Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Newburgh during CMS and state inspections, most recent first.
Surveyors found that two residents did not receive medications according to physician orders and facility policy. Medications were left unattended at the bedside, and staff did not consistently observe residents taking their medications. In some cases, required vital signs were not recorded before administration, and medications were held without proper physician orders.
The facility failed to ensure proper dish sanitization in the kitchen, as the dishwasher did not achieve the required chlorine levels and staff lacked knowledge on correct testing procedures. Despite inadequate sanitization, kitchen staff continued to use the dishwasher and serve meals on these dishes, and there was confusion about alternative cleaning methods when the dishwasher was not working.
Several residents who were dependent on staff for ADL assistance did not receive scheduled showers or bed baths as documented in facility records. Residents with conditions such as diabetes, epilepsy, and end stage renal disease reported missed hygiene care, and observations confirmed lapses in scheduled bathing routines. Staff interviews and documentation practices indicated that required hygiene care was not consistently provided according to facility policy.
Surveyors found multiple instances of improperly stored and unlabeled medications, including loose pills, undated liquids, and expired drugs in several medication and treatment carts. Staff interviews revealed gaps in knowledge and adherence to facility policies regarding medication labeling and expiration checks.
A Corporate Manager transferred clean laundry from the washer without wearing an apron, allowing items to touch her clothing and arms, contrary to facility policy and infection prevention protocols. The DON confirmed that staff should avoid contact between clean laundry and uniforms.
Two residents received PRN medications, including ondansetron, lorazepam, and Tylenol, from QMAs without the required preauthorization from a licensed nurse. Facility records and staff interviews confirmed that nurse authorization and documentation were not obtained prior to administration, contrary to facility policy.
A nurse failed to check gastric residuals before administering a tube feeding to a resident with a G-tube, despite physician orders and facility policy requiring this step. The resident, who had multiple medical conditions including dysphagia and a tracheostomy, did not consistently have residuals checked prior to feedings, as confirmed by staff, a family member, and the DON.
A resident with a laryngectomy did not receive proper airway management due to inaccurate documentation, lack of assessment for self-care ability, and absence of necessary equipment for the laryngectomy tube. Staff inconsistently performed and documented stoma care, and the care plan did not reflect the resident's involvement in self-care. The facility's policies and training did not address the specific requirements for laryngectomy care.
Two residents experienced deficiencies in clinical record documentation, including missing entries for abnormal vital signs, falls, and care plan interventions. For one resident, abnormal blood pressure and heart rate readings were not properly documented or communicated to a physician, and for another, fall incidents and related notifications were not recorded in the medical record. Facility policies requiring timely and complete documentation were not followed, and risk management reports were not integrated into the official clinical record.
A current nurse staffing sheet was not posted for one day during the survey period. The displayed sheet was outdated, and the process for updating the sheet depended on staff manually switching pre-filled sheets in the absence of the scheduler, without a formal policy in place.
A resident with hemiplegia was observed without prescribed hand splints and was given a straw to drink, contrary to physician orders. Despite documentation indicating compliance, staff were unaware of the no-straw order and failed to apply hand splints as required. The facility lacked a policy on following physician orders.
The facility was cited for failing to maintain a sanitary kitchen environment, with debris buildup observed on floors and equipment during inspections. Despite having cleaning schedules and policies in place, the facility did not adhere to them, resulting in unsanitary conditions.
A resident with an indwelling urinary catheter was not effectively assessed or monitored for adverse outcomes, leading to hospitalization for obstructive uropathy, sepsis, and acute kidney injury. Despite physician orders and a care plan, there were significant lapses in documentation and care, and staff failed to address reported issues of blood in the catheter tubing.
The facility failed to ensure that food was served at an appetizing temperature for multiple residents. Observations and interviews revealed consistent complaints about the food being cold, tough, overcooked, or burnt. A test tray showed food temperatures significantly below the expected serving temperatures, and the Dietary Manager confirmed the discrepancy with the facility's Food Preparation policy.
The facility failed to store and prepare food under sanitary conditions, with food items found open to air and without proper labeling or dating. Staff members were observed with improper hair restraints and inadequate hand hygiene practices, contrary to facility policies.
The facility failed to immediately notify the family of a resident involved in a resident-to-resident altercation. A resident with severe cognitive impairment was attacked by a roommate, resulting in bruising. The family was not informed until the next morning, despite the facility's policy to notify families immediately in such cases.
The facility failed to ensure accurate MDS assessments for three residents, leading to incorrect documentation of antipsychotic medication use, significant weight loss, and dental status. Errors were confirmed by staff, who admitted to relying on second-hand information and not adhering to the RAI Manual.
