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Majestic Care Of Carmel

12999 N Pennsylvania St, Carmel, IN 46032 · For profit - Corporation · 94 certified beds · (317) 848-2448 Medicare & Medicaid certified

Call the home — (317) 848-2448 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • about 21% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
13080 Grand Blvd Ste 110 · (317) 575-1133 · Call to confirm hours
Pharmacy
1001 W Main St · (317) 688-7050 · Call to confirm hours
Grocery
Meijer0.3 mi
1424 W Carmel Dr · (317) 573-8300 · Call to confirm hours
Park
West Park0.5 mi
Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.1%11.0%15.4%better
Long-stay residents who lose too much weight2.9%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%1.1%2.0%better
Long-stay residents with depressive symptoms99.3%25.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury9.9%3.9%3.3%worse
Long-stay residents whose ability to walk worsened10.8%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication27.7%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine94.9%95.4%95.3%typical
Long-stay residents with pressure ulcers2.5%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control27.8%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table10.4%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine60.3%79.0%79.4%worse
Short-stay residents rehospitalized after admission21.9%22.2%22.6%typical
Short-stay residents with an outpatient ER visit19.7%10.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.421.611.67worse
Long-stay outpatient ER visits per 1,000 resident days2.831.441.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

42.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 104 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

42.7%U.S. median 51.5%
Got home and stayed home
9.2%U.S. median 10.7%
Went back to hospital
70.2%U.S. median 56.6%
Met the expected recovery
0.41U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.20hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 70.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 57 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.41 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF42.7%CMS range 34.8–51.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.2%CMS range 6.2–13.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge70.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge70.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge66.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting96.5%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.8%CMS range 3.6–11.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.211.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.53
RN hours/ resident / day
0.93
LPN hours/ resident / day
1.90
Aide hours/ resident / day
3.36
Total nurse hours/ resident / day
0.39
RN hoursweekends
50.0%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 94 beds and averages 56.1 residents a day — about 60% occupied, or roughly 38 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.90 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.92 hrs/resident/day on weekends vs 3.54 on weekdays — 17% thinner on weekends. RN hours go from 0.59 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

5
deficiencies at the latest standard inspection (2025-07-28)
6
at the previous standard inspection (2024-07-30)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · D2025-07-28 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the State Long-Term Care Ombudsman was notified after a resident was discharged to the hospital for 2 of 3 residents reviewed for hospitalization. (Resident 13 and 6)Findings include:1. The clinical record for Resident 13 was reviewed on 7/22/25 at 1:45 p.m. The diagnoses included, but were not limited to, fracture of the right femur, dementia, and anxiety.The clinical record indicated Resident 13 was discharged to the hospital after a fall on 6/12/25 and was readmitted back into the facility on 6/19/25.A document, titled Admission/Discharge To/From Report, dated 6/1/25 to 6/30/25 did not have Resident 13 listed as a discharged resident in the month of June.2. The clinical record for Resident 6 was reviewed on 7/23/25 at 1:21 p.m. The diagnoses included, but were not limited to, hypotension (low blood pressure), dementia, and traumatic subdural hemorrhage.The clinical record indicated Resident 6 was discharged to the hospital on 2/16/25 and was readmitted back into the facility on 2/18/25.A document, titled…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-28 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a Preadmission Screening and Record Review (PASARR) was completed after new psychotropic medications were prescribed for 2 of 3 residents reviewed for PASARR. (Resident 35 and 13)Findings include:1. The clinical record for Resident 35 was reviewed on 7/22/25 at 2:52 p.m. The diagnoses included, but were not limited to, major depressive disorder, insomnia, and heart failure. A notice of PASARR level II outcome, dated 10/26/22, indicated Resident 35 had no mental health medications and if there was a significant change in physical or mental health, a new Level II evaluation would be needed. The