Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Southport during CMS and state inspections, most recent first.
Food was not prepared in a sanitary manner during kitchen observations because a dietary aide was seen scooping dessert and plating the noon meal without full hair coverage, including two inches of hair on the forehead. The ED stated all kitchen staff should have all hair covered, and the facility policy required hair to be confined in a hair net or cap.
Daily weights ordered for a resident with ESRD, dialysis dependence, and HF were not consistently obtained or documented by qualified nursing personnel. Staff initialed the MAR to show weights were done, but the actual weights were not recorded, and multiple days had no weight documented at all. The resident stated she was only weighed on dialysis days, despite the order for daily weights.
A resident with DM and neuropathy had an order for left heel wound care with skin prep twice daily, but the MAR lacked signatures showing the treatment was completed on multiple occasions. The DON stated the treatments were completed, and the facility policy required accurate, complete, and timely documentation in the medical record.
A facility failed to document a resident's transfer to the emergency department in the medical record. The resident, with conditions including bladder cancer and chronic atrial fibrillation, was found lethargic by her daughter, who called 911. The Director of Nursing confirmed that the nurse should have documented the transfer, as required by the facility's policy.
A resident with anxiety and depression was verbally and physically abused by another resident with schizophrenia and dementia. The aggressor followed the victim to her room, threatened her, and spat on her, despite staff intervention. Witnesses confirmed the incident, highlighting a failure to uphold the facility's abuse prevention policy.
A facility failed to report an abuse incident where a resident verbally abused and attempted to spit on another resident. The incident was documented, and the Director of Nursing was notified, but the report to the state health department was delayed. Interviews revealed that an LPN witnessed the incident but did not report it until the next day, and another LPN was unsure if she had reported it. The facility's policy requires immediate reporting of abuse allegations, which was not followed.
A facility failed to maintain resident dignity during meal assistance when a staff member stood over a resident with Alzheimer's disease, instead of sitting at eye level as required by policy. The resident required extensive assistance with eating.
A resident's call light was repeatedly found out of reach, despite facility policy and care plan requirements to keep it accessible due to the resident's fall risk. Observations and interviews confirmed the deficiency, highlighting a failure to accommodate the resident's needs.
A facility failed to provide a written Notice of Transfer and Discharge to a resident and their representative for a hospital transfer. The clinical record lacked documentation of the notice, and Unit Manager 2 confirmed the transfer without evidence of notice issuance. The facility's policy requires such notices, but it was not followed in this instance.
A facility failed to provide a written bed hold notification to a resident with COPD, heart failure, and type 2 diabetes, and their representative during a hospital transfer. The clinical record lacked documentation of the notification, and the Unit Manager confirmed the oversight. The facility's policy requires notifications at the time of transfer or within 24 hours for emergencies, with a signed copy in the resident's file.
A facility failed to create a comprehensive care plan for a resident who refused care, including showers, resulting in a strong foul odor in the resident's room. Despite the resident's diagnoses of morbid obesity, respiratory failure, heart failure, and decreased mobility, the care plan did not address the refusal of care. The DON confirmed the lack of a care plan for the resident's refusal, which is required by the facility's policy.
A facility failed to record and monitor a resident's weight changes as ordered by a physician. Despite a history of abnormal weight loss and a care plan indicating nutritional risk, the resident's weekly weights were not documented, and significant weight changes were not reported to the physician. Interviews revealed that the weights were not entered into the clinical record, and no interventions were implemented.
The facility failed to document drug disposition records for two discharged residents, leading to a deficiency in pharmaceutical services. One resident passed away without documentation of medication return or destruction, while another was discharged without a medication release form. The Director of Nursing confirmed the lack of documentation, which violated the facility's policy.
The facility failed to ensure posted menus matched the meals served, causing resident confusion. Observations showed discrepancies between posted menus and actual meals, with staff confirming the menus were outdated. A resident reported never knowing meal details until receiving their tray, as posted menus were consistently incorrect.
The facility failed to report allegations of abuse for two residents to the State Survey Agency. One resident, who is severely cognitively impaired, reported being hit by a staff member, and another resident, who is cognitively intact, reported rough care. Both allegations were investigated but not substantiated, and the required reporting was not completed.
The facility failed to provide appropriate care for a resident diagnosed with PTSD, who was found consuming and distributing alcohol. Despite a diagnosis of PTSD, the resident's care plan did not address this condition, contrary to the facility's policy on individualized interventions.
