Cycle 1
Health 2025-07-28 · Fire 2025-07-28
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Carmel, IN
Majestic Care Of Carmel
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
12999 N Pennsylvania St, Carmel, IN
(317) 848-2448
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
94
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Majestic Care
Operator or chain grouping
Approved since
1997-01-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 3 overall / 2 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.63
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.05
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.09
CMS adjusted total nurse staffing hours
Case-mix index
1.61
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,548
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9871
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.25
Baseline 18.67% · Performance 19.46% · Measure score 4.25 · Achievement 4.25 · Improvement 0
Healthcare-associated infections
3.48
Baseline 7.34% · Performance 6.79% · Measure score 3.48 · Achievement 3.48 · Improvement 1.83
Total nurse turnover
5.28
Performance 42.10% · Measure score 5.28 · Achievement 5.28 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.37 hours · Performance 2.90 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.21% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 116 · Observed rate 6.03% · Lower 95% interval 6.25% |
| Discharge to community | 42.74% |
50.57%
7.8 pts worse
|
No Different than the National Rate · Eligible stays 104 · Observed rate 36.54% · Lower 95% interval 34.79% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 96.83% |
95.27%
1.6 pts better
|
Numerator 61 · Denominator 63 |
| Falls with major injury | 1.59% |
0.77%
0.8 pts worse
|
Numerator 1 · Denominator 63 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 28 · Denominator 42 |
| Discharge mobility score | 59.52% |
50.94%
8.6 pts better
|
Numerator 25 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 3.17% |
2.29%
0.9 pts worse
|
Numerator 2 · Denominator 63 · Adjusted rate 2.95% |
| Healthcare-associated infections requiring hospitalization | 6.79% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 4.92% · Lower 95% interval 3.63% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 43 |
| Staff flu vaccination coverage | 17.5% |
42%
24.5 pts worse
|
Numerator 7 · Denominator 40 |
| Discharge function score | 61.9% |
56.45%
5.4 pts better
|
Numerator 26 · Denominator 42 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 37 · Denominator 37 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 15.79% |
25.2%
9.4 pts worse
|
Numerator 6 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.6
0.6 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.2 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.5
1.2 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.7% |
93.6%
7.9 pts worse
|
93.4%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 57.1% · Q2 89.5% · Q3 97.5% · Q4 95.1% · 4Q avg 85.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.9% |
95.4%
0.5 pts worse
|
95.5%
0.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.4% |
3.8%
4.6 pts worse
|
3.3%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.3% · Q3 10.0% · Q4 14.6% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 97.9% |
24.6%
73.3 pts worse
|
11.4%
86.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 94.4% · Q3 100.0% · Q4 97.3% · 4Q avg 97.9% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
5.6%
2.5 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.8% |
23.5%
4.3 pts worse
|
19.6%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 29.0% · Q3 29.7% · Q4 25.7% · 4Q avg 27.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.5% |
14.8%
4.7 pts worse
|
16.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 25.0% · Q3 18.2% · Q4 10.3% · 4Q avg 19.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.8% |
13.3%
5.5 pts better
|
16.3%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 18.3% · Q4 4.3% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.5% |
11.7%
6.2 pts better
|
14.9%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.9% · Q3 8.3% · Q4 0.0% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.2%
0.5 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.2% |
24.2%
1 pts worse
|
19.8%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 28.0% · Q3 21.6% · Q4 25.3% · 4Q avg 25.2% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
4.1%
1.9 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 7.9% · Q3 7.1% · Q4 3.0% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 38.5% |
81.6%
43.1 pts worse
|
81.7%
43.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 39.7% · Q2 28.8% · Q3 50.0% · Q4 37.3% · 4Q avg 38.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.7% |
10.5%
10.2 pts worse
|
12.0%
8.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 20.7% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.3% |
79.0%
18.7 pts worse
|
79.7%
19.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.8% |
22.4%
3.4 pts worse
|
23.9%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 24.1% · Expected 22.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-30 · Fire 2024-07-30
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-05-19 · Fire 2023-05-19
13 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-28
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2026-01-09
F · Potential for more than minimal harm
2025-07-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-09
E · Potential for more than minimal harm
2024-07-30
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-09-03
E · Potential for more than minimal harm
2024-07-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-03
F · Potential for more than minimal harm
2023-05-19
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-08-02
F · Potential for more than minimal harm
2023-05-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-02
F · Potential for more than minimal harm
2023-05-19
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-08-02
F · Potential for more than minimal harm
2023-05-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-02
F · Potential for more than minimal harm
2023-05-19
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-08-02
E · Potential for more than minimal harm
2023-05-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-05-19
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-08-02
E · Potential for more than minimal harm
2023-05-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-02
E · Potential for more than minimal harm
2023-05-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-18
C · Minimal harm
2023-05-19
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-08-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-28
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-20
D · Potential for more than minimal harm
2025-07-28
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-08-20
D · Potential for more than minimal harm
2025-07-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-20
D · Potential for more than minimal harm
2025-07-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-08-20
D · Potential for more than minimal harm
2025-07-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-20
E · Potential for more than minimal harm
2024-07-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-30
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-30
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-08-26
D · Potential for more than minimal harm
2023-11-15
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-11-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-11-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-11-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-05-19
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-05-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-05-19
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-05-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-05-19
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-05-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-05-19
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-05-19
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-05-19
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-06-07
Penalties and ownership
What sits behind the stars
Ownership
Pulaski Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Barry, Thomas
Corporate Officer · Individual
Malott, Gregg
Corporate Officer · Individual
Smith, Todd
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Wellbrooke Of Carmel
Carmel, IN
3-star overall rating with 2-star inspections with $15,646 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Barrington Of Carmel, The
Carmel, IN
5-star overall rating with 5-star inspections
#3
Restoracy Of Carmel
Carmel, IN
4-star overall rating with 3-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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