nursing facility must submit an updated Level I screening to see if a further PASARR evaluation was needed. A physician's order, dated 7/1/25, indicated to administer Sertraline HCL (an antidepressant medication) 25 milligrams (mg) 3 tablets one time per day for depression. There was not another PASARR in the electronic medical record. During an interview, on 7/23/25 at 10:23 a.m., the Social Services Director (SSD) indicated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-28 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the physician's orders related to medication hold parameters were followed for 3 of 3 residents reviewed for quality of care. (Resident 13, 2 and 4)Findings include: 1. The clinical record for Resident 13 was reviewed on 7/22/25 at 1:45 p.m. The diagnoses included, but were not limited to, hypertension (high blood pressure), anxiety disorder, and dementia. A physician's order, dated 12/28/22, indicated to administer metoprolol succinate ER (extended release) 25 milligrams (mg), one time a day, with instructions to hold the medication if the systolic blood pressure was below 120. The Medication Administration Record (MAR) for April 2025, June 2025, and July 2025 were reviewed and indicated metoprolol was administered below the ordered hold parameter of 120 on the following days: a. On 4/15/25, with a systolic blood pressure of 93. b. On 4/17/25, with a systolic blood pressure of 117. c. On 4/23/25, with a systolic blood pressure of 110. d. On 6/29/25, with a systolic blood pressure of 114. e. On 7/9/25, with a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-28 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident was assessed and provided pain management prior to the physician's ordered wound treatment for 1 of 1 resident reviewed for pain. (Resident 4)Findings include:During an observation, on 7/21/25 at 12:01 p.m., Resident 4 was sitting in bed with a wound VAC (vacuum assisted closure) (a device used to help close and heal wounds) in place on her left thigh.During an interview, on 7/21/25 at 12:01 p.m., Resident 4 indicated the pain during her wound VAC dressing changes was especially excruciating. She had told the staff every time someone messed with the wound VAC. She indicated the wound VAC was a torture device and the pain from the wound VAC has kept her from getting out of bed and doing things.During an observation, on 7/23/25 at 7:58 a.m., Resident 4 was in bed waiting for the dressing to be changed for her wound VAC. She appeared very anxious with her jaw tight, teeth clenched, and a grimace look on her face. She…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-28 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the Medication and Treatment Administration Records were complete and accurately documented for 3 of 5 residents reviewed for complete and accurate medical records. (Resident 37, 2 and 41)Findings include: 1. The clinical record for Resident 37 was reviewed on 7/22/25 at 10:27 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), hypertension, and bipolar disorder. The Medication Administration Record (MAR) and Treatment Administration Record (TAR), for June 2025, were missing the following documentation for Resident 37: a. The administration of Aricept (a medication used to treat symptoms of Alzheimer's disease and dementia) 5 milligrams (mg) on 6/10/25 at 6:00 p.m. b. The administration of Ativan (an anxiety medication) 0.5 mg on 6/10/25 at 6:00 p.m. c. A completed skin evaluation on 6/11/25 for the evening shift. d. The administration of melatonin (a medication used to mimic the body's natural sleep hormone) 5 mg on 6/10/25 at 6:00 p.m. e. The administration of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-30 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure catheter tubing was not touching the ground, oral care products were stored properly, and clean laundry and linen were stored and handled appropriately for 12 of 12 residents randomly observed for infection control. (Residents 34, 302, 4, 27, 11, 38, 13, 15, 4, 17, 9 and 30) Findings include: 1. During an observation, on 7/24/24 at 12:10 p.m., Resident 34's catheter tubing was touching the floor while she was in the commons area on the 1st floor. During an observation, on 7/29/24 at 1:27 p.m., Resident 34's catheter tubing was touching the ground. During an interview, on 7/29/24 at 1:28 p.m., the Director of Nursing (DON) indicated the catheter tubing was touching the ground and needed fixed. The clinical record for Resident 34 was reviewed on 7/26/24 at 9:55 a.m. The diagnoses included, but were not limited to, chronic kidney disease stage 3, neuromuscular dysfunction of the bladder, and dementia. A current physician's order, with a revision date of 5/29/24, indicated may anchor a 10ml/14fr Foley…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-30 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to provide a resident with a call light he was physically capable of activating for 1 of 1 resident reviewed for accommodation of needs. (Resident 40) Finding includes: During an observation, on 7/24/24 at 12:35 p.m., the resident was in the dining room. A nurse was assisting the resident to eat. The resident's hands