Majestic Care North Vernon: X-Ray Injury Risk Violation - IN
The resident she had X-rayed, identified in inspection records as Resident B, had lived with a severe contracture of her right arm for years, the lasting damage of a stroke. She also had osteoporosis. She needed two staff members just to get dressed or repositioned. She could not have helped an X-ray technician maneuver her arm into position. She would not have been able to.
What she could do, because she was cognitively intact, was feel pain. And if that contracted arm had been pulled, a nurse practitioner told inspectors, it could have caused her a great deal of it — or snapped the bone entirely.
The October 16 inspection at Majestic Care of North Vernon, a complaint investigation, found the facility had failed to protect Resident B from the foreseeable risk created when an outside contractor handled a medically fragile resident without any staff present, any staff notified, or any information passed along about what the resident needed. Federal inspectors rated the violation as causing actual harm.
Certified Nurse Aide 4 had been working at the facility the day the X-ray technician came in August. She told inspectors she was there when the tech arrived but was never asked to assist and never heard anyone else being asked either. She didn't know the technician had been in the resident's room until after the tech was already gone.
That, she said, was not how it was supposed to work.
In her experience, X-ray technicians who came to the facility would always ask for help. They would ask staff to explain what assistance the resident needed before they began. She had never seen a technician go into a room without that step. "She had never seen them go into a room blindly and complete an x-ray," the inspection report states. When the X-ray tech came to the facility, CNA 4 said, she would almost always go into the room and assist them herself.
Resident B, she told inspectors, would not have been able to assist the X-ray tech with an X-ray of her right arm. Not at all.
Nurse Practitioner 6 reviewed the case with inspectors on the morning of October 16. She confirmed she had reviewed the resident's X-ray results in October and had referred Resident B to see an orthopedic physician. The referral itself raises the question the inspection report leaves hanging: what did those X-ray results show that required an orthopedic consultation? The report does not say. What NP 6 did say was direct. If a resident had a contracture of the arm and the arm got pulled, it could put the resident in a lot of pain. It could even cause a fracture.
Resident B had osteoporosis. Bones weakened by that condition fracture under stresses that healthy bone absorbs. A contracted arm, already pulled tight by years of muscle and tissue changes following a stroke, is not a limb that tolerates careless handling. The combination, NP 6 told inspectors, meant that anything could happen.
The administrator, interviewed the same morning, acknowledged the facility had not provided the X-ray company with any training information. She said the contract with the X-ray company should include language requiring them to follow regulations, and that she was unsure what their training was. The X-ray company, she said, would handle and have records of their own training.
That contract existed. The administrator provided it to inspectors during the visit. A Portable Imaging and Diagnostic Testing Services Agreement, dated April 1, 2025, was on file. It ran to several paragraphs of compliance language. It committed both parties to following all applicable federal, state, and local laws and regulations. It described a Code of Conduct. It referenced policies to detect, address, and prevent fraud, waste, and abuse. It stated that the facility would educate all service provider employees and contractors who worked on matters related to the contract.
The X-ray technician's own company had a procedure manual. A regional president provided a portion of it to inspectors. That manual said plainly: if a resident must be transferred or significantly repositioned to perform the exam, facility staff must assist in the transfer or repositioning.
The manual said staff must assist. The contract said both parties committed to compliance. The aide who had worked there for years said technicians always asked for help and she always gave it.
In August, none of that happened. The technician went in. The technician left. CNA 4 found out after the fact.
What the inspection record does not resolve is whether Resident B was hurt during that August visit. The referral to an orthopedic physician came in October, after NP 6 reviewed X-ray results. The timeline is there in the report. The connection between them is not stated. The inspection was triggered by a complaint. The violation was rated as actual harm.
Resident B had survived a stroke. She had lived for years with the contracture that stroke left behind. She was, by the account of the aide who knew her care routine, someone who needed two people to help her with the most basic tasks — getting dressed, staying clean, shifting position in bed. She could feed herself some. She was aware of her surroundings. She was aware of pain.
The facility's contract with the imaging company was seven months old when inspectors arrived. The language about educating service provider employees was in there. The commitment to compliance was in there. What was not in place, on the day the technician came to X-ray a stroke survivor's contracted, osteoporotic arm, was another person in the room who knew what they were dealing with.
CNA 4 would have been there. She said so. The technicians always asked. This one didn't, or nobody made sure she did, or nobody made sure she knew she needed to.
Resident B's orthopedic referral was pending as of the inspection date.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Majestic Care of North Vernon from 2025-10-16 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
MAJESTIC CARE OF NORTH VERNON in NORTH VERNON, IN was cited for violations during a health inspection on October 16, 2025.
She needed two staff members just to get dressed or repositioned.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.