Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 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.
Expired and moldy bread was found in dry storage, and multiple leftover items in the walk-in refrigerator lacked required prep and discard dates. During food prep, a cook with a full beard and mustache wore a beard restraint and hair net that did not fully cover his facial hair or the back of his head while making sandwiches for residents.
Failure to provide nail care and shaving during ADL care. Several residents who needed assistance were observed with long fingernails, debris under the nails, chipped nail polish, and heavy beard growth. Records and shower documentation did not show that nail care was offered, provided, or refused, and staff interviews confirmed that grooming care was expected on shower days and as needed.
A wound nurse was observed performing dressing changes for two residents without proper hand hygiene and with supplies placed directly on resident surfaces without a barrier. One resident had a coccyx pressure ulcer that was documented as stage 2 before later worsening to stage 3, but the wound was not accurately restaged when slough appeared and physician notification of the deterioration was not documented. The other resident had a stage 4 hip wound, and the DON stated a barrier should have been used and handwashing should have occurred between wound treatments.
Failure to document and report a change in condition for a resident with a suprapubic catheter. A resident with DM2, urinary retention, depression, and neurogenic bladder was observed with a catheter that was not draining and was leaking, with no urine seen in the tubing or bag. The next day, the resident was again wet with an empty catheter bag, while RN staff said they had not been informed of the issue. The DON acknowledged the resident had a long-standing catheter issue and that CNA documentation should only reflect actual catheter output.
Nebulizer equipment for a resident with dementia and COPD was observed unbagged and left next to the bedside table on multiple occasions, and the nebulizer mask and tubing were later seen lying in the resident’s bed. The resident had orders for nebulizer treatments, was assessed after treatment per the MAR, and the facility policy stated delivery devices were to be kept covered in a plastic bag when not in use.
Medication Storage and Labeling Deficiencies: Unattended medications for a resident were observed left on the nurses' station counter after the resident was discharged, and an LPN stated they should have been in the pharmacy. An RN stated the med cart and computer screen must be locked when unattended. An opened vial of Aplisol in the pharmacy med room was also observed without a date opened, despite policy requiring drugs and biologicals to be stored in locked compartments and multi-dose vials to be dated when opened.
Missing MAR Documentation for Ordered Medications: A resident with DM2 and hypothyroidism had multiple ordered medications, including insulin glargine, insulin aspart, gabapentin, and levothyroxine, that were not documented as administered on the MAR on several occasions. The record also lacked any documentation of refusal or unavailability, and the DON stated medications should be given as scheduled and signed on the MAR after administration.
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.
Expired Food, Improper Labeling, and Inadequate Hair Restraints in Dietary Area
Penalty
Summary
The facility failed to ensure expired and moldy foods were removed from storage and failed to ensure refrigerated leftovers were properly labeled with preparation and discard dates. During a kitchen observation, an unopened package of hamburger buns was moldy, an entire loaf of French bread contained mold, and several packages of sliced raisin bread had a use-by date of 8/29/25. In the walk-in refrigerator, a container of cooked spiral pasta, a metal container of mashed potatoes, a metal container of chicken noodle soup, and a sheet pan of leftover garlic bread did not have labels showing a prepared date or use-by date. The Dietary Manager stated that leftover food was good for 3 days and then should be discarded, and that all food should be labeled with a prepared date and a use-by date. The facility also failed to ensure a cook’s facial hair and head hair were fully covered during food preparation. During a second kitchen observation, the cook entered the kitchen, washed his hands, and began making ham and cheese sandwiches for 4 residents while wearing a beard restraint that did not cover the sides of his beard or his mustache, and his hair net did not cover the entire back side of his head. The Dietary Manager stated that all facial hair should be covered with beard restraints. The facility policy provided by the Administrator stated that opened and leftover items must be labeled with the date of opening or storage and a discard/use-by date, and that hair restraints including beard restraints must be worn to keep hair from contacting exposed food.