were contracted with all fingers flat against his palms. He could not grip or use his thumbs. During an observation, on 7/25/24 at 9:50 a.m., the resident was in his room in his reclining Broda chair with a standard small push button call light clipped to his pant leg. The resident indicated he needed to go to the bathroom. He made multiple attempts to push the small red button on the call light. He tried several different ways but was never able to push the small button to activate the call system. The resident was visibly distressed and indicated he was frustrated because the call light did not work most of the time, so he had to call out for help. The resident's voice was low in volume and tone…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-30 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a new PASARR (pre-admission screening and resident review) level 1 request was submitted when changes in medications and diagnoses occurred for 3 of 3 residents reviewed for PASARR. (Resident 35, 40 and 46) Findings include: 1. The clinical record for Resident 35 was reviewed on 7/26/24 at 10:22 a.m. The diagnoses included, but were not limited to, general anxiety disorder, recurrent depressive disorder, Parkinson's disease without dyskinesia (involuntary movements), puerperal psychosis, dementia in other disease mild without behavioral symptoms, psychotic or mood disturbance, and anxiety. A PASARR level 1, dated 2/17/22, indicated no level 2 was required due to no significant mental illness, intellectual disability, or related conditions. The level 1 screen indicated a PASARR disability was not present because of the following reason: There was no evidence of a PASARR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occurred or new information refuted these…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-30 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to develop a comprehensive care plan for the diagnoses of mental health conditions and the use of antipsychotic medications for 1 of 5 residents reviewed for unnecessary medications. (Resident 19) Finding includes: The clinical record for Resident 19 was reviewed on 7/24/24 at 3:45 p.m. The diagnoses included, but were not limited to, bipolar type schizoaffective disorder, bipolar disorder, metabolic encephalopathy (a brain disorder caused by a chemical imbalance), intellectual disabilities, and type 2 diabetes mellitus. A physician's order, dated 6/28/24, indicated to give risperidone (an antipsychotic medication) 1 milligram (mg) two times a day related to schizophrenia. A psychiatry progress note, dated 7/23/24, indicated the resident was seen for ongoing monitoring and management of mood, behavior and cognition. The diagnoses included, but were not limited to, bipolar type schizoaffective disorder, bipolar disorder, and unspecified intellectual disabilities. The care plans did not include the mental health diagnoses of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure staff followed the physician ordered hold parameters for a medication and failed to ensure treatments were documented in the Treatment Administration Record for 3 of 3 residents reviewed for quality of care. (Resident B, 34 and 46) Finding includes: The record for Resident B was reviewed on 7/26/24 at 9:00 a.m. Diagnoses included, but were not limited to, hypertension, dementia, hallucination, and major depressive disorder A physician's order, dated 3/23/23, indicated hydralazine (a blood pressure medication) 10 mg was to be given by mouth three times a day related to hypertension and to hold if the systolic blood pressure (SBP) was less than 160. The Medication Administration Record (MAR), dated 7/1/24 through 7/31/24, indicated the following: a. the morning administration of hydralazine 10 mg was given to Resident B six (6) times when the systolic blood pressure was below the physician ordered hold parameters. b. the afternoon administration of hydralazine 10 mg was given to Resident B two (2) times when the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2024-07-30 · tag F0882 — isolated
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to have an Infection Preventionist (IP) who was able to fulfill the role at least part-time and was not preforming the duties of the full-time Director of Nursing (DON) for 1 of 1 Infection Preventionist reviewed. Finding includes: During an interview, on 7/24/24 at 11:15 a.m., the Executive Director (ED) indicated the facility's Infection Preventionist (IP) was the Director of Nursing (DON). He indicated it was not a separate position and no other employees held an infection prevention certification. During an interview, on 7/30/24 at 2:45 p.m., the DON indicated he performed all the infection prevention tracking and duties along with all his DON duties. He indicated he was the only employee who held an infection prevention certification, and no other employees assisted him with the infection control duties. The facility's employee records did not contain an employee with the title of Infection Preventionist. A current policy, titled Infection Control, dated 1/02/24 and received from the Executive Director (ED) on 7/24/24,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-15 