Failure to Fully Cover Hair During Food Preparation
Penalty
Summary
Food was not prepared in a sanitary manner for 3 of 3 kitchen observations because Dietary Aide 2 did not have hair fully covered while handling food. During an observation on 9/22/25 from 8:40 a.m. to 9:00 a.m., Dietary Aide 2 was seen in the dishwashing and food preparation areas scooping dessert into small bowls for the noon meal while lacking hair coverage for the hair on her forehead, which measured two inches in length. During another observation on 9/22/25 at 12:37 p.m., Dietary Aide 2 was again observed placing food on plates for the noon meal without hair coverage for the same forehead hair. The Executive Director stated that all kitchen staff should have all of their hair covered and provided the facility's Dining Services policy, which required staff to have hair off the shoulders and confined in a hair net or cap. The Indiana Food Establishment Sanitation Requirements were also cited as requiring food employees to wear hair restraints designed to keep hair from contacting exposed food.
Daily Weights Not Obtained or Documented as Ordered
Penalty
Summary
The facility failed to ensure physician-ordered daily weights were obtained and documented by qualified personnel for a resident with end stage renal disease, dependence on renal dialysis, and heart failure. The resident’s physician orders required daily weights with notification of the MD for a weight gain greater than 3 pounds in a day or 5 pounds in a week, starting 8/27/25 with no end date. The resident’s admission MDS dated 9/1/25 indicated the resident was cognitively intact. Review of the September 2025 MAR showed nursing staff initialed the record from 9/1/25 through 9/24/25 to indicate daily weights had been obtained, but the document did not include the actual weight values. The DNS stated the MAR lacked documentation identifying what the daily weights were and that staff had not recorded the weights on the MAR. Review of the recorded weights for September 2025 showed no weights documented for 9/4/25, 9/6/25, 9/11/25, 9/13/25, 9/14/25, 9/16/25, 9/18/25, 9/20/25, and 9/21/25. The DNS stated there were nine days where no weights had been obtained or recorded, and the resident stated she was only weighed on dialysis days.
Incomplete documentation of wound care treatments
Penalty
Summary
The facility failed to document treatments that were completed in the clinical record for 1 of 3 residents reviewed for skin issues, Resident B. Resident B had diagnoses including diabetes mellitus and neuropathy, and physician orders dated August 2025 directed wound care to the left heel with skin prep applied every morning and at bedtime. The Medication Administration Record did not contain signatures showing the treatment was completed on multiple dates and times, including August 8 at bedtime, August 9 in the morning, August 10 at bedtime, August 13 in the morning, August 15 in the morning, August 16 in the morning and at bedtime, and August 19 in the morning. During interview, the DON stated the treatments were completed, and the Executive Director provided the facility policy stating the medical record must contain accurate, complete, and timely documentation of the resident's actual experiences.
Failure to Document Resident Transfer to Emergency Department
Penalty
Summary
The facility failed to document a resident's transfer to the emergency department in the medical record, as required by their policy. Resident B, who had diagnoses including bladder cancer, asthma, and chronic atrial fibrillation, was observed by her daughter to be lethargic, prompting a call to 911 for emergency assistance. The hospital palliative care note confirmed that Resident B was admitted to the hospital with altered mental status. During an interview, the Director of Nursing acknowledged that the nurse responsible for Resident B at the time of transfer should have documented the event in the resident's medical record. The facility's policy, titled Transfer Discharge, mandates that relevant information regarding transfers be documented, which was not adhered to in this instance.
Failure to Protect Resident from Verbal and Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and physical abuse when Resident C verbally and physically assaulted Resident B. On the evening of January 22 or 23, Resident B was waiting to go outside to smoke when Resident C approached and verbally abused her, calling her derogatory names. Resident B, feeling scared, attempted to retreat to her room, but Resident C followed her, continuing the verbal assault and threatening physical harm. Despite the intervention of LPN 2, who directed Resident C to the nursing station, Resident C returned shortly after and spat on Resident B, further escalating the situation. Resident B, who has diagnoses including anxiety, depression, and psychotic disorder, was left feeling unsafe and tearful, expressing fear of Resident C. The incident was corroborated by other residents, Resident D and Resident E, who witnessed the altercation and confirmed Resident C's aggressive behavior. Resident C, with a history of schizophrenia, alcohol abuse, and dementia, was noted to be moderately cognitively impaired. The facility's policy on abuse, which states residents have the right to be free from abuse, was not upheld in this instance, as evidenced by the failure to prevent Resident C's repeated aggressive actions towards Resident B.
