Inspection Reports for Majestic Care of Terre Haute
3150 N SEVENTH ST, IN, 47804
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Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Apr 30, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00456220.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00456220 found no deficiencies related to the allegations.
Report Facts
Census: 68
Total Capacity: 68
Medicare Census: 8
Medicaid Census: 54
Other Payor Census: 6
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 0
Feb 21, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00450840 and IN00453575 at Majestic Care of Terre Haute.
Findings
No deficiencies related to the allegations in complaints IN00450840 and IN00453575 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00450840 and IN00453575. Both complaints were found to have no deficiencies related to the allegations.
Report Facts
Census: 71
Total Capacity: 71
Medicare Census: 12
Medicaid Census: 48
Other Payor Census: 11
Inspection Report
Life Safety
Deficiencies: 0
Oct 8, 2024
Visit Reason
The survey was a Life Safety Code Recertification and State Licensure Survey conducted on 09/24/2024 and completed on 10/08/2024.
Findings
Majestic Care of Terre Haute 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 (LSC) and 410 IAC 16.2. The building was surveyed with Chapter 19, Existing Health Care Occupancies.
Inspection Report
Life Safety
Census: 62
Capacity: 104
Deficiencies: 2
Sep 24, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 Life Safety Code requirements.
Findings
The facility was found not in compliance with Life Safety Code requirements due to failure to maintain the fire alarm system with required semi-annual visual inspections and improper storage of an oxygen cylinder that was not properly secured. Corrective actions and plans of correction were requested.
Severity Breakdown
SS=F: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain 1 of 1 fire alarm systems with required semi-annual visual inspections as per NFPA 72. | SS=F |
| Failed to ensure 1 of 1 nonflammable gas cylinders were properly secured from falling; an 'E' type oxygen cylinder was found unsecured in resident room 112. | SS=D |
Report Facts
Certified beds: 104
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Sue McNamara-Baker | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Annual Inspection
Census: 70
Capacity: 70
Deficiencies: 7
Aug 29, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00437150.
Findings
The facility was found deficient in several areas including accuracy of Minimum Data Set (MDS) assessments, respiratory care and nebulizer treatment orders, pain management medication administration, pharmacy recommendation follow-up, medication labeling and storage, food preparation sanitation, and accurate documentation of peritoneal dialysis administration. No deficiencies were related to the complaint investigation.
Complaint Details
Complaint IN00437150 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
SS=A: 1
SS=D: 5
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure a Minimum Data Set (MDS) assessment was completed accurately for 1 of 21 residents. | SS=A |
| Failed to ensure proper storage of respiratory equipment and obtain physician orders for nebulizer treatments for 2 of 4 residents reviewed for respiratory care. | SS=D |
| Failed to follow physician orders for Lidocaine patch application for 1 of 4 residents observed for medication administration. | SS=D |
| Failed to ensure pharmacy recommendations were reviewed, addressed, and dated in a timely manner and failed to document rationale for pharmacy recommendations for 1 of 5 residents reviewed for unnecessary medications. | SS=D |
| Failed to ensure multi-dose bottle of eye drops and multi-dose vial of tuberculin solution were dated when opened for medication storage. | SS=D |
| Failed to ensure food was prepared in a sanitary manner during puree food preparation and beverage handling. | SS=E |
| Failed to accurately document medication administration for 1 of 1 resident reviewed for peritoneal dialysis; unlicensed staff documented administration without proper training. | SS=D |
Report Facts
Survey dates: 6
Census: 70
Total capacity: 70
Residents receiving antipsychotic medication: 1
Residents reviewed for respiratory care: 4
Residents observed for medication administration: 4
Residents reviewed for unnecessary medications: 5
Medication carts observed: 2
Residents affected by food preparation observation: 35
Peritoneal dialysis resident: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Sue McNamara-Baker | HFA | Laboratory Director or Provider/Supplier Representative who signed the report. |
| LPN 5 | Licensed Practical Nurse | Observed medication administration and discussed nebulizer and PD training. |
| Cook 11 | Observed during puree food preparation with hand hygiene and sanitation issues. | |
| Dietary Aide 10 | Observed handling lemonade with ungloved finger. | |
| Director of Nursing | DON | Provided interviews and facility policies, discussed deficiencies and corrective actions. |
| Executive Director | ED | Provided facility policies and interviewed regarding food safety and medication administration. |
Inspection Report
Renewal
Deficiencies: 0
Aug 29, 2024
Visit Reason
The inspection was a paper compliance review related to the Recertification and State Licensure Survey completed on August 29, 2024.
Findings
Majestic Care of Terre Haute was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
May 24, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00434033.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00434033 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 12
Medicaid census: 59
Other payor census: 7
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Jan 30, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00425665.
Findings
No deficiencies related to the allegations of Complaint IN00425665 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00425665 found no deficiencies related to the allegations.