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure a resident was assessed to self-administer medications for 1 of 2 residents observed for medication administration. (Resident D) Findings include: During a random observation, on 11/14/23 at 9:51 a.m., a medication cup of pills was observed left on the bedside table. There were no qualified staff in the room at the time to observe the medication administration. Resident D was left to take her medication unattended. The record for Resident D was reviewed on 11/14/23 at 10:42 a.m. Diagnoses included, but were not limited to, Parkinson's disease, type 2 diabetes, and hypertension. Resident D did not have an order to self-administer medications in her record. Resident D did not have a self-administration assessment in her record to indicated she was able to safely self-administer medications. Resident D was not care planned to self-administer medications. During an interview, on 11/14/23 at 9:53 a.m., Resident D indicated staff did not always leave her medications with her and she was getting ready to take…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure a medication was administered per the physician's order for 1 of 2 residents observed for quality of care. (Resident B) Finding includes: During a random observation, on 11/14/23 at 10:16 a.m., Resident B was observed resting in bed. The resident had a Scopolamine transdermal patch (used to decrease secretions) behind his right ear. The patch had been dated 11/9/23. The record for Resident B was reviewed on 11/14/23 at 10:52 a.m. Diagnoses included, but were not limited to, paralytic syndrome following cerebrovascular disease (paralysis), dysphagia (difficulty swallowing), and persistent vegetative state. A physician's order, dated 12/31/20, indicated to administer a Scopolamine Patch 72 hour in the morning every three (3) days and remove per schedule. During an interview, on 11/14/23 at 10:22 a.m., LPN 1 indicated the patch was changed on the night shift and he was not sure how often the patch needed to be changed. He would check the medication order to see how often the patch needed to be changed. A…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff contacted the physician, dietitian, or nurse practitioner to get an order for nutritional formula administration for 1 of 2 residents reviewed for gastronomy tube feedings. (Resident C) Finding includes: The record for Resident C was reviewed on 11/14/23 at 1:08 p.m. Diagnoses included, but were not limited to, malignant neoplasm of laryngeal cartilage (throat cancer), emphysema, and bipolar disorder. A care plan, initiated on 10/19/23, indicated Resident C was at risk for fluid imbalance due to chronic kidney disease and NPO (nothing to be given orally) status. The October Medication and Treatment Administration record did not have any documentation to show Resident C had received any meals or fluids via the gastronomy tube, for approximately 15 hours, from 10/17/23 beginning at 6:00 p.m., until a grievance was filed and investigated on 10/18/23 at 9:30 a.m. The resident admitted to the facility on [DATE] at 5:37 p.m. The hospital…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-15 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure documentation was correct in the resident record when the administration of a transdermal medication patch found on a resident was dated for 11/9/23 but charted as being changed on 11/12/23 for 1 of 3 residents reviewed for documentation in the medical record. (Resident B) Finding includes: During a random observation, on 11/14/23 at 10:16 a.m., Resident B was observed resting in bed. The resident had a Scopolamine transdermal patch (used to decrease secretions) behind his right ear. The patch had been dated 11/9/23. The record for Resident B was reviewed on 11/14/23 at 10:52 a.m. Diagnoses included, but were not limited to, paralytic syndrome following cerebrovascular disease (paralysis), dysphagia (difficulty swallowing), and persistent vegetative state. A physician's order, dated 12/31/20, indicated to administer a Scopolamine Patch 72 hour in the morning every three (3) days and remove per schedule. The Medication Administration Record indicated the Scopolamine patch was documented as changed on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-19 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure notices were given 48 hours prior to the Medicare benefits ending date and to ensure the residents chose an option for ongoing services for 3 of 3 residents reviewed for beneficiary notices. (Resident 153, 17 and 45) Findings include: 1. The NOMC (Notice of Medicare Non-Coverage) form for Resident 153 indicated the coverage of Medicare Part A services would end on 2/7/23. The daughter was telephoned, on 2/6/2 at 3:20 p.m., to notify her of the end of coverage date. During an interview, on 5/18/23 at 2:42 p.m., the BOM (Business Office Manager) indicated the Social Services Director was in charge of giving notices to the resident or resident representative. The notice should have been given on 2/5/23 for the required 48-hour notice. 