Inspection Reports for Majestic Care of Carmel Assisted Living
12999 N Pennsylvania St, Carmel, IN 46032, United States, IN, 46032
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 3, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving life safety code issues such as delayed egress locks and corridor doors not latching properly, as well as care planning, medication administration, infection control, and documentation concerns. Some complaint investigations were substantiated with deficiencies cited, including a resident death due to failure to supervise and issues with psychotropic medication consents, but enforcement actions like fines or license suspensions were not listed in the available reports. Most complaint investigations were unsubstantiated or found no deficiencies related to allegations. The facility’s record shows ongoing challenges with life safety compliance and resident care documentation, though recent inspections indicate some corrective actions and improvements in complaint-related issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
181% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
128 residents
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 0
Date: Feb 3, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00451152.
Complaint Details
Complaint IN00451152 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Report Facts
Census Bed Type - SNF: 19
Census Bed Type - SNF/NF: 27
Census Bed Type - Residential: 82
Census Total: 128
Census Payor Type - Medicare: 13
Census Payor Type - Medicaid: 27
Census Payor Type - Other: 6
Census Payor Type - Total: 46
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Date: Sep 23, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00439912, IN00440428, and IN00442867.
Complaint Details
Complaints IN00439912, IN00440428, and IN00442867 were investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with relevant federal and state regulations.
Report Facts
Census Bed Type: 44
Census Bed Type - SNF/NF: 29
Census Bed Type - SNF: 15
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 29
Census Payor Type - Other: 9
Inspection Report
Life Safety
Census: 49
Capacity: 104
Deficiencies: 0
Date: Sep 10, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/15/24 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR Life Safety Code survey, Majestic Care of Carmel was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Life Safety
Census: 55
Capacity: 104
Deficiencies: 2
Date: Aug 15, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 08/15/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies were identified related to delayed egress locking arrangements and corridor doors failing to latch properly.
Deficiencies (2)
Failed to ensure 1 of over 5 delayed egress locking arrangements released the lock in the direction of egress within 15 seconds as required, affecting 10 residents.
Failed to ensure all corridor doors had no impediment to closing and latching into the door frame and would resist the passage of smoke, affecting 2 residents.
Report Facts
Certified beds: 104
Census: 55
Delayed egress locking arrangements: 5
Residents potentially affected: 10
Residents potentially affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Seib | Executive Director | Named in relation to findings and exit conference |
| Maintenance Director | Named in relation to findings and corrective actions |
Inspection Report
Recertification
Census: 79
Capacity: 128
Deficiencies: 12
Date: Jul 30, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of multiple complaints.
Complaint Details
Complaint IN00435957 had state deficiencies related to allegations cited at R144 and R217. Complaints IN00436846, IN00438695, and IN00438807 had no deficiencies related to the allegations cited.
Findings
The facility was cited for deficiencies related to reasonable accommodations, PASARR coordination, comprehensive care planning, quality of care, infection prevention and control, personnel sufficiency, sanitation and safety, medication administration, and health assessments.
Deficiencies (12)
Failed to provide a resident with a call light he was physically capable of activating.
Failed to ensure a new PASARR level 1 request was submitted when changes in medications and diagnoses occurred for 3 residents.
Failed to develop a comprehensive care plan for the diagnoses of mental health conditions and the use of antipsychotic medications for 1 resident.
Failed to ensure staff followed physician ordered hold parameters for medications and failed to ensure treatments were documented in the Treatment Administration Record for 3 residents.
Failed to ensure infection prevention and control practices including catheter tubing management, oral care product storage, and linen handling were properly followed for 12 residents.
Failed to designate an Infection Preventionist who works at least part-time and completed specialized training in infection prevention and control.
Failed to have sufficient first aid certified staff for 16 of 21 shifts reviewed.
Failed to ensure the facility was clean and reasonable comfort was provided related to a resident with incontinent concerns.
Failed to update a service plan to include services required for a resident who was incontinent and soiled common areas.
Failed to ensure PRN medications were authorized by a licensed nurse and documented prior to administration by a Qualified Medication Aide for 1 resident.
Failed to ensure refrigerated medications were kept at a safe temperature, daily temperatures were recorded, medication labels had opened dates, and loose pills were not stored in medication carts.
Failed to ensure residents had an annual statement showing no evidence of tuberculosis in an infectious stage verified upon admission and yearly thereafter for 2 residents.
