Cycle 1
Health 2025-09-11 · Fire 2025-09-11
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Terre Haute, IN
Majestic Care Of Terre Haute
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3150 N Seventh St, Terre Haute, IN
(812) 466-5217
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
104
Certified beds
Average residents
69
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Majestic Care
Operator or chain grouping
Approved since
1973-01-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 3 overall / 2 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.76
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.30
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.47
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,016
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.73
Composite VBP score used to determine payment impact.
Payment multiplier
0.9909
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.28
Baseline 21.40% · Performance 18.98% · Measure score 5.28 · Achievement 5.28 · Improvement 5.03
Healthcare-associated infections
5.49
Baseline 7.68% · Performance 6.19% · Measure score 5.49 · Achievement 5.49 · Improvement 5.04
Total nurse turnover
4.32
Baseline 52.54% · Performance 46.03% · Measure score 4.32 · Achievement 4.32 · Improvement 1.85
Adjusted total nurse staffing
0
Baseline 2.92 hours · Performance 2.67 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.02% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 80 · Observed rate 15% · Lower 95% interval 8.09% |
| Discharge to community | 50.45% |
50.57%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 42.86% · Lower 95% interval 37.38% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 36 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 8 · Denominator 24 |
| Discharge mobility score | 62.5% |
50.94%
11.6 pts better
|
Numerator 15 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 2.78% |
2.29%
0.5 pts worse
|
Numerator 1 · Denominator 36 · Adjusted rate 2.37% |
| Healthcare-associated infections requiring hospitalization | 6.19% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 2.78% · Lower 95% interval 3.64% |
| Staff COVID-19 vaccination coverage | 23.26% |
8.2%
15.1 pts better
|
Numerator 20 · Denominator 86 |
| Staff flu vaccination coverage | 15.27% |
42%
26.7 pts worse
|
Numerator 20 · Denominator 131 |
| Discharge function score | 58.33% |
56.45%
1.9 pts better
|
Numerator 14 · Denominator 24 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 8% |
25.2%
17.2 pts worse
|
Numerator 2 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.6
0.9 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.5
0.8 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
93.6%
5.1 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 95.0% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.0% |
95.4%
0.4 pts worse
|
95.5%
0.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.0% |
3.8%
3.2 pts worse
|
3.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 3.6% · Q3 10.9% · Q4 8.3% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.6% |
24.6%
18 pts better
|
11.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 26.4% · 4Q avg 6.6% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
5.6%
1.6 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 10.2% · Q3 8.0% · Q4 5.6% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.1% |
23.5%
8.4 pts better
|
19.6%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 16.0% · Q3 15.1% · Q4 16.4% · 4Q avg 15.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.3% |
14.8%
12.5 pts better
|
16.7%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 0.0% · Q4 6.5% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.4% |
13.3%
6.9 pts better
|
16.3%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 11.6% · Q3 7.0% · Q4 0.0% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.2% |
11.7%
4.5 pts better
|
14.9%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 10.2% · Q3 5.8% · Q4 5.7% · 4Q avg 7.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.2%
0.8 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.2% |
24.2%
9 pts worse
|
19.8%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 40.3% · Q3 24.8% · Q4 36.8% · 4Q avg 33.2% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
4.1%
2.2 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 7.7% · Q3 4.5% · Q4 10.8% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
81.6%
17 pts better
|
81.7%
16.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 93.9% · 4Q avg 98.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
10.5%
1.4 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 10.5% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.3%
0.1 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
79.0%
14.8 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.6% |
22.4%
0.8 pts better
|
23.9%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 26.3% · Expected 29.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-29 · Fire 2024-08-29
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-06-30 · Fire 2023-06-30
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-11
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-11-21
F · Potential for more than minimal harm
2024-08-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-08-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-27
E · Potential for more than minimal harm
2023-06-30
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 2023-07-21
C · Minimal harm
2023-06-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-28
C · Minimal harm
2023-06-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-11
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 2025-09-30
E · Potential for more than minimal harm
2025-09-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-09-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-09-11
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-09-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-09-11
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 2025-09-30
D · Potential for more than minimal harm
2025-09-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-07-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-28
E · Potential for more than minimal harm
2024-08-29
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 2024-09-17
D · Potential for more than minimal harm
2024-08-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-08-29
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-08-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-08-29
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 2024-09-17
D · Potential for more than minimal harm
2024-08-29
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-09-17
E · Potential for more than minimal harm
2023-06-30
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-30
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-30
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-06-30
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 2023-07-21
Penalties and ownership
What sits behind the stars
Ownership
Major Hospital
5% Or Greater Direct Ownership Interest · Organization
Horner, John
Corporate Officer · Individual
Majestic Care Of Terre Haute LLC
Operational/Managerial Control · Organization
Marx, David
Contracted Managing Employee · Individual
Sunset Harbor, Inc.
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Harrison's Crossing Health Campus
Terre Haute, IN
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Signature Healthcare Of Terre Haute
Terre Haute, IN
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $66,207 in total fines with 20 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Majestic Care Of Deming Park
Terre Haute, IN
2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $49,917 in total fines with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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