A list of the most recent deficiencies for Majestic Care of Carmel. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-11-15 | 2023-12-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-15 | 2023-12-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-15 | 2023-12-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-15 | 2023-12-06 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-13 | 2023-08-18 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-05-19 | 2023-06-07 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-19 | 2023-06-07 | N |
| Provide activities to meet all resident's needs. | Health | 2023-05-19 | 2023-06-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-19 | 2023-06-07 | N |
| 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. | Health | 2023-05-19 | 2023-06-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-19 | 2023-06-07 | N |
| 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. | Health | 2023-05-19 | 2023-06-07 | N |
| 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. | Health | 2023-05-19 | 2023-06-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-19 | 2023-06-07 | Y |
| 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. | Health | 2022-10-20 | 2022-10-28 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-23 | 2022-08-30 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-06-23 | 2022-08-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Develop a communication plan. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-23 | 2022-08-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-25 | 2022-06-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-25 | 2022-06-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-25 | 2022-06-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-25 | 2022-06-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-05-25 | 2022-06-15 | N |
| 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. | Health | 2022-05-25 | 2022-06-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-25 | 2022-06-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-15 | 2022-03-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-14 | 2021-12-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-14 | 2021-12-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-14 | 2021-12-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-14 | 2021-12-28 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-30 | 2021-05-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-30 | 2021-05-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-04-30 | 2021-05-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-30 | 2021-05-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-04-30 | 2021-05-28 | N |
| 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. | Health | 2021-04-30 | 2021-05-28 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-04-30 | 2021-05-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-30 | 2021-05-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-04-30 | 2021-05-28 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-06 | 2021-05-27 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-05-06 | 2021-05-27 | N |
| Develop a communication plan. | Fire Safety | 2021-05-06 | 2021-05-27 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-05-06 | 2021-05-27 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-05-06 | 2021-05-27 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-05-06 | 2021-05-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-05-06 | 2021-05-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-05-06 | 2021-05-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-05-06 | 2021-05-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-05-06 | 2021-05-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-06 | 2021-05-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-06 | 2021-05-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-06 | 2021-05-27 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-05-06 | 2021-05-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-06 | 2021-05-27 | N |