Report Facts
Survey dates: 5
Census: 79
Total capacity: 128
Deficiency shifts without first aid coverage: 16
Temperature reading: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Seib | Executive Director | Signed the report and referenced in interviews. |
| LPN 4 | Licensed Practical Nurse | Noted medication refrigerator temperature and loose pills in medication cart. |
| DON | Director of Nursing | Performed infection prevention duties and participated in interviews. |
| ED | Executive Director | Provided policies and participated in interviews. |
| Assisted Living Clinical Director | Provided clinical interviews and explanations related to resident care and medication administration. |
Inspection Report
Renewal
Deficiencies: 0
Date: Jul 30, 2024
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure survey.
Findings
Majestic Care of Carmel was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Date: Mar 6, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00428752 and IN00429056 at Majestic Care of Carmel.
Complaint Details
Complaint IN00428752 and Complaint IN00429056 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations in complaints IN00428752 and IN00429056 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 28
Census Bed Type - SNF: 19
Census Total: 47
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 28
Census Payor Type - Other: 11
Inspection Report
Complaint Investigation
Census: 85
Capacity: 139
Deficiencies: 1
Date: Feb 7, 2024
Visit Reason
The visit was conducted for the investigation of multiple nursing home and assisted living complaints (IN00424001, IN00426976, IN00425860, IN00426915).
Complaint Details
Complaint IN00425860 was substantiated with state deficiencies cited at R352. Complaints IN00424001, IN00426976, and IN00426915 had no deficiencies related to the allegations cited.
Findings
No deficiencies were cited related to complaints IN00424001, IN00426976, and IN00426915. State deficiencies related to complaint IN00425860 were cited at R352 for failure to maintain a complete and accurate medical record documenting an assessment for a resident who experienced a change in condition.
Deficiencies (1)
Failure to maintain a complete and accurate medical record to indicate an assessment had been completed and documented for a resident who experienced a change in condition (Resident B).
Report Facts
Census Bed Type - Residential: 85
Total Capacity: 139
Survey Dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Seib | Executive Director | Signed the report as the facility representative. |
| LPN 2 | Nurse involved in the assessment and documentation related to Resident B's change in condition; received coaching and counseling for documentation deficiencies. | |
| Dietary Aide 3 | Reported Resident B's condition and assisted in moving him; involved in the incident leading to the documentation deficiency. | |
| CNA 4 | Assisted Dietary Aide 3 with Resident B during the incident; involved in resident care and transfer. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 18, 2023
Visit Reason
The visit was conducted as a paper compliance review related to the Investigation of Complaint IN00420094 and unrelated deficiencies completed on November 15, 2023.
Complaint Details
Investigation of Complaint IN00420094 was reviewed and found to be in compliance.
Findings
Majestic Care of Carmel was found to be in compliance with 42 CFR part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation and unrelated deficiencies.
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 4
Date: Nov 14, 2023
Visit Reason
This visit was for the Investigation of Nursing Home Complaints IN00420094 and IN00420266, and Residential Complaint IN00421773.
Complaint Details
Complaint IN00420094 had federal/state deficiencies related to the allegations cited at F692. Complaint IN00420266 and IN00421773 had no deficiencies related to the allegations.
Findings
The facility was found to have deficiencies related to medication self-administration assessment, medication administration per physician orders, nutrition/hydration status maintenance, and resident record documentation accuracy. Some complaints were substantiated with cited deficiencies, while others had no deficiencies related to the allegations.
Deficiencies (4)
Failed to ensure a resident was assessed to self-administer medications.
Failed to ensure a medication was administered per physician's order for a resident.
Failed to ensure staff contacted the physician, dietitian, or nurse practitioner to get an order for nutritional formula administration for a resident with gastronomy tube feeding.
Failed to ensure documentation was correct in the resident record when the administration of a transdermal medication patch was incorrectly documented.