2. A Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for Resident 17 indicated beginning on 2/2/23 the resident may have to pay out of pocked for care if there was no other insurance to cover the costs. The form included 3 options: 1. The resident wanted the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-19 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During an observation, on 05/16/23 at 12:01 p.m., Resident 35 was on contact isolation for Escherichia Coli (E. coli) and ESBL (Extended Spectrum Beta-Lactamase, a bacteria that could not be killed by many antibiotics which made it harder to treat) in the urine. The record for Resident 35 was reviewed on 05/17/2023 at 11:13 a.m. Diagnosis included, but were not limited to, schizophrenia, anxiety, essential hypertension, ischemic cardiomyopathy, bipolar disorder, heart failure, asthma, allergic rhinitis, personal history of covid-19, and sleep disorder. The facility matrix indicated the resident was in transmission-based precautions for ESBL. A physician's order, dated 05/07/23, indicated Amoxicillin-Pot Clavulanate (an antibiotic) tablet 875-125 mg (milligram) was started on 05/07/2023 and to give 1 tablet by mouth two times a day due to a UTI bacterial infection for 28 days. During an interview, on 05/18/23 at 2:47 p.m., the Regional Support indicated there was not a care plan for the UTI and there should…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-19 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure a resident received twice weekly activities and a resident received the identified preference for the activity of their choice for 2 of 5 residents for activities. (Resident 3 and 253) Findings include: 1. During an observation, on 5/15/23 at 2:56 p.m., Resident 3 was in his room, lying in his bed, and the television (TV) was on. During an observation, on 5/16/23 at 11:12 a.m., the resident was in his room, lying in his bed, and the TV was on. Other residents were observed in the common area playing bingo. During an observation, 5/17/23 at 10:57 a.m., the resident was in his room, lying in his bed, and the TV was on. Other residents were observed in the dining room listening to live music. During an observation, on 5/18/23 at 3:09 p.m., the resident was in his room, lying in bed, and the TV was on. Other residents were observed in the common area. The record for Resident 3 was reviewed on 5/17/23 at 10:03 a.m. Diagnosis included, but were not limited to, persistent vegetative state, unspecified…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure the physician was notified of a weight gain as ordered for a resident who was diagnosed with congestive heart failure for 1 of 1 resident reviewed for edema. (Resident 41) Finding includes: During an observation, on 5/15/23 at 12:52 p.m., Resident 41 was sitting in her recliner with both legs elevated. The resident's bilateral legs and ankles were swollen. The record for Resident 41 was reviewed on 5/16/23 at 4:42 p.m. Diagnosis included, but were not limited to, congestive heart failure, hypertension, urine retention, and depressive disorder. A physician's order, dated 10/25/22, indicated daily weight and to notify the provider of a 3-pound weight gain in two days or a 5-pound weight gain in a week and to weigh before breakfast related to congestive heart failure. A physician's order, dated 1/4/23, indicated furosemide (a diuretic) 20 mg (milligrams) tablet give two tablets daily related to edema. During a record review, the physician was not notified for the following weight gains: a. 3/9/23 to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-19 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure a resident was re-assessed for interventions to treat and prevent further contracture for 1 of 2 residents reviewed for limited range of motion. (Resident 3) Finding includes: During an observation, on 05/15/23 at 3:00 p.m., the resident was in his room lying in bed. The resident had contractures of both hands. During an observation, on 05/17/23 at 11:03 a.m., the resident was in his room lying in bed with rolled up washcloths in both hands. During an observation, on 05/18/23 at 12:23 p.m., the resident was in his room lying in bed with rolled up washcloths in both hands. The resident did not have elbow splints or hand splints during the observations. The record for Resident 3 was reviewed on 05/17/23 at 10:03 am. Diagnoses included, but were not limited to, persistent vegetative state, unspecified intercranial injury, cerebrovascular disease, paralytic syndrome, and chronic pain. A physician's order, dated 03/31/2016, indicated hand splints to be worn daily from 8:00 a.m. through 5:00 p.m. A…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure a resident who was at risk for falls had their bed in the lowest position for 1 of 4 residents reviewed for falls. (Resident 3) Finding includes: During an observation, on 05/15/23 at 3:00 p.m., Resident 3 was lying in bed with the bed in a high position. During an observation, on 05/17/23 at 11:03 a.m., Resident 3 was lying in bed with the bed in a high position. During an observation, on 05/15/23 at 12:14 p.m., Resident 3 was lying in bed with the bed in a high position. During an observation, at 05/18/23 at 3:09 p.m., with the Regional Support Nurse, the resident's bed was in the high position. The