The facility failed to ensure care plan interventions were implemented for a resident reviewed for falls. The resident was observed with the call light not within reach on two occasions, despite care plan interventions specifying that the call light and personal items should be within reach. The resident has Alzheimer's Disease, dementia, and generalized anxiety disorder, and is a fall risk requiring substantial to maximum assistance for mobility, transfer, and eating.
The facility failed to revise the care plan for a resident with a history of falls and cognitive impairment after an unwitnessed fall resulted in fractures. The care plan was inappropriately updated to continue with current interventions, contrary to the facility's Fall Management policy.
A resident with hypotension and type 1 diabetes was given midodrine outside of prescribed parameters and IM glucagon without an active order during a hypoglycemic episode. The DON confirmed the medication errors and lack of proper documentation, leading to a deficiency in medication administration.
The facility failed to provide adequate nutritional and hydration care to two residents, resulting in significant weight loss and dehydration. One resident experienced severe weight loss due to lack of assistance with meals and failure to obtain weekly weights. Another resident was provided with insufficient fluids, leading to dehydration and a urinary tract infection. Staff interviews revealed ongoing issues with documentation and adherence to care plans.
The facility failed to ensure proper labeling of oxygen equipment and the presence of oxygen administration signs for three residents. Observations revealed undated oxygen tubing and missing warning signs, despite physician orders and care plans indicating the need for continuous oxygen and weekly tubing changes. A policy on oxygen equipment dating and labeling was requested but not provided.
The facility failed to provide appropriate pain assessments and management for a resident with severe cognitive impairment and multiple diagnoses, leading to inadequate pain management despite clear signs of distress.
The facility failed to ensure that a CNA had a current and valid certificate to work. Despite the expiration of the certificate, the CNA worked on 10 shifts. The facility's policy requiring non-certified placement or removal from the schedule until renewal was not followed.
The facility had a medication error rate of 7.7%, exceeding the acceptable 5%. Errors included a QMA not obtaining a required blood pressure reading and not checking the EDK for an unavailable medication, and an RN not priming an insulin pen needle before administration.
The facility failed to discard deteriorated medications for one of three medication carts observed. Several loose and unlabeled medications were found in the 100 Hall Cart 1. An LPN confirmed the issue and disposed of the medications. The facility's policy requires clear labeling of medications with specific information.
A resident with a documented lactose intolerance was repeatedly given milk with meals, despite clear dietary restrictions noted in their care plan and posted in the kitchen. This failure was confirmed by both a family member and the DON, indicating a lapse in the facility's adherence to its own dining and food preferences policy.
The facility failed to ensure complete and accurate resident records for three residents. Confusion regarding insulin administration for a resident, inaccurate documentation of medication refusal for another, and missing vital signs documentation after a fall for a third resident were observed.
The facility failed to ensure proper infection control practices during wound care for two residents. Staff did not change gloves or perform hand hygiene as required, leading to potential contamination during wound care procedures.
Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
Surveyors identified that the facility failed to ensure physicians' orders were followed for two of three residents reviewed for medication administration. In one instance, a medication cup with pills was observed on a resident's bedside table, and the resident stated she delays taking her medications until after breakfast. Review of her clinical record showed multiple diagnoses, including hypertensive heart disease, chronic kidney disease, Parkinson's disease, and diabetes. The electronic medication administration record (EMAR) revealed several instances where blood pressure readings were not recorded, and medications were not signed as given, with code 4 (vitals outside parameters) used despite no physician's order specifying parameters for holding the medication. Additionally, another resident reported that medications were left on her over-bed table, and she took them without staff present, sometimes receiving additional medications shortly after. Interviews with staff confirmed that medications were sometimes left unattended at the bedside, contrary to facility policy, which requires staff to observe medication consumption and prohibits leaving medications unless the resident has been assessed for safe self-administration. Staff also indicated uncertainty regarding physician orders for holding medications based on vital signs.
Dishwasher Sanitization Failure and Staff Knowledge Deficit
Penalty
Summary
The facility failed to ensure that the dishwasher in the kitchen was properly sanitizing dishes and that staff were knowledgeable about how to test for proper sanitization. During multiple observations, the dishwasher's rinse cycle did not reach the required temperature, and chlorine test strips consistently read zero parts per million (ppm), indicating no chemical sanitization was occurring. Despite these findings, kitchen staff continued to use the dishwasher to clean dishes, and meals were served on these inadequately sanitized dishes. Staff interviews revealed a lack of understanding regarding proper testing procedures for the dishwasher's sanitization process, with some staff expressing difficulty in safely testing the water and others unfamiliar with the equipment's operation. The facility's policy required a low temperature dishwasher to use a final rinse with at least 50 ppm hypochlorite for a minimum of 10 seconds, but this standard was not met during the observed periods. The deficiency was further compounded by the fact that staff continued to use the dishwasher and serve food on dishes that had not been properly sanitized, and there was confusion among staff about alternative procedures when the dishwasher was not functioning correctly.