Report Facts
Medicare census: 9
Medicaid census: 58
Other payor census: 7
Inspection Report
Re-Inspection
Census: 74
Capacity: 104
Deficiencies: 0
Aug 22, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 07/18/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility 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. The building was fully sprinklered with a fire alarm system and hard wired smoke detectors in all required areas.
Report Facts
Facility capacity: 104
Census: 74
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 0
Aug 8, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413947.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00413947 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 6
Medicaid residents: 54
Other payor residents: 13
Inspection Report
Life Safety
Census: 75
Capacity: 104
Deficiencies: 3
Jul 18, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with Life Safety Code requirements.
Findings
The facility was found not in compliance with Life Safety Code requirements due to deficiencies including a corridor door to a hazardous area failing to self-close and latch, lack of spare sidewall sprinklers in the sprinkler cabinet, and missing written records of weekly generator inspections for 2 of 52 weeks.
Severity Breakdown
SS=E: 1
SS=C: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Corridor door to Central Supply room failed to fully self-close and latch into the door frame. | SS=E |
| Sprinkler system was missing spare sidewall sprinklers in the spare sprinkler cabinet. | SS=C |
| Written record of weekly generator inspections was not maintained for 2 of 52 weeks. | SS=C |
Report Facts
Certified beds: 104
Census: 75
Deficiency count: 3
Weeks missing generator inspection records: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy McNamara Baker | HFA | Signed as Laboratory Director's or Provider/Supplier Representative's signature |
| Maintenance Director | Interviewed regarding door self-closing deficiency and sprinkler cabinet deficiency | |
| Executive Director | Interviewed and present during observations and exit conference |
Inspection Report
Renewal
Census: 73
Capacity: 73
Deficiencies: 6
Jun 30, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from June 26 to June 30, 2023.
Findings
The facility was found deficient in several areas including failure to provide a safe, clean, and homelike environment, incomplete investigation of resident-to-resident abuse allegations, improper respiratory care practices, inaccurate nurse staffing postings, improper medication labeling, and insufficient dietary support personnel.
Severity Breakdown
SS=D: 4
SS=A: 1
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure a resident was provided a comfortable and sanitary environment due to marked and scratched drywall in resident's room. | SS=D |
| Failure to ensure complete investigation of resident-to-resident abuse allegations for two residents. | SS=D |
| Failure to ensure proper storage of respiratory equipment and failure to obtain and follow physician orders for respiratory care for two residents. | SS=D |
| Failure to ensure accurate nurse staffing sheets were posted daily for one of five days during the survey. | SS=A |
| Failure to ensure proper labeling on a medication card for one resident, with medication label not reflecting current physician order. | SS=D |
| Failure to provide sufficient dietary support personnel in the kitchen, resulting in use of paper plates due to insufficient staff to wash dishes. | SS=E |
Report Facts
Census: 73
Total Capacity: 73
Medicare Census: 7
Medicaid Census: 62
Other Payor Census: 4
Survey Dates: 5
Medication Cards Reviewed: 7
Residents Receiving Food: 73
Staffing Posting Days Reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy McNamara Baker | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| LPN 12 | Licensed Practical Nurse | Named in medication administration and respiratory care findings |
| LPN 13 | Licensed Practical Nurse | Named in medication administration findings |
| LPN 14 | Licensed Practical Nurse | Named in respiratory care findings |
| Certified Nurse Aide 5 | CNA | Named in abuse investigation findings |
| Certified Nurse Aide 8 | CNA | Named in abuse investigation findings |
| Licensed Practical Nurse 7 | LPN | Named in abuse investigation findings |
| Licensed Practical Nurse 11 | LPN | Named in abuse investigation findings |
| Certified Nurse Aide 10 | CNA | Named in abuse investigation findings |
| Business Office Manager | BOM | Named in abuse investigation findings |
| Dietary Manager | DM | Named in dietary staffing findings |
| Registered Dietician Consultant | RD | Named in dietary staffing findings |
| Regional Nurse Consultant | Named in respiratory care and medication administration findings | |
| Administrator | Named in staffing posting findings and abuse investigation | |
| Executive Director | Named in abuse investigation and staffing posting findings | |
| Director of Nursing | DON | Named in abuse investigation findings |
Inspection Report
Renewal
Deficiencies: 0
Jun 30, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on June 30, 2023.
Findings
Majestic Care of Terre Haute was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 0
Mar 23, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00400245.
Findings
No deficiencies related to the allegations in Complaint IN00400245 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaint IN00400245. No deficiencies related to the allegations were cited.
Report Facts
Census: 73
Total Capacity: 73
Medicare Residents: 9
Medicaid Residents: 47
Other Payor Residents: 17
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 0
Mar 14, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00430370.
Findings
No deficiencies related to the allegations in Complaint IN00430370 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00430370 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 10
Medicaid residents: 57
Other residents: 10
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Jan 26, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00395344.
Findings
The complaint was found to be unsubstantiated due to lack of evidence, and the facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00395344 was investigated and found unsubstantiated due to lack of evidence.
Report Facts
Medicare residents: 15
Medicaid residents: 43
Other residents: 16
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