Failure to Report Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the state health department involving two residents. Resident B reported that on the evening of January 22 or 23, Resident C verbally abused and attempted to spit on Resident B. The clinical record for Resident C, who has diagnoses including schizophrenia and substance abuse, noted that Resident C became agitated and argumentative with Resident B, and attempted to spit on her. The incident was documented in a progress note, and the Director of Nursing was notified. Interviews revealed that the facility staff did not report the incident in a timely manner. The Administrator was informed of the verbal altercation by an LPN, who witnessed the incident but did not report it until the following day. Another LPN was unsure if she had reported the incident to the Administrator and Director of Nursing. The facility's policy requires all allegations of abuse to be reported immediately to the Administrator or designee, which was not adhered to in this case.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with dignity during meal times, as observed with one resident during the noon meal. The Unit Manager assisted the resident with their meal while standing over them, rather than sitting at eye level, which is against the facility's policy. The Director of Nursing confirmed that staff should be seated at eye level when assisting residents with meals. The resident involved had a diagnosis of Alzheimer's disease and required extensive assistance with eating, as indicated in their clinical record and a recent Minimum Data Set assessment.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for a resident, identified as Resident 8, by not ensuring the call light was within reach. During observations on two separate occasions, the call light was found mounted to the wall between Resident 8's bed and the roommate's bed, with the cord lying on the floor behind the headboard, making it inaccessible to the resident. Interviews with Resident 8, RN 3, and Unit Manager 2 confirmed that the call light was not within reach, which contradicted the facility's policy and the resident's care plan that emphasized keeping the call light accessible due to the resident's risk for falls. Resident 8's clinical record indicated a history of falling and anemia, and the resident was assessed as moderately cognitively intact. The care plan, revised months prior, included an intervention to keep the call light within reach, highlighting the importance of this measure for the resident's safety. The Director of Nursing Services confirmed the facility's policy required call lights to be accessible to residents while in bed, aligning with the resident's right to a safe environment as per the Resident Rights policy.
Failure to Provide Transfer Notice
Penalty
Summary
The facility failed to provide a written Notice of Transfer and Discharge to a resident and the resident's representative for a facility-initiated hospital transfer. This deficiency was identified during a review of Resident 10's clinical record, which showed that the resident was transferred to the hospital emergency department on May 23, 2024. The clinical record did not contain documentation that the required notice was given to either the resident or their representative. During an interview, Unit Manager 2 confirmed that the transfer occurred on the specified date, but the facility could not provide evidence that the notice was issued. The facility's Transfer & Discharge policy, dated December 12, 2023, mandates that such notices be provided in a language and manner understandable to the resident and their representative, including information about the facility's bed hold policy. However, this procedure was not followed in the case of Resident 10.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide written bed hold notifications to a resident and their representative during a hospital transfer. Resident 10, who has diagnoses including COPD, heart failure, and type 2 diabetes, was transferred to the hospital emergency department. The clinical record indicated that the resident returned from the emergency department, but there was no documentation of a written bed hold notification being provided to the resident or their representative. During an interview, the Unit Manager confirmed the lack of verification for the bed hold notification. The facility's bed hold policy requires that such notifications be given at the time of transfer or within 24 hours for emergency transfers, with a signed and dated copy kept in the resident's file.
Failure to Develop Comprehensive Care Plan for Resident Refusing Care
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who refused care, specifically showers and other activities of daily living. This deficiency was identified through observations and interviews conducted over several days. On multiple occasions, a strong foul odor was noted in the resident's room, indicating a lack of personal hygiene care. The resident, diagnosed with morbid obesity, acute on chronic respiratory failure, heart failure, and decreased mobility, required assistance with activities of daily living. However, the care plan dated July 19, 2024, did not address the resident's refusal of care. During an interview, the Director of Nursing (DON) confirmed that the resident refused care, including showers, and acknowledged that there was no care plan available to address this refusal. The facility's policy on comprehensive care plans, dated January 2, 2024, requires that the care plan describe any services not provided due to the resident's refusal of treatment. The absence of a care plan addressing the resident's refusal of care constitutes a failure to meet the facility's policy requirements.
Failure to Monitor and Record Resident's Weight Changes
Penalty
Summary
The facility failed to ensure that weekly weights were recorded in the clinical record and did not monitor a resident's weight for significant changes. Resident 23, who had a history of abnormal weight loss and required assistance with meals, was not properly monitored despite physician orders for weekly weights. The clinical record lacked documentation of the actual weekly recorded weight amounts, and there was no evidence that the physician was notified of significant weight changes. The resident's care plan indicated a potential nutritional risk, but the necessary interventions were not implemented. Interviews with facility staff revealed that the weekly weights were supposed to be recorded in the electronic clinical record, but the actual weight amounts were missing. The Assistant Director of Nursing Services suggested a possible issue with the weight scale machine, but no updated weight monitoring or interventions were documented. The Director of Nursing Services confirmed that the weekly weights should have been accurately entered into the clinical record, and no additional assessments or interventions were made in response to the resident's weight changes. The facility's Nutrition Management and Physician Orders policies were not followed, leading to this deficiency.