Failure to Provide Nail Care and Shaving During ADL Care
Penalty
Summary
The facility failed to provide fingernail care and shaving for residents who required assistance with ADLs. Resident 4 was observed on two occasions with long, jagged fingernails, chipped nail polish, and dark debris under the nails. The resident had diagnoses including dementia and type 2 diabetes mellitus, and a significant change MDS assessment indicated severe cognitive impairment and substantial assistance needed for personal hygiene. The care plan called for nail care on bath days and as needed, but progress notes and shower documentation for August and September 2025 did not show that fingernail care was offered, provided, or refused. Resident 5 was observed with dark debris under both fingernails and chipped nail polish, and a family member reported that the resident’s fingernails were often not clean. The resident had diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, and type 2 diabetes mellitus. A quarterly MDS assessment indicated severe cognitive impairment and dependence on staff for personal hygiene, and the care plan required assistance with ADLs, including nail care on bath days and as needed. However, progress notes and shower sheets did not document that fingernail care was offered, provided, or refused, and the DON stated fingernail care should have been provided with showers. Resident 10 was observed with long fingernails with debris under the nails and heavy beard growth, and the resident stated staff had not shaved him for a long time even though he was supposed to be shaved during showers. Resident 52 was also observed with heavy beard growth and stated he wanted to be shaved, but staff had not provided assistance. Both residents had MDS assessments showing a need for assistance with daily care needs, and staff interviews indicated shaving and nail care were to be done on shower days and as needed. The facility policy stated grooming care, including bathing, dressing, grooming, oral care, and routine nail care, would be provided during ADL care, and that only a licensed nurse would trim or file fingernails of residents with diabetes.
Inadequate hand hygiene and inaccurate pressure ulcer staging during wound care
Penalty
Summary
Pressure ulcer care was not provided with appropriate hand hygiene and wound handling practices during dressing changes for two residents. On 9/9/25, the wound nurse was observed changing Resident 4’s coccyx pressure ulcer dressing while wearing gloves from outside the room, carrying supplies into the room with gloved hands, placing supplies directly on the bedside table without a barrier, touching the privacy curtain and wheelchair with the same gloves, and changing gloves without performing hand hygiene. The nurse also removed gloves, did not perform hand hygiene, and opened the resident’s door to retrieve more supplies. Resident 4 had dementia and type 2 diabetes mellitus, required substantial assistance with ADLs, and had a coccyx pressure ulcer that progressed from stage 2 to stage 3 during the course of wound assessments. Resident 4’s wound record showed the coccyx wound was first identified as a stage 2 pressure ulcer on 5/30/25 and remained stage 2 on several subsequent skin evaluations. On 7/1/25, the wound bed was documented with 80 percent granulation tissue and 20 percent slough, but the evaluation did not document that the pressure ulcer stage was upgraded to stage 3. On 7/15/25, the wound was documented as deteriorated to stage 3 with increased size and 70 percent slough, but the evaluation did not document physician notification, and progress notes from 7/15/25 through 7/23/25 also lacked documentation that the physician was notified of the deterioration. The wound nurse later stated she was not sure the wound should have been upgraded when slough was noted and could not provide further documentation that the physician had been notified before the treatment was changed on 7/23/25. A second wound care observation on 9/9/25 showed similar hand hygiene and contamination concerns during treatment of another resident’s wounds. The wound nurse gathered supplies, entered the room with gloves already on, placed supplies directly on the resident’s mattress and bedside table without a barrier, removed the old dressing from the right hip, changed gloves and sanitized hands between procedures, then returned to the room and began treatment to a surgical wound without washing her hands between the two wound procedures. The resident had severe cognitive deficit, was dependent for all ADLs, and had a stage 4 pressure wound to the right hip. The DON stated a barrier should have been used under wound treatment supplies and handwashing should have been completed between treatments of different wounds.
