Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Majestic Care Of Terre Haute during CMS and state inspections, most recent first.
A resident with cognitive limitations and psychiatric diagnoses required staff assistance with ADLs, including bathing and hygiene, but facility records showed long gaps without documented baths, limited shower documentation, and no specific care plan for refusal of care despite later evidence of care rejection. Surveyors observed the resident with disheveled hair and food-stained clothing, while skin assessments from the facility inconsistently documented issues, noting only intermittent redness under the breasts. Upon admission to a behavioral center, the resident was found wearing a tight lace bralette that had to be cut off, with bilateral under-breast areas excoriated and seeping green-yellow pus, and additional pressure-related and skin-tear findings. Interviews with CNAs, an LPN, the DON, the administrator, the behavioral center director, and the resident’s POA revealed inconsistent accounts of bathing, lack of documented partial baths, absence of documented family notification of refusals, and no routine discharge skin assessment, despite facility policies requiring necessary ADL services and timely recognition and treatment of impaired skin integrity.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility failed to maintain sanitary conditions during food preparation, affecting 35-38 residents. Staff did not follow hand hygiene protocols, leading to potential cross-contamination during the preparation of pureed food and lemonade. The Dietary Manager confirmed the breach of policy, as staff used bare hands inappropriately and did not perform hand hygiene between tasks.
The facility failed to properly store respiratory equipment and administer nebulizer treatments without physician orders for two residents. One resident continued receiving treatments after the order was discontinued, and another had a nebulizer at the bedside without an order. The facility's policies on medication and oxygen administration were not followed, leading to these deficiencies.
A facility failed to follow physician orders for a resident's pain management. An LPN removed an undated Lidocaine patch from a resident's back, which should have been removed the previous night according to the physician's order. The resident, with osteoporosis and moderate cognitive impairment, was to have the patch on for 12 hours and off for 12 hours. The facility's policy required adherence to physician orders, which was not followed in this case.
A facility failed to ensure timely review and documentation of pharmacy recommendations for a resident with multiple chronic conditions. Recommendations to adjust or discontinue medications were not addressed by the physician in a timely manner, leading to a deficiency. Interviews revealed awareness of delays in physician responses, contrary to facility policy.
The facility failed to date a multi-dose bottle of Latanoprost eye drops and a vial of Tuberculin solution upon opening, as required by policy. An LPN acknowledged the oversight, and the DON confirmed the medications' limited effectiveness post-opening. This deficiency was observed during a review of medication storage and administration practices.
A resident with chronic kidney disease stage 5, dependent on renal dialysis, had inaccurate documentation of peritoneal dialysis (PD) administration. QMAs, not trained to administer PD, were documented as having done so. Interviews revealed that nurses were responsible for setting up and documenting PD, but errors occurred due to computers being logged in under QMA credentials. The facility's policy required medications to be administered by authorized personnel, highlighting a breach in documentation practices.
Failure to Provide Consistent ADL Care and Skin Assessment for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, prevent, and treat skin conditions and to provide consistent ADL care, including bathing and hygiene, for one resident. The resident had multiple psychiatric diagnoses, cognitive limitations, and required staff assistance with ADLs per repeated MDS assessments and care plans. Care plans identified the need for assistance with bathing, dressing, and personal hygiene, and noted delusional thinking with an intervention to postpone and re-approach care if the resident became combative or resistive. However, the medical record lacked a specific care plan and interventions addressing refusal of care, despite a discharge MDS later indicating that the resident had exhibited rejection of care 1 to 3 times during the assessment period. Surveyors’ review of skin assessments showed multiple entries documenting no skin issues on several dates, with one assessment on 1/9/26 noting a right wrist skin issue and another on 2/4/26 noting redness under the breasts. A nursing admission assessment on 2/4/26 also documented redness under the breasts and the need for physical assistance with bathing. Shower sheets provided by the DON showed a shower on 1/16/26 and refusals on 1/20/26 and 1/23/26, but no other showers documented during that period. Point-of-care (POC) documentation indicated the resident was not provided a bath from 1/17/26 through 1/27/26, aside from the two documented refusals. The medical record lacked nursing or social services documentation of shower or bathing refusals and lacked documentation of family notification regarding such refusals. When the resident was observed by surveyors on 2/4/26, she was alert, answered questions appropriately, and reported having had a shower the previous evening, but her hair was uncombed and disheveled and her clothing was stained with food. Interviews with CNAs revealed inconsistent accounts: one CNA stated the resident did not refuse showers if given before dark and that skin issues would be reported and documented; another CNA stated the last shower was on 1/16/26 and that the resident often would not allow staff to change her, sometimes allowing only one person to assist. A CNA who cared for the resident on the day of transfer to a behavioral center reported giving a partial bath and removing the bra, noting only some redness under the breasts, but this partial bath was not documented in the record. At the behavioral center, an admission skin assessment documented that the resident arrived wearing a tight lace bralette that had to be cut off because it was too tight and appeared to cut into the skin under the breasts. The garment was saturated with green and yellow pus and had a foul odor, and the bilateral under-breast areas were described as excoriated, seeping yellow-green pus, and requiring cleansing and dressings. The behavioral center also documented a stage 1 deep tissue injury to a heel and a skin tear to a toe. The behavioral center’s director reported that they did not contact the originating facility about these concerns but did notify the resident’s POA. The POA later reported being told that the bra had to be cut off and that the resident had a rash under the breasts, and also stated she had not been informed by the facility of any refusal of showers or baths. The facility’s own policies on ADLs and wound management required necessary services to maintain hygiene and timely recognition and treatment of impaired skin integrity, but the documentation and interviews showed gaps in bathing provision, skin assessment prior to discharge, and care planning for refusal of care. Additional interviews with facility staff further highlighted the lack of consistent skin assessment and documentation. An LPN who sent the resident out reported only bruising to the right arm and “a little redness” under the breasts and stated she was not aware of other skin issues. The DON stated she did not believe there was a policy to perform a skin assessment prior to discharge and that she would not normally do one, and indicated the facility relied on weekly skin checks and monthly skin sweeps. At the time of the survey interview, the DON stated the resident did not have any skin issues. The administrator stated that if a resident refused a shower, the facility would contact the family and attempt multiple times to provide bathing, but the record did not contain documentation of such contacts or repeated attempts for this resident. These combined observations, record reviews, and interviews formed the basis for the cited failure to provide appropriate treatment and care according to orders, and to adequately assess, prevent, and treat the resident’s skin conditions and daily care needs.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Sanitation Deficiency in Food Preparation
Penalty
Summary
The facility failed to ensure food was prepared in a sanitary manner during a kitchen observation, which had the potential to affect 35-38 residents. During the preparation of pureed food, a staff member washed her hands for less than 20 seconds and proceeded to handle food and utensils without performing additional hand hygiene. She used a wet spatula to transfer pureed vegetables, which could lead to cross-contamination. The staff member also dried a container with a paper towel instead of allowing it to air dry, which is against the facility's policy. Additionally, another staff member, a dietary aide, was observed preparing lemonade and used his ungloved finger to remove a particle from the inside of a pitcher, contaminating the lemonade. The Dietary Manager confirmed that staff should not touch the inside of drink pitchers with ungloved hands and acknowledged the cross-contamination risk. The facility's policies on hand hygiene and food production were not followed, as staff did not perform hand hygiene when moving between clean and dirty tasks, and bare hands were used inappropriately during food preparation.
Failure to Ensure Proper Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment and did not obtain a physician order for nebulizer treatments for two residents. Resident 22's nebulizer mouthpiece and tubing were found unbagged on the resident's side table with a clear liquid in the medication chamber, and the nebulizer machine was on the bed. The resident's record indicated a diagnosis of chronic obstructive pulmonary disease (COPD) and acute respiratory failure with hypoxia. Although a physician order for nebulizer treatment was discontinued on 8/21/24, the resident continued to receive treatments without a current order, as confirmed by interviews with the resident, a Qualified Medication Aide (QMA), and the Director of Nursing (DON). Similarly, Resident 4's nebulizer unit was observed unbagged on the bedside table during multiple observations. The resident, diagnosed with COPD, indicated she had as-needed breathing treatments, but the record lacked documentation of any physician order for nebulizer treatments. Interviews revealed that the resident had a PRN inhaler but rarely requested it, and a nebulizer treatment was administered without a documented order. The DON confirmed the absence of an order and stated that nebulizer equipment should not be at the bedside without one. The facility's policies on medication and oxygen administration were reviewed, indicating that medications should be administered as ordered by the physician and that delivery devices should be covered in a plastic bag when not in use. The Executive Director provided these policies, which were dated 12/12/23, but the facility failed to adhere to them, resulting in the deficiencies observed during the survey.
Failure to Follow Physician Orders for Pain Management
Penalty
Summary
The facility failed to follow physician orders for a resident requiring pain management, specifically in the administration of a Lidocaine patch. During a medication pass observation, an LPN was seen removing an undated Lidocaine patch from a resident's back before applying a new one. The removed patch should have been taken off the previous night, as the physician's order specified that the patch should be on for 12 hours and then off for 12 hours. The LPN confirmed that the patch was not labeled or dated, and the medication administration record (MAR) lacked a section to document the removal of patches. The resident involved had a diagnosis of osteoporosis and pain, with a moderate cognitive impairment as indicated by a BIMS score of 12. The physician's order, dated a few days prior, instructed the application of a Lidocaine 5% patch to the resident's lower back daily, every morning for pain management. The facility's medication administration policy required medications to be administered as ordered by the physician and in accordance with professional standards, which was not adhered to in this instance.
Failure to Address Pharmacy Recommendations Timely
Penalty
Summary
The facility failed to ensure timely review and documentation of pharmacy recommendations for Resident 45, who had multiple chronic conditions including type 2 diabetes, COPD, chronic diastolic congestive heart failure, and end-stage renal disease. The resident's medication regimen included insulin, anti-depressants, anti-coagulants, diuretics, and opioids. Several pharmacy recommendations were made to adjust or discontinue medications due to potential contraindications or the need for lab monitoring, but these were not addressed or documented by the physician in a timely manner. Specifically, recommendations to reduce the dose of midodrine and discontinue Hiprex due to renal impairment were not signed or addressed by the physician. Additionally, recommendations for lab work related to several medications were not acted upon promptly. A recommendation to reduce the dose of Protonix was eventually signed and acted upon, but only after a significant delay. Similarly, a recommendation to discontinue Cymbalta was delayed, despite a behavior meeting indicating the need for a gradual dose reduction. Interviews with the Director of Nursing and Social Service Director revealed awareness of delays in physician responses to pharmacy recommendations. The facility's policy required provider intervention within a specified timeframe, but this was not adhered to, leading to the deficiency. The lack of timely action and documentation regarding pharmacy recommendations for Resident 45's medication regimen highlights the facility's failure to ensure the resident's drug regimen was free from unnecessary medications.
Failure to Date Opened Medications
Penalty
Summary
The facility failed to ensure that a multi-dose bottle of Latanoprost eye drops and a multi-dose vial of Tuberculin solution were dated when opened, which is a requirement for proper medication management. During an observation, it was noted that the medication cart contained an opened but undated bottle of Latanoprost eye drops for a resident diagnosed with glaucoma. The LPN acknowledged that both the bottle and container should be dated upon opening. The Director of Nursing confirmed that the Latanoprost eye drops are only effective for six weeks after opening, highlighting the importance of proper labeling. Additionally, a multi-dose vial of Tuberculin solution was found in the medication storage room refrigerator without an opening date. The LPN mentioned that the box is usually dated when opened, but was unsure of the vial's opening date. The Director of Nursing indicated that the Tuberculin solution is only viable for 30 days after opening. Facility policies require that multi-dose vials be labeled with the date they are opened and discarded within 28 days unless specified otherwise by the manufacturer. The failure to date these medications upon opening is a deviation from the facility's medication administration and drug expiration dating policies.
Inaccurate Documentation of Peritoneal Dialysis Administration
Penalty
Summary
The facility failed to accurately document medication administration for a resident undergoing peritoneal dialysis (PD). The resident, who had chronic kidney disease stage 5 and was dependent on renal dialysis, had a physician's order to receive PD treatment at bedtime. However, the Medication Administration Records (MAR) for June and July 2024 showed that Qualified Medication Aides (QMAs) documented the administration of PD, despite not being trained or certified to do so. Interviews revealed that QMAs were not allowed to administer PD, and it was the responsibility of the nurse to set up and document the procedure. The documentation errors were attributed to the possibility of nurses using computers logged in under QMA credentials, leading to incorrect documentation. The Director of Nursing and the Unit Manager acknowledged that staff should not leave computers logged in and that documentation should not be done under someone else's login. The facility's policy stated that medications should be administered by licensed nurses or authorized staff, but the documentation errors indicated a breach of this policy. The Executive Director provided a policy document that emphasized the need for medications to be administered by authorized personnel to prevent contamination or infection. The report highlights the need for proper documentation practices and adherence to professional standards in medication administration.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Terre Haute
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harrison's Crossing Health Campus | 1.4 mi | — | 2 | 0 |
| Signature Healthcare Of Terre Haute | 2.2 mi | — | 18 | 0 |
| Majestic Care Of Deming Park | 3.6 mi | — | 4 | 2 |
| Providence Health Care Center | 3.6 mi | — | 1 | 0 |
| Westridge Health Care Center | 5 mi | — | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.