Failure to Document Drug Disposition Records for Discharged Residents
Penalty
Summary
The facility failed to document the drug disposition records for two discharged residents, leading to a deficiency in pharmaceutical services. Resident 77, who had diagnoses including COPD and type 2 diabetes, passed away at the facility. The clinical record for Resident 77 lacked documentation of medications being sent back to the pharmacy or destroyed, as required by the facility's policy. This oversight was identified during a review of the resident's clinical record, which included various medications such as acetaminophen, insulin, and sertraline. Similarly, Resident 78, who had diagnoses including COPD and unspecified heart failure, was discharged from the facility with all medications and belongings. However, the clinical record for Resident 78 did not include a medication release form listing all medications sent home with the resident or their representative. The Director of Nursing confirmed the lack of documentation for drug dispositions for both residents. The facility's policy, which mandates logging all items returned to the pharmacy on a medication return form, was not adhered to in these cases.
Inaccurate Menu Postings Lead to Resident Confusion
Penalty
Summary
The facility failed to ensure that the posted menus accurately reflected the meals being served to residents. On October 7, 2024, observations revealed discrepancies between the posted menus and the actual meals served. In the main dining room, the posted menu indicated it was week 4, with a lunch of turkey, carrots, mashed potatoes, and a roll, while another menu at the entrance to the B wing indicated it was week 3, with a lunch of cheesy ham and macaroni, spinach, corn bread, and pineapple tidbits. However, the meal served to residents consisted of brochette chicken, parmesan noodles, green beans, and a dinner roll. Interviews with the Staff Scheduler and the Dietary Manager confirmed that the posted menus should have been updated to reflect day two of week one, and the menus should have been changed on October 5, 2024. During a Resident Council meeting on October 9, 2024, a resident expressed that they were unaware of what meals they would receive until the meal tray was delivered, as the posted menus were consistently incorrect. The facility's policy, dated October 2022, stated that menus should be served as written unless a substitution is provided in response to preference, and that menus should be posted in the Dining Services department, dining rooms, and resident/patient care areas. This policy was not adhered to, leading to confusion and dissatisfaction among residents regarding their meals.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure allegations of abuse were reported to the State Survey Agency for two residents. Resident B, who is severely cognitively impaired with diagnoses including anxiety and depression, reported that a staff member hit him in the back of the head. Despite the facility's investigation, which could not substantiate the allegation, the incident was not reported to the State Survey Agency as required. The incident was documented in the resident's clinical record and a concern form was filled out, but the necessary reporting was not completed. Similarly, Resident C, who is cognitively intact with diagnoses including alcohol abuse, altered mental status, and major depression, alleged that a staff member was rough while providing care. The allegation was reported internally, and the Administrator spoke with Resident C, but the facility did not substantiate the claim and failed to report it to the State Survey Agency. The facility's policy on abuse prevention clearly states that such allegations should be reported to the State certification agency, but this protocol was not followed in these instances.
Failure to Provide Care for Resident with PTSD
Penalty
Summary
The facility failed to provide appropriate care and services for a resident diagnosed with PTSD. Resident D, who had a history of schizophrenia, major depression, psychoactive substance abuse, and alcohol dependence, was found to have brought vodka into the facility and consumed it, leading to increased hallucinations. Despite being diagnosed with PTSD by a psychiatric progress note, Resident D's clinical record lacked a person-centered care plan for this condition. The facility's policy on mood and behavior management, which emphasizes individualized interventions, was not followed in this case. Multiple residents reported to the Administrator that Resident D was supplying alcohol to other residents. The Administrator confirmed finding a bottle of vodka in Resident D's room and subsequently discontinued Resident D's independent leave of absence. However, the facility did not address Resident D's PTSD in their care plan, as confirmed by the Administrator and the review of the clinical records. This oversight indicates a failure to provide necessary mental health services and interventions tailored to Resident D's specific needs.
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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 Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hawthorne Healthcare Center | 0.7 mi | ★★★★★ | 10 | 0 |
| Southpointe Healthcare Center | 1.8 mi | ★★★★★ | 13 | 0 |
| Forest Creek Village | 2 mi | ★★★★★ | 7 | 0 |
| University Heights Health And Living Community | 2.3 mi | ★★★★★ | 3 | 0 |
| Rosegate Village | 2.7 mi | ★★★★★ | 5 | 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.