Failure to Provide Scheduled Showers or Bed Baths to Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers or complete bed baths to residents who were dependent on staff for assistance with activities of daily living (ADLs). Multiple residents, all of whom were cognitively intact and required varying levels of staff assistance for bathing, reported not receiving their scheduled showers or bed baths. Documentation in the Point of Care charting system and written shower sheets confirmed that these residents did not receive or refuse their scheduled hygiene care on specific dates. For example, one resident with diabetes mellitus had not received or refused showers on two scheduled days and was noted to have a strong, pungent odor. Another resident with epilepsy, who preferred morning showers due to seizure risk, did not receive or refuse showers on three scheduled days. A third resident with end stage renal disease preferred bed baths but did not receive or refuse them on two scheduled days and was observed with oily hair. Interviews with residents revealed that they were aware of their scheduled hygiene routines but reported missed care, sometimes being told by staff that they would be attended to if time allowed. A Certified Nurse Aide confirmed the facility's process for offering and documenting showers, bed baths, and refusals. The facility's policy required staff to assist residents with bathing according to schedule or resident request, but the documented lapses indicate that this policy was not consistently followed for several residents with significant medical needs.
Improper Storage and Labeling of Medications
Penalty
Summary
Surveyors observed that medications and biologicals were not properly stored or labeled in multiple medication and treatment carts throughout the facility. Specifically, loose pills of various types and unidentified medications were found in several medication carts, with no identifying information such as resident name or medication label. Liquid medications and creams were also found without open dates or proper labeling, and expired medications were present in the carts. Additionally, medication drawers were noted to be unclean, with sticky residues and dried drippings observed. These findings were consistent across four medication carts and one treatment cart. Interviews with staff revealed a lack of knowledge and training regarding the facility's policies for checking and labeling medications. Some staff members were unaware of how often to check the carts or how to identify and handle unlabeled or expired medications. Facility policies provided by the administrator indicated that medications should be labeled with open dates and checked regularly for expiration, but these procedures were not being followed as evidenced by the observations and staff interviews.
Failure to Follow Infection Prevention Practices During Laundry Handling
Penalty
Summary
During an observation of laundry services, the Corporate Manager was seen emptying the washer without wearing an apron, allowing clean laundry items to come into direct contact with her shirt, pants, and arms. An interview with the Director of Nursing confirmed that staff are expected to prevent clean laundry from touching their uniforms during transfer. A review of the facility's policy on Personal Laundry Handling and Processing indicated that items should be moved from the washer to the dryer in a manner that minimizes the risk of contamination or re-soiling. These actions did not align with the facility's infection prevention and control protocols.
PRN Medications Administered by QMAs Without Nurse Authorization
Penalty
Summary
The facility failed to ensure that as-needed (PRN) medications administered by Qualified Medication Aides (QMAs) were preauthorized by a licensed nurse, as required by facility policy and job descriptions. For one resident with gastroesophageal reflux disease, ondansetron was administered on two occasions by QMAs without prior authorization from a licensed nurse. The resident's records showed that the medication was given as needed for nausea and vomiting, but there was no documentation of nurse authorization as required. For another resident with generalized anxiety disorder, severe cognitive impairment, and osteoarthritis, both lorazepam and Tylenol Arthritis Pain Extended Release were administered by QMAs on multiple occasions without documented authorization from a licensed nurse. Facility documentation and staff interviews confirmed that QMAs are required to obtain and document nurse authorization before administering PRN medications, but this process was not followed for these residents during the review period.
Failure to Check Tube Feeding Residuals as Ordered
Penalty
Summary
A deficiency was identified when a nurse failed to check for gastric residuals prior to administering a tube feeding to a resident with a gastro/jejunal feeding tube, as required by physician orders and facility policy. Observation showed that the LPN administered the feeding without verifying residuals, and the nurse later confirmed that this step was not always performed before feedings. The resident's care plan and physician orders specifically required checking tube placement and residual volume before each feeding and medication administration, with instructions to hold feedings if residuals exceeded a certain amount. The resident involved had diagnoses including tracheostomy, neoplasm of the larynx, and dysphagia, and was cognitively intact, requiring supervision for certain activities. Review of the clinical record and interviews with staff and a family member confirmed that the practice of checking residuals was not consistently followed. The Director of Nursing also acknowledged that staff were expected to check residuals prior to each feeding, in accordance with facility policy and physician orders.
