Cycle 1
Health 2025-04-03 · Fire 2025-04-03
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Sheridan, IN
Majestic Care Of Sheridan
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
803 S Hamilton St, Sheridan, IN
(317) 758-4426
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
78
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Majestic Care
Operator or chain grouping
Approved since
1991-05-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing
LPN hours / resident day
0.75
Licensed practical nurse staffing
Aide hours / resident day
1.91
Nurse aide staffing
Weekend hours
2.73
Weekend nurse staffing
RN turnover
43%
Annual RN turnover
Total nurse turnover
33%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
1.5
1.5 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
93.6%
6.1 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
3.8%
0.8 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 79.1% |
24.6%
54.5 pts worse
|
11.4%
67.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.5% |
5.6%
0.9 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 41.8% |
23.5%
18.3 pts worse
|
19.6%
22.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 36.6% |
14.8%
21.8 pts worse
|
16.7%
19.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.3% |
0.0%
0.3 pts worse
|
0.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.4% |
13.3%
8.9 pts better
|
16.3%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.8% |
11.7%
7.9 pts better
|
14.9%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.2%
0.9 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.5% |
24.2%
6.7 pts better
|
19.8%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.1%
2 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.4% |
81.6%
2.2 pts worse
|
81.7%
2.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-25 · Fire 2024-03-25
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
15 fire-safety deficiencies
Top issue: Egress (5 deficiencies)
Cycle 3
Health 2023-01-11 · Fire 2023-01-11
4 health deficiencies
Top issue: Environmental (1 deficiency)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-01
F · Potential for more than minimal harm
2025-04-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-01
E · Potential for more than minimal harm
2025-04-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-01
E · Potential for more than minimal harm
2025-04-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-01
F · Potential for more than minimal harm
2024-03-25
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-05-19
F · Potential for more than minimal harm
2024-03-25
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-05-19
F · Potential for more than minimal harm
2024-03-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-19
F · Potential for more than minimal harm
2024-03-25
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-05-19
F · Potential for more than minimal harm
2024-03-25
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-06-14
F · Potential for more than minimal harm
2024-03-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-19
F · Potential for more than minimal harm
2024-03-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-19
E · Potential for more than minimal harm
2024-03-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-19
E · Potential for more than minimal harm
2024-03-25
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-05-19
E · Potential for more than minimal harm
2024-03-25
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-05-19
E · Potential for more than minimal harm
2024-03-25
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-05-19
E · Potential for more than minimal harm
2024-03-25
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-05-19
E · Potential for more than minimal harm
2024-03-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-19
D · Potential for more than minimal harm
2024-03-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-19
C · Minimal harm
2024-03-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-19
F · Potential for more than minimal harm
2023-01-11
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-01-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-01-11
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-01-11
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-01-11
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-01-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-01-11
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-03-13
E · Potential for more than minimal harm
2023-01-11
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-04-18
E · Potential for more than minimal harm
2023-01-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-03-13
E · Potential for more than minimal harm
2023-01-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-13
E · Potential for more than minimal harm
2023-01-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-13
E · Potential for more than minimal harm
2023-01-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-13
E · Potential for more than minimal harm
2023-01-11
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-03-13
E · Potential for more than minimal harm
2023-01-11
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-03-13
C · Minimal harm
2023-01-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-03
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-04-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-04-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-21
D · Potential for more than minimal harm
2024-03-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-25
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-15
F · Potential for more than minimal harm
2023-01-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-11
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-02-06
Penalties and ownership
What sits behind the stars
Ownership
Daviess County Hospital
5% Or Greater Direct Ownership Interest · Organization
Alexander, James
Operational/Managerial Control · Individual
Chamberlain, Margaret
Corporate Officer · Individual
Daviess County Hospital
Operational/Managerial Control · Organization
Kirkwood, Lauren
Operational/Managerial Control · Individual
Majestic Care Of Sheridan LLC
Operational/Managerial Control · Organization
Majestic Management LLC
Operational/Managerial Control · Organization
Marx, David
Operational/Managerial Control · Individual
Pike, James
Operational/Managerial Control · Individual
Pruitt, Paul
Operational/Managerial Control · Individual
Pruitt, Paul
Corporate Officer · Individual
Rewa, Angela
Operational/Managerial Control · Individual
Russell, Robert
Operational/Managerial Control · Individual
Settles, April
Operational/Managerial Control · Individual
Shatrov, Anzhelika
Operational/Managerial Control · Individual
Shatrov, Anzhelika
Corporate Officer · Individual
Steiner, Deron
Operational/Managerial Control · Individual
Wolfe, Eric
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Wellbrooke Of Westfield
Westfield, IN
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Maple Park Village
Westfield, IN
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Copper Trace Health & Living Community
Westfield, IN
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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