans for seizure disorders. Resident 9, who was diagnosed with dementia and a seizure disorder, was observed on multiple occasions without padded side rails, despite a care plan indicating their necessity. Similarly, Resident D, who had a history of stroke and was cognitively intact, was also observed without padded side rails, contrary to the care plan requirements. Interviews with staff confirmed the absence of padded side rails for both residents, indicating a failure to adhere to the facility's policy on providing necessary assistive devices. Additionally, the facility did not follow the manufacturer's guidelines for using a Hoyer lift for Resident D, who required assistance for transfers. During an observed transfer, staff did not crisscross the leg straps as instructed in the Hoyer lift's operator manual, and there was a delay in transferring Resident D to her recliner due to it being unplugged. This resulted in Resident D expressing discomfort and pain during the transfer process. The facility's policy on safe resident handling and transfers was not followed, as evidenced by the improper use of the Hoyer lift and the lack of adherence to the manufacturer's instructions.
Excessive Dosage of Antipsychotic Medication Administered
Penalty
Summary
The facility administered an excessive dosage of antipsychotic medication to a resident, identified as Resident H, who was diagnosed with psychotic disorder with delusions, major depression, and dementia. The resident's care plan included medication management for these conditions. However, a discrepancy occurred when the resident received 0.5 mg of Risperdal three times a day instead of the intended twice daily dosage. This error persisted from February 10 to February 15, 2024, due to a failure to discontinue an existing evening order in the electronic health record, resulting in an unintended increase in dosage. The error was identified during a review of the resident's clinical records and interviews with facility staff and a family member. The family member expressed concerns about the resident receiving too many psychotropic medications and noted that she was not informed of the medication change. The Director of Nursing acknowledged the oversight, explaining that the intended decrease in Risperdal dosage was not properly executed in the electronic health record, leading to the administration of an excessive dosage. The facility's policy on the use of psychotropic medication emphasizes that such drugs should only be administered when necessary and beneficial, as documented in the clinical record.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to utilize Enhanced Barrier Precautions (EBP) for Resident D, who was one of five residents reviewed for infection control. Resident D had a medical history that included a stroke and an overactive bladder and was cognitively intact. The resident utilized an indwelling urinary device, specifically a suprapubic catheter. A care plan dated 3/28/2024 indicated the use of a gown and gloves during high contact care with Resident D, and a physician order dated 3/27/2024 specified the use of EBP during such care activities. On 5/21/2024, during an observation, CNAs 4 and 5 provided Resident D with a bed bath, catheter care, and transfer, using only disposable gloves and not the required gown as part of EBP. CNA 5 later acknowledged in an interview that they usually use both gloves and a gown but had forgotten on this occasion. The facility's policy on EBP, provided by the Director of Nursing, indicated that EBP should be used for residents with indwelling medical devices, including urinary catheters, and included the use of gown and gloves during high contact care.
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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 Mccordsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westminster Village North | 1.9 mi | ★★★★★ | 27 | 0 |
| Harrison Terrace | 5.9 mi | ★★★★★ | 14 | 0 |
| Castleton Health Care Center | 6.3 mi | ★★★★★ | 36 | 0 |
| Brickyard Healthcare - Brookview Care Center | 6.3 mi | ★★★★★ | 11 | 1 |
| Waters Of Castleton Skilled Nursing Facility, The | 6.5 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.