Report Facts
Census Bed Type - SNF/NF: 26
Census Bed Type - SNF: 29
Census Bed Type - Residential: 76
Census Bed Type - Total: 131
Census Payor Type - Medicare: 13
Census Payor Type - Medicaid: 26
Census Payor Type - Other: 16
Census Payor Type - Total: 55
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Seib | Executive Director | Signed the report |
| LPN 1 | Named in medication patch documentation deficiency and provided education and disciplinary action | |
| RN 2 | Interviewed regarding nutritional orders for gastronomy tube feeding | |
| Assistant Director of Nursing | Interviewed regarding medication administration practices | |
| Director of Nursing | Provided facility policies and interviewed regarding medication administration and documentation |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 29, 2023
Visit Reason
The document reports on the paper compliance to the Post Survey Revisit (PSR) conducted on 08/03/23 for the Life Safety Code Recertification and State Licensure Survey conducted on 06/13/23.
Findings
Majestic Care of Carmel was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Date: Aug 11, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00414186.
Complaint Details
Complaint IN00414186 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type Total: 57
Census Payor Type Medicare: 12
Census Payor Type Medicaid: 27
Census Payor Type Other: 18
Inspection Report
Re-Inspection
Census: 54
Capacity: 104
Deficiencies: 2
Date: Aug 3, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on previous Emergency Preparedness and Life Safety Code surveys that exited on 06/13/23, to verify compliance with federal and state regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included exit doors not opening in the direction of egress travel and corridor doors lacking proper latching hardware to resist smoke passage. Corrective actions and monitoring plans were described.
Deficiencies (2)
Failed to ensure that all exit doors opened in the direction of egress travel, specifically the first-floor stairwell exit door near resident room #138 opened into the building.
Failed to ensure all corridor doors had no impediment to closing and latching into the door frame and would resist the passage of smoke; Therapy Doors #1 and #2 lacked proper latching hardware.
Report Facts
Certified beds: 104
Census: 54
Residents potentially affected: 25
Residents potentially affected: 15
Staff potentially affected: 6
Deficiency completion date: Nov 30, 2023
Deficiency completion date: Aug 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Seib | Executive Director | Interviewed and acknowledged findings related to exit door and corridor door deficiencies |
| Maintenance Director | Interviewed and acknowledged findings; involved in corrective actions and monitoring |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 135
Deficiencies: 0
Date: Jul 31, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00414049 and IN00413658 at Majestic Care of Carmel.
Complaint Details
Investigation of Complaints IN00414049 and IN00413658 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in Complaints IN00414049 and IN00413658 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type: 25
Census Bed Type: 28
Census Bed Type: 82
Total Capacity: 135
Census Payor Type: 12
Census Payor Type: 25
Census Payor Type: 16
Current Census: 53
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Date: Jul 13, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00409830, IN00412246, and IN00412377 at Majestic Care of Carmel.
Complaint Details
Investigation of Complaints IN00409830, IN00412246, IN00412377 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00409830, IN00412246, and IN00412377 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Report Facts
Residential Census: 81
Inspection Report
Complaint Investigation
Census: 53
Capacity: 104
Deficiencies: 0
Date: Jul 11, 2023
Visit Reason
An investigation of Complaint Number IN00412371 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Complaint Details
Complaint IN00412371 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Report Facts
Facility capacity: 104
Census: 53
Inspection Report
Routine
Census: 58
Capacity: 104
Deficiencies: 9
Date: Jun 13, 2023
Visit Reason
Routine Emergency Preparedness and Life Safety Code Recertification survey conducted by the Indiana Department of Health.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but had multiple deficiencies related to life safety code including delayed egress door malfunctions, inadequate egress lighting, missing self-closing devices on hazardous area doors, corridor doors not latching properly, missing fire door certification tags, and improper signage in oxygen storage/transfer room.
Deficiencies (9)
Emergency Preparedness Plan failed to include a method for sharing information with residents and families.
Delayed egress locking arrangements failed to release locks within required time and excessive pressure needed to open doors.
Exit doors were not readily accessible and required excessive force to open.
Egress lighting failed to provide continuity for 2 of 2 exits.
Hazardous area door (Activities Office) lacked a self-closing device and did not latch.
Dining area open to corridor without required smoke detection and separation.
Corridor doors failed to latch properly or were impeded from closing.
Annual inspection and testing of fire door assemblies incomplete; missing certification tags on several doors.
Oxygen storage/transfer room lacked signage indicating when transferring is occurring.
Report Facts
Certified beds: 104
Census: 58
Fire door inspection results: 5
Fire door inspection results: 11
Delayed egress doors affected: 3
Residents potentially affected: 22
Exits with egress lighting issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Seib | Executive Director | Interviewed and acknowledged findings throughout the survey. |
| Maintenance Director | Interviewed and acknowledged findings; responsible for corrective actions. |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 9
Date: May 19, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey and included the Investigation of Residential Complaints IN00406339, IN00404866, IN00404606, and IN00403105.