Failure to Document and Report Non-Draining Suprapubic Catheter
Penalty
Summary
The facility failed to ensure timely documentation and reporting of a change in condition for a resident with a suprapubic catheter. Resident 65 had diagnoses including type 2 diabetes, urinary retention, depression, and neurogenic bladder, and had a physician order for a suprapubic tube catheter to bedside drainage and another order for suprapubic catheter care every shift. During observation, the resident stated he did not know why he had the catheter, said it was not draining, and reported that it was leaking. No urine was seen in the tubing or drainage bag at that time. The next day, the resident was again observed with an empty catheter bag and no urine in the drainage tube, and he stated he had just been changed and was very wet. RN 8 stated she was not aware the catheter had not been draining and had not been informed. Review of the record showed urinary output documented as 450 cc, and the DON stated the resident had a long-standing issue with the catheter and continued to urinate normally. The DON also acknowledged that CNA documentation should only reflect actual catheter output. CNA 7 stated that if a resident with a catheter was leaking or not draining urine, she would report it immediately to the nurse as a change in condition. The facility policy provided by the DON stated documentation must be accurate, relevant, and complete.
Nebulizer Equipment Left Unbagged and Improperly Stored
Penalty
Summary
The facility failed to ensure respiratory equipment was cleaned and stored appropriately after use for one resident with dementia and COPD who required assistance with daily care needs. During observations on 9/07/2025, 9/08/2025, and 9/09/2025, nebulizer equipment was seen unbagged next to the bedside table, and later the nebulizer mask and tubing were observed unbagged lying in the resident’s bed. An oxygen storage bag was also observed on the bedside table dated 8/25/25. The resident’s record showed physician orders for nebulizer treatments, including albuterol sulfate as needed for shortness of breath or wheezing and ipratropium-albuterol every 4 hours for shortness of breath for 7 days. The care plan identified the resident as at risk for respiratory distress related to COPD and needing assistance with activities of daily living. The MAR indicated the resident was assessed by the nurse after nebulizer treatment. During interview, an LPN stated that after a nebulizer treatment she would assess the resident, obtain vital signs, clean the nebulizer equipment with a bleach wipe, and leave it to dry for three minutes. The facility policy provided by the DON stated that delivery devices were to be kept covered in a plastic bag when not in use.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with facility policy and accepted professional principles. On 9/7/25, unattended medications for Resident 47 were observed on the counter at the nurses' station after the resident had been discharged from the facility that same day. During interview, an LPN stated the medications should not have been left unattended at the nurses' station and said the resident had just passed away and the medications were removed and left there, adding they should have been in the pharmacy. An RN also stated the medication cart and computer screen must be locked when she was not at the medication cart. On 9/9/25, an opened and undated vial of Aplisol Tuberculin testing solution was observed in the refrigerator in the 200 hall pharmacy medication room, and the LPN stated the vial should have been dated when opened. The facility policy provided by the Administrator stated all drugs and biologicals would be stored in locked compartments, and the medication administration policy stated multi-dose medication vials/devices should be labeled with the date opened/accessed.
Missing MAR Documentation for Ordered Medications
Penalty
Summary
The facility failed to ensure that medications were documented as administered for one resident reviewed for unnecessary medications. The resident had diagnoses including type 2 diabetes mellitus and hypothyroidism, and an admission MDS dated 6/11/25 indicated no cognitive deficit and no documented behavior of refusals of care. The resident's care plan did not include documentation of refusals of medications, treatments, or care. Physician orders directed administration of insulin glargine at bedtime for diabetes, insulin aspart with meals for diabetes, gabapentin three times daily for pain, and levothyroxine sodium twice daily for hypothyroidism. The July 2025 MAR lacked documentation of the 6:00 p.m. insulin glargine dose on 7/22/25 and the 5:00 p.m. insulin aspart dose on 7/22/25. The August 2025 MAR lacked documentation of the morning gabapentin dose on 8/15/25 and the morning levothyroxine dose on 8/15/25. In each instance, the record lacked documentation of a resident refusal or unavailability. During interview, the DON stated medications should be administered at the scheduled time and documented on the MAR, or if not administered, a reason should be documented. The DON also provided the facility's Medication Administration policy, which stated to administer medications as ordered and sign the MAR after administration.
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 | ★★★★★ | 19 | 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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