Majestic Care of Carmel

In the surveyor’s words

From the most serious findings on record at Majestic Care of Carmel, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Jul 30, 2024

  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. […]

• No harm, potential for more than minimal, patternF842Dec 14, 2021

  Based on interview and record review, the facility failed to ensure resident records had complete and accurate documentation for 5 of 5 residents reviewed for documentation in the medical record. (Residents C, D, E, F and B) Findings include: 1. During an interview, on December 13, 2021 at 4:58 p.m., Resident C indicated he did received bed baths twice a week. The record for Resident C was reviewed on December 13, 2021 at 1:31 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation found in the record to show resident had received bed baths or showers. […]

• No harm, potential for more than minimal, patternF880Dec 14, 2021

  Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures for infection control, to contain the spread of the Covid-19 virus, when the facility failed to ensure staff performed hand hygiene after touching face masks and failed to ensure staff were properly wearing Personal Protective Equipment for 6 of 6 randomly observed staff members. (LPN 1, CNA 2, Housekeeping Supervisor, Cook 8, CNA 6 and CNA 9) Findings include: 1. During a random observation, on December 13, 2021 at 8:20 a.m., LPN 1 was observed standing at the medication cart parked at the nursing station, her mask was observed to be worn under her chin. Her nose and mouth were not covered. […]

• No harm, potential for more than minimal, patternF758Apr 30, 2021

  Based on interview and record review, the facility failed to monitor for targeted behaviors and to provide non-pharmacological interventions for 4 of 5 residents reviewed for unnecessary medications (Resident 17, 23, 20 and 21). Findings include: 1. The record for Resident 17 was reviewed on 04/27/2021 at 2:45 p.m. Diagnoses include, but were not limited to, heart failure, depressive disorder and anxiety. A physician's order, dated 03/19/2021, indicated to give [MEDICATION(S)] delayed release 60 mg (milligrams) once daily for depression. A physician's order, dated 03/18/2021, indicated to give Trazadone 150 mg once daily for sleep. A physician's order, dated 03/18/2021, indicated to give [MEDICATION(S)] 10 mg twice daily for anxiety. […]

• No harm, potential for more than minimal, isolatedF628Jul 28, 2025

  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. […]