Failure to Provide Proper Laryngectomy Care and Airway Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a laryngectomy, resulting in improper airway management. The resident, who was cognitively impaired and required supervision with hygiene and other activities, had a history of laryngectomy, tracheostomy, and related complications. Observations revealed that the resident's laryngectomy tube was found out of place and the resident reinserted it himself. Documentation and care records indicated inconsistencies, such as staff documenting that they performed stoma care even when the resident did it himself, and a lack of accurate assessment of the resident's ability to perform self-care. Physician orders specified that staff should monitor the tube and stoma site every shift, cleanse the area, and reinsert the tube as needed, with specific instructions for emergency situations. However, the clinical record lacked an assessment of the resident's skills for laryngectomy care, and there were no physician orders permitting the resident to perform his own stoma care. The care plan did not reflect the resident's involvement in self-care, and staff were not consistently following the prescribed care procedures. Additionally, the facility did not have the correct equipment for the laryngectomy tube, and staff initially treated the stoma as a tracheostomy rather than a laryngectomy. Interviews with staff and family confirmed that the resident's stoma care was not being performed as ordered, and the facility lacked the necessary supplies for proper care. Staff training was inconsistent, with verbal instructions being relayed rather than formal training or skills assessments specific to laryngectomy care. The facility's policies and documentation did not address the unique needs of laryngectomy care, contributing to the deficiency.
Incomplete and Inaccurate Documentation of Resident Care and Incident Response
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the clinical records for two residents, specifically regarding falls, abnormal vital signs, and changes in condition. For one resident with congestive heart failure, the clinical record showed an episode of abnormal low blood pressure and high heart rate, but lacked documentation of a rechecked blood pressure or physician notification. Although the administrator stated that a second set of vitals was obtained and found to be normal, there was no documentation to support this, and the information could not be provided upon request. Facility policies required timely and complete documentation of assessments, interventions, and notifications, which was not followed in this instance. For another resident with Alzheimer's Disease and a history of falls, the clinical record did not contain documentation that the physician and resident representative were notified of two separate falls, nor was there evidence of an assessment after one of the falls until the following morning. Additionally, a fall prevention intervention to keep the resident's door open for visualization was not consistently implemented, as the door was observed closed on multiple occasions. The care plan was not updated to reflect the resident's preference for a closed door, and discussions with the resident representative regarding this change were not documented in the clinical record. Risk management reports indicated that assessments and notifications were completed at the time of the incidents, but these reports were not part of the official medical record. The facility's documentation policies required that all relevant information be entered into the clinical record, but this was not done, resulting in incomplete and inaccurate records for both residents.
Failure to Post Current Nurse Staffing Sheet
Penalty
Summary
The facility failed to post a current nurse staffing sheet for one of five days during the survey period. On the morning of 6/29/25, the posted nurse staffing sheet displayed in the main lobby was found to be dated two days prior, indicating it was not current. Interviews with the Administrator revealed that the scheduler was responsible for preparing the staffing sheets, and when absent, would leave a pre-filled sheet for night shift staff to display. However, there was no formal policy in place for posting nurse staffing information, and the process relied on staff manually updating the sheet, which did not occur as required on the identified day.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident, identified as Resident B, who was observed without hand splints and was given a straw to drink with, contrary to the care plan and physician orders. Resident B, who has diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed multiple times without the prescribed hand splints, which were to be applied for up to four hours in the morning and afternoon. Despite the nursing staff signing off on the application of hand splints in the electronic medication administration record, observations indicated that the splints were not applied during the specified times. Additionally, Resident B was observed being given a straw to drink with, despite a clear order for no straws due to dysphagia and the risk of aspiration. The nursing staff, including RN 1, were unaware of the no-straw order and had noticed unthickened liquids on Resident B's bedside table. The facility's policy on comprehensive care plans indicated that qualified staff should be notified of their roles and responsibilities, but there was no policy provided on following physician orders. This deficiency was related to complaints IN00434521 and IN00437811.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, as observed during two separate inspections. On the first inspection, debris was found accumulated on the kitchen floors, particularly along the edges of the walls, under storage racks and tables, behind the stove and warmers, and under the dish machine and steam table. The dry pantry floor also had debris buildup, with condiment packets scattered on the floor and under food racks. Additionally, debris was noted on the sides of the stove, the shelf above the stove, and the shelves on the stainless steel table where the steamer was placed. These unsanitary conditions were observed again during a follow-up inspection. The facility's cleaning schedules were reviewed, indicating that the AM cook was responsible for cleaning the three-compartment sink and the stove, while the PM cook and servers were tasked with cleaning and sanitizing the floors and walls. Despite these schedules, the District Dietary Manager confirmed that the floors were only spot mopped during the day and fully swept and mopped at night. The facility's policy, revised in February 2023, required all food preparation and service areas to be maintained in a clean and sanitary condition, with a routine cleaning schedule for all cooking equipment and surfaces. However, the observations during the inspections indicated a failure to adhere to these policies, leading to the cited deficiency.