record for Resident 3 was reviewed on 05/17/23 at 10:03 a.m. Diagnoses included, but were not limited to, persistent vegetative state, unspecified intracranial injury, cerebrovascular disease, paralytic syndrome, and chronic pain. A care plan, dated 12/28/20 and last revised on 02/02/23, indicated the resident was at risk for falls due to involuntary movements, current medical comorbidities, vegetative…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-19 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure an informed consent was completed for the use of side rails for 1 of 2 residents reviewed for accident hazards. (Resident 3) Finding includes: During an observation, on 5/18/23 at 12:18 p.m., the resident's bed had two quarter side rails in the raised position. The record for Resident 3 was reviewed on 5/17/23 at 10:03 a.m. Diagnoses included, but were not limited to, persistent vegetative state, unspecified intracranial injury, cerebrovascular disease, paralytic syndrome, and chronic pain. An Adaptive Device Review, dated 4/25/23, indicated the resident had an other type of device in use to promote independence. There was not a consent form signed. The Adaptive Device Review did not state what type of device was utilized. A Resident Care sheet, dated 5/18/23, indicated the resident had assist rails to enhance bed mobility. During an interview, on 5/18/23 at 2:47 p.m., the Regional Support Nurse indicated there was no consent for the side rails in the electronic health record. A current policy, titled…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    2. The record for Resident 45 was reviewed on 05/16/23 at 4:44 p.m. Diagnoses included, but were not limited to, Parkinson's disease, anxiety, and insomnia. A physician's order, dated 2/18/23, indicated lorazepam (a medication for anxiety) 0.25 mg (milligrams) every 12 hour as needed. A physician's order, dated 3/21/23, indicated lorazepam 0.25 mg every 12 hours as needed. A physician's order, dated 5/10/23, indicated lorazepam 0.25 ml every 4 hours as needed. During an interview, on 05/19/23 at 4:03 p.m., Anonymous Staff 5 indicated the resident was frequently restless and they tried to keep her occupied. The staff member was not aware the PRN order for the lorazepam needed reviewed every 14 days. A recent publication of PDR.net indicated .risperidone (Risperdal) was indicated for the treatment of schizophrenia .the black box warning indicated antipsychotics are not approved for the treatment of dementia-related psychosis in geriatric patients and the use of risperidone in this population should be avoided if possible due to an increase in morbidity and mortality A current policy,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-19 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure ceilings panels were free from stains, rooms were free from flying insects and garbage, loose baseboard trim and paint on a bathroom floor, and failed to ensure the second-floor dining room was free from scuff marks and gouges on the walls for 8 of 36 rooms observed. (room [ROOM NUMBER], 219, 220, 222, 238, 239, 240, 245 and the second-floor dining room) Findings include: During an observation, beginning at 3:12 p.m., on 5/17/23 with the Executive Director, Director of Nursing (DON), Administrator in Training (AIT), Housekeeping Director, and the Maintenance Director the following were observed: 1. room [ROOM NUMBER] had one ceiling panel by the window with a large brown stain and two smaller brown stains. 2. room [ROOM NUMBER] had seven ceiling panels by the window with eight brown stains. 3. room [ROOM NUMBER] had little flying insects around the room and on the bedside table. 4. room [ROOM NUMBER] had little flying insects around her food…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to MAJESTIC CARE — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.5-0.5 vs chain
Health inspection 3 of 52.1+0.9 vs chain
Staffing 1 of 51.7-0.7 vs chain
Quality measures 4 of 54.5-0.5 vs chain
The other 21 homes this chain runs (chain average 2.5★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
PULASKI MEMORIAL HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/01/2021
SMITH, TODDIndividualCONTRACTED MANAGING EMPLOYEEsince 07/01/2021
BARRY, THOMASIndividualCORPORATE OFFICERsince 07/01/2021
MALOTT, GREGGIndividualCORPORATE OFFICERsince 07/01/2021

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$9.1M
Net patient revenuemost recent cost report
-4.1%
Operating marginrevenue minus expenses
$2.0M
Related-party expense21% of expenses
Who pays — share of resident-days
Medicaid 50%Medicare 22%Other / private 28%

This home reported $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$476per resident / day
operating cost
$14,469per month
≈ monthly operating cost
$457per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IN

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.

Typical monthly cost in Indiana
$8,943/mo
Nursing home (semi-private)
$10,326/mo
Nursing home (private)
$5,639/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155618. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-28, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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