Complaint Details
Complaint IN00406339 - No deficiencies related to the allegations are cited. Complaint IN00404866 - State deficiencies related to the allegations are cited at R0148. Complaint IN00404606 - State deficiencies related to the allegations are cited at R0148. Complaint IN00403105 - No deficiencies related to the allegations are cited.
Findings
The facility was cited for deficiencies related to Medicaid/Medicare coverage notices, care plan timing and revision, activities meeting resident needs, quality of care including failure to notify physician of weight gain, range of motion interventions, fall prevention including bed positioning, bedrail consent, psychotropic medication use, and environmental maintenance issues including stained ceiling panels, flying insects, damaged flooring, and open windows without screens.
Deficiencies (9)
Failed to ensure notices were given 48 hours prior to Medicare benefits ending and residents chose an option for ongoing services for 3 residents.
Failed to offer care plan meeting and initiate care plan for urinary tract infection for 2 residents.
Failed to ensure residents received activities per their preferences and frequency.
Failed to notify physician of significant weight gains for a resident with congestive heart failure.
Failed to reassess and provide interventions to prevent further contractures for a resident with limited range of motion.
Failed to ensure a resident at risk for falls had bed in lowest position.
Failed to obtain informed consent for use of side rails for a resident.
Failed to maintain laundry rooms and common area in clean condition and good repair, including stained ceiling panels, flying insects, damaged flooring, missing cove base, and open windows without screens.
Failed to maintain buildings, grounds, and equipment in clean condition, good repair, and free of hazards that may adversely affect residents or public.
Report Facts
Survey dates: May 15-19, 2023
Census: 75
Deficiency count: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Seib | Executive Director | Signed report on 06/07/2023 |
Inspection Report
Renewal
Deficiencies: 0
Date: May 19, 2023
Visit Reason
Paper compliance to the Recertification and State Licensure survey completed on May 19, 2023.
Findings
Majestic Care of Carmel was found to be in compliance with 42 CFR part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 0
Date: Feb 15, 2023
Visit Reason
This visit was for the investigation of Nursing Home Complaint IN00401521 and Residential Complaint IN00400275.
Complaint Details
Complaint IN00401521 - Substantiated with no deficiencies cited. Complaint IN00400275 - Substantiated with no deficiencies cited.
Findings
Both complaints IN00401521 and IN00400275 were substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF: 29
Census Bed Type - SNF/NF: 26
Census Bed Type - Residential: 66
Census Bed Type - Total: 121
Census Payor Type - Medicare: 14
Census Payor Type - Medicaid: 26
Census Payor Type - Other: 15
Census Payor Type - Total: 55
Inspection Report
Follow-Up
Census: 68
Deficiencies: 0
Date: Feb 9, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00395453, IN00397504, and IN00397569 completed on December 22, 2022.
Complaint Details
This visit was related to complaints IN00395453, IN00397504, and IN00397569. All complaints were corrected.
Findings
The facility was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to the Investigation of Complaints IN00395453, IN00397504, and IN00397569. All complaints were corrected.
Report Facts
Residential Census: 68
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 5
Date: Dec 21, 2022
Visit Reason
This visit was for the investigation of complaints IN00397504, IN00395453, and IN00397569 involving allegations of neglect, failure to supervise, medication administration errors, and lack of comprehensive care plans for residents with major mental illness.
Complaint Details
Complaint IN00397504 - Substantiated with deficiencies cited related to neglect and failure to supervise resulting in resident death. Complaint IN00395453 - Substantiated with deficiencies cited related to failure to evaluate and update service plans after falls. Complaint IN00397569 - Substantiated with deficiencies cited related to medication administration errors and lack of monitoring.
Findings
The facility failed to supervise a resident with suicidal ideation resulting in the resident's death by drowning, failed to evaluate and update service plans after falls for a resident, failed to ensure medications were administered by licensed personnel or qualified aides, failed to monitor residents for medication side effects, and failed to develop comprehensive care plans for residents with major mental illness.
Deficiencies (5)
Failure to supervise a resident with suicidal ideation resulting in resident drowning in facility retention pond.
Failure to evaluate residents for change in condition and update service plans after falls resulting in injury.
Failure to ensure medications were administered by licensed nursing personnel or qualified medication aides; housekeeper applied medication cream and residents self-administered medications without physician orders or assessments.
Failure to observe and document effects of medications including antipsychotics and antidepressants, and notify physician of undesirable effects.
Failure to create and implement comprehensive care plans in cooperation with psychiatric physicians for residents with major mental illness within 30 days of admission.
Report Facts
Residents reviewed for falls: 3
Residents reviewed for medication administration: 7
Residents with major mental illness: 22
Residents with major mental illness reviewed for care plans: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper 14 | Housekeeper | Applied medication cream to resident without being qualified or authorized. |
| LPN 7 | Licensed Practical Nurse | Failed to verify resident location when resident missed medication and assumed resident was on leave of absence. |
| LPN 11 | Licensed Practical Nurse | Did not verify resident location or check sign out log when resident was missing. |
| LPN 18 | Licensed Practical Nurse | Observed resident self-administering medications without physician order or assessment. |
| AL DNS | Assisted Living Director of Nursing Services | Oversaw nursing services, acknowledged lack of psychiatric care plans and monitoring, and admitted to lack of knowledge about care planning requirements in Assisted Living. |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Date: Nov 2, 2022
Visit Reason
This visit was for the investigation of Residential Complaint IN00393455.
Complaint Details
Complaint IN00393455 - Substantiated. No deficiencies related to the allegations are cited.
Findings
Complaint IN00393455 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 20, 2022
Visit Reason
Investigation of Complaint IN00387754 completed on October 20, 2022.
Complaint Details
Investigation of Complaint IN00387754 completed; facility found in compliance.
Findings
Majestic Care of Carmel was found to be in compliance with 42 CFR part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 1
Date: Oct 18, 2022
Visit Reason
This visit was for the investigation of multiple nursing home complaints (IN00387754, IN00383851, IN00389712, IN00392263) and a residential complaint (IN00387578).
Complaint Details
Complaint IN00387754 was substantiated with federal/state deficiencies cited at F758. Other complaints IN00383851, IN00389712, IN00392263, and IN00387578 were substantiated but had no deficiencies related to the allegations.
Findings
The facility was found to have deficiencies related to the substantiated complaint IN00387754 involving failure to obtain signed consents for psychotropic medication use for 3 of 3 residents reviewed. Other complaints were substantiated but had no deficiencies cited. The facility lacked a policy for obtaining informed consent for psychotropic medications and had incomplete consent documentation.
Deficiencies (1)
Failed to ensure signed consents for the use of psychotropic medications were obtained from the resident or resident's representative related to the risks and benefits of using psychotropic medications for 3 of 3 residents reviewed.
Report Facts
Census Bed Type - SNF/NF: 29
Census Bed Type - SNF: 25
Census Bed Type - Residential: 70
Total Census: 124
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 29
Deficiencies cited: 1
Inspection Report
Life Safety
Deficiencies: 0
Date: Aug 30, 2022
Visit Reason
The visit was a Post Survey Revisit (PSR) conducted on 08/19/22 for the Life Safety Code Recertification and State Licensure Survey originally conducted on 06/23/22.
Findings
Majestic Care of Carmel was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Re-Inspection
Census: 61
Capacity: 104
Deficiencies: 2
Date: Aug 19, 2022
Visit Reason
This was a Post Survey Revisit (PSR) to verify correction of deficiencies cited during the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted on 06/23/22.
Findings
At the Emergency Preparedness PSR, the facility was found in compliance with requirements. However, at the Life Safety Code PSR, the facility was found not in compliance due to deficiencies related to corridor doors not latching properly and the oxygen transfilling room door not being properly fire-resistive and not latching. Corrective actions were implemented including installation of new door closers and doors.
Deficiencies (2)
Facility failed to ensure all corridor doors had no impediment to closing and latching into the door frame and would resist the passage of smoke, affecting 3 staff.
Facility failed to ensure 1 of 1 oxygen transfilling rooms was separated from other areas in the facility in a room protected with a one-hour fire-resistive construction, affecting 25 residents in 3 smoke compartments.
Report Facts
Certified beds: 104
Census: 61
Affected staff: 3
Affected residents: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed regarding door deficiencies and corrective actions; acknowledged deficiencies and oversaw corrective actions |
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