Inspection Reports for
Majestic Care of Terre Haute
3150 N SEVENTH ST, TERRE HAUTE, IN, 47804
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
12.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
202% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
100% occupied
Based on a April 2025 inspection.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 7
Date: Sep 11, 2025
Visit Reason
Routine inspection to assess compliance with regulations regarding resident care, wound management, catheter care, respiratory care, medication storage and administration, and food safety.
Findings
The facility was found deficient in providing adequate assistance with activities of daily living including fingernail care and shaving, proper wound care and hand hygiene during dressing changes, timely documentation and reporting of catheter issues, appropriate cleaning and storage of respiratory equipment, secure and dated medication storage, proper food labeling and hair restraint use in the kitchen, and accurate medication administration documentation.
Deficiencies (7)
F 0677: Facility failed to provide fingernail care and shaving assistance to residents requiring ADL help, with lack of documentation of refusals or care provided.
F 0686: Pressure ulcer dressing changes were performed without appropriate hand hygiene and supplies were placed without barriers; pressure ulcers were not accurately staged or promptly reported to physicians.
F 0690: Facility failed to ensure timely documentation and reporting of change in condition related to a suprapubic catheter that was not draining.
F 0695: Respiratory equipment was observed unbagged and not stored properly after use, increasing risk of contamination.
F 0761: Medications were left unattended at the nurses' station and multi-dose vials were not dated when opened.
F 0812: Expired foods were found in dry storage and unlabeled leftovers were stored in the walk-in refrigerator; facial hair was not properly restrained in the kitchen.
F 0842: Medication administration records lacked documentation of administered doses for multiple medications without documented refusals or reasons.
Report Facts
Residents reviewed for ADLs: 24
Residents affected by fingernail/shaving care deficiency: 4
Residents reviewed for pressure ulcers: 4
Residents affected by pressure ulcer care deficiency: 2
Residents reviewed for catheter care: 1
Residents reviewed for respiratory care: 1
Residents affected by medication storage deficiency: 2
Residents affected by food safety deficiency: 68
Residents reviewed for medication administration: 5
Residents affected by medication administration documentation deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding ADL care refusals, wound care policies, catheter care, respiratory care, and medication administration. |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding resident refusals of care. |
| Licensed Practical Nurse 5 | Licensed Practical Nurse (LPN) 5 | Interviewed regarding fingernail care and medication storage. |
| Certified Nursing Assistant 11 | Certified Nursing Assistant (CNA) 11 | Observed assisting with wound care and interviewed regarding shaving residents. |
| Wound Nurse | Wound Nurse | Observed performing wound dressing changes and interviewed regarding wound care procedures. |
| Administrator | Administrator | Provided facility policies and interviewed regarding food safety and medication storage. |
| Registered Nurse 8 | Registered Nurse (RN) 8 | Interviewed regarding medication cart security. |
| Certified Nurse Aide 7 | Certified Nurse Aide (CNA) 7 | Interviewed regarding catheter care reporting. |
| Licensed Practical Nurse 10 | Licensed Practical Nurse (LPN) 10 | Interviewed regarding respiratory care and nebulizer cleaning. |
| Dietary Manager | Dietary Manager | Interviewed regarding hair restraint policy in kitchen. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 25, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of neglect involving Resident B, who was found deceased after not receiving adequate monitoring and care for 8 hours.
Complaint Details
This citation relates to Complaint 2571065. The complaint was substantiated based on evidence that Resident B was neglected for 8 hours without monitoring or care, leading to death.
Findings
The facility failed to protect Resident B from neglect by not providing monitoring or care for an 8-hour period, resulting in the resident being found deceased. Staff statements about care frequency were contradicted by family-installed motion sensor video footage, and several staff members were suspended pending investigation.
Deficiencies (1)
F 0600: The facility failed to protect residents from neglect by not providing adequate monitoring and care to Resident B for 8 hours, resulting in the resident's death. Staff documentation and statements were inconsistent with video evidence showing lack of care.
Report Facts
Duration of neglect: 8
Residents reviewed for neglect: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 6 | Registered Nurse | Found Resident B deceased and was suspended pending investigation |
| CNA 4 | Certified Nurse's Aide | Worked evening and night shifts, completed bed checks, no longer employed as of investigation |
| CNA 8 | Certified Nurse's Aide | Suspended pending investigation |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Date: Apr 30, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00456220.
Complaint Details
Investigation of Complaint IN00456220 found no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
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
Date: Feb 21, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00450840 and IN00453575 at Majestic Care of Terre Haute.
Complaint Details
Investigation of Complaints IN00450840 and IN00453575. Both complaints were found to have no deficiencies related to the allegations.
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.
Report Facts
Census: 71
Total Capacity: 71
Medicare Census: 12
Medicaid Census: 48
Other Payor Census: 11
Inspection Report
Life Safety
Deficiencies: 0
Date: 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
Date: 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.
Deficiencies (2)
Failure to maintain 1 of 1 fire alarm systems with required semi-annual visual inspections as per NFPA 72.
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.
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
Deficiencies: 6
Date: Aug 29, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare regulations and standards at Majestic Care of Terre Haute.
Findings
The facility was found to have multiple deficiencies including failure to ensure proper respiratory care and physician orders for nebulizer treatments, improper medication administration and documentation, failure to address pharmacy recommendations timely, improper labeling and storage of medications, unsanitary food preparation practices, and inaccurate documentation of peritoneal dialysis treatments.
Deficiencies (6)
F 0695: The facility failed to ensure proper storage of respiratory equipment and obtain physician orders for nebulizer treatments for 2 of 4 residents reviewed.
F 0697: The facility failed to follow physician orders for medication administration for 1 of 4 residents observed, including improper handling of Lidocaine patches.
F 0757: The facility failed to ensure pharmacy recommendations were reviewed, addressed, and documented in a timely manner for 1 of 5 residents reviewed for unnecessary medications.
F 0761: The facility failed to ensure multi-dose bottles and vials were dated when opened for medication storage for 1 of 2 medication carts and 1 medication room observed.
F 0812: The facility failed to ensure food was prepared in a sanitary manner during kitchen observations, risking cross-contamination and improper hand hygiene.
F 0842: The facility failed to accurately document medication administration for 1 of 1 resident reviewed for peritoneal dialysis, including documentation by untrained staff and improper login use.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 35
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 3 | LPN | Indicated no nebulizer treatment was given due to lack of physician order |
| Licensed Practical Nurse 5 | LPN | Observed medication administration and discussed peritoneal dialysis training |
| Director of Nursing | DON | Provided interviews regarding nebulizer treatments, pharmacy recommendations, medication storage, and documentation issues |
| Executive Director | ED | Provided facility policies related to medication administration and oxygen administration |
| Qualified Medication Aide 8 | QMA | Reported administering nebulizer treatment without physician order |
| Dietary Manager | Provided interviews and policies regarding food preparation and hand hygiene | |
| Qualified Medication Aide 12 | QMA | Reported not trained to administer peritoneal dialysis |
| Qualified Medication Aide 15 | QMA | Reported on peritoneal dialysis administration and documentation issues |
| Social Service Director | SSD | Discussed pharmacy recommendation response delays |
Inspection Report
Annual Inspection
Census: 70
Capacity: 70
Deficiencies: 7
Date: Aug 29, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00437150.
Complaint Details
Complaint IN00437150 was investigated and no deficiencies related to the allegations were cited.
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.
Deficiencies (7)
Failed to ensure a Minimum Data Set (MDS) assessment was completed accurately for 1 of 21 residents.
Failed to ensure proper storage of respiratory equipment and obtain physician orders for nebulizer treatments for 2 of 4 residents reviewed for respiratory care.
Failed to follow physician orders for Lidocaine patch application for 1 of 4 residents observed for medication administration.
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.
Failed to ensure multi-dose bottle of eye drops and multi-dose vial of tuberculin solution were dated when opened for medication storage.
Failed to ensure food was prepared in a sanitary manner during puree food preparation and beverage handling.
Failed to accurately document medication administration for 1 of 1 resident reviewed for peritoneal dialysis; unlicensed staff documented administration without proper training.
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
Date: 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
Date: May 24, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00434033.
Complaint Details
Complaint IN00434033 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 12
Medicaid census: 59
Other payor census: 7
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Date: Jan 30, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00425665.
Complaint Details
Investigation of Complaint IN00425665 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations of Complaint IN00425665 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 9
Medicaid census: 58
Other payor census: 7
Inspection Report
Re-Inspection
Census: 74
Capacity: 104
Deficiencies: 0
Date: 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
Date: Aug 8, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413947.
Complaint Details
Complaint IN00413947 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 6
Medicaid residents: 54
Other payor residents: 13
Inspection Report
Life Safety
Census: 75
Capacity: 104
Deficiencies: 3
Date: 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.
Deficiencies (3)
Corridor door to Central Supply room failed to fully self-close and latch into the door frame.
Sprinkler system was missing spare sidewall sprinklers in the spare sprinkler cabinet.
Written record of weekly generator inspections was not maintained for 2 of 52 weeks.
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
Annual Inspection
Deficiencies: 6
Date: Jun 30, 2023
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including environmental maintenance, incomplete investigation of resident-to-resident abuse allegations, improper respiratory equipment storage and oxygen order compliance, inaccurate staffing reporting, medication labeling errors, and insufficient dietary staffing.
Deficiencies (6)
F 0584: The facility failed to provide a comfortable and sanitary environment for 1 of 24 residents, with a bed placed too close to a damaged wall that was not repaired or painted as required.
F 0610: The facility failed to ensure a complete investigation of a resident-to-resident abuse allegation involving 2 residents, with multiple staff not interviewed and incomplete follow-up documentation.
F 0695: The facility failed to properly store respiratory equipment and failed to obtain and follow physician orders for oxygen therapy for 2 residents, including unbagged nebulizer equipment and oxygen tubing without dates.
F 0725: The facility failed to accurately report weekend staffing hours in the payroll-based journal for 1 of 2 quarters reviewed, resulting in low reported staffing and a 1-star rating.
F 0761: The facility failed to ensure proper labeling on a medication card for 1 of 7 residents, with outdated dosage instructions not corrected after a medication order change.
F 0802: The facility failed to provide sufficient dietary support personnel in the kitchen for 72 of 73 residents during 1 week, resulting in use of paper plates due to inadequate staff to wash dishes.
Report Facts
Residents reviewed for home-like environment: 24
Residents reviewed for abuse allegations: 2
Residents reviewed for respiratory care: 2
Residents reviewed for medication administration: 7
Residents receiving food from kitchen: 73
Staffing quarters reviewed: 2
Inspection Report
Renewal
Census: 73
Capacity: 73
Deficiencies: 6
Date: 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.
Deficiencies (6)
Failure to ensure a resident was provided a comfortable and sanitary environment due to marked and scratched drywall in resident's room.
Failure to ensure complete investigation of resident-to-resident abuse allegations for two residents.
Failure to ensure proper storage of respiratory equipment and failure to obtain and follow physician orders for respiratory care for two residents.
Failure to ensure accurate nurse staffing sheets were posted daily for one of five days during the survey.
Failure to ensure proper labeling on a medication card for one resident, with medication label not reflecting current physician order.
Failure to provide sufficient dietary support personnel in the kitchen, resulting in use of paper plates due to insufficient staff to wash dishes.
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
Date: 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
Date: Mar 23, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00400245.
Complaint Details
Investigation of Complaint IN00400245. No deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in Complaint IN00400245 were cited. The facility was found to be in compliance with relevant regulations.
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
Date: Mar 14, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00430370.
Complaint Details
Complaint IN00430370 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00430370 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 10
Medicaid residents: 57
Other residents: 10
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Date: Jan 26, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00395344.
Complaint Details
Complaint IN00395344 was investigated and found unsubstantiated due to lack of evidence.
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.
Report Facts
Medicare residents: 15
Medicaid residents: 43
Other residents: 16
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