Failure to Monitor and Care for Resident with Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter was effectively assessed and monitored for adverse outcomes, received appropriate treatment and services to prevent infection, and was monitored for complications. Resident 35, who had a history of UTIs, chronic kidney disease, and dementia, was admitted with an indwelling Foley catheter. Despite physician orders and a care plan that included regular catheter care and monitoring, there were significant lapses in documentation and care. The resident's medical record lacked necessary assessments and monitoring for signs of infection or complications related to the catheter, and there were multiple instances where catheter care was not documented as completed according to the physician's orders and the plan of care. On several occasions, the resident's family reported blood in the catheter tubing and bag, but staff did not take appropriate action, stating that they no longer changed catheters. The resident's condition deteriorated, showing signs of infection and sepsis, which were not adequately addressed by the facility staff. The resident was eventually hospitalized with obstructive uropathy, sepsis secondary to a UTI, and acute kidney injury. Hospital staff found that the Foley catheter balloon was inflated in the urethra, causing significant complications. Interviews with facility staff revealed that there was confusion and inconsistency in documenting catheter assessments and care. The Director of Nursing confirmed that if tasks were not initiated on the Treatment Administration Record (TAR), the task was not completed. The Infection Preventionist also indicated that the resident had not been tracked for UTI or related urinary symptoms since the previous year. The facility's policies on catheter care and monitoring were not followed, leading to the resident's severe health decline and subsequent hospitalization.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
The facility failed to ensure that food was served at an appetizing temperature for multiple residents. Observations and interviews with residents revealed consistent complaints about the food being cold, tough, overcooked, or burnt. Specific instances included Resident 21, Resident 246, Resident 74, Resident 73, Resident 87, Resident 4, Resident 24, Resident 55, and Resident 25, all of whom reported issues with the temperature and quality of their meals. A test tray obtained on 5/2/24 showed that the food temperatures were significantly below the expected serving temperatures, with baked chicken at 100 degrees F, mac and cheese at 92 degrees F, carrots at 88 degrees F, and pumpkin pie at 76 degrees F. The Dietary Manager confirmed that the expected serving temperatures for meat and vegetables were 155 degrees F and 140 degrees F, respectively. The facility's Food Preparation policy, revised in 2/2024, indicated that food items should be kept at temperatures greater than 41 degrees F and/or less than 135 degrees F, which was not adhered to in this instance.
Sanitation and Hygiene Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions during multiple kitchen and nutrition pantry observations. Specifically, food items in the freezer and refrigerators were found open to air and without proper labeling or dating. Additionally, expired food items were not disposed of, and the kitchen floor was observed to be dirty with food debris, liquid spills, and other contaminants. The dry pantry also had a sticky floor with a brown liquid and dented cans stored improperly. These observations were made during a full kitchen tour and follow-up walkthroughs with the Dietary Aide and Dietary Manager present. Furthermore, staff members were observed not adhering to proper hygiene protocols. Dietary Aides and the Dietary Manager were seen with loose hair coming out of their hair nets, and the Dietary Manager was observed multiple times without a beard net or wearing it incorrectly. Hand hygiene practices were also inadequate, with one Dietary Aide lathering her hands for significantly less than the required 20 seconds on multiple occasions. The Infection Preventionist confirmed that these practices were against the facility's policies, which mandate proper hair and beard restraints and a minimum of 20 seconds for handwashing.
Failure to Immediately Notify Family of Resident Altercation
Penalty
Summary
The facility failed to immediately notify the family of a resident involved in a resident-to-resident altercation. Resident 35, who had severe cognitive impairment and diagnoses including dementia and major depressive disorder, was attacked by a roommate with a walker and a drawer, resulting in bruising to Resident 35's hand. The incident occurred on the evening of 2/26/24, but the family was not notified until 11:07 A.M. the next morning, despite the facility's policy to notify families immediately in case of emergencies, which includes resident-to-resident altercations. Interviews and record reviews confirmed the delay in notification. A family member reported not being contacted until the morning after the incident. The Administrator and Director of Nursing (DON) acknowledged that the family should have been notified immediately, as per the facility's Change in Condition policy. Documentation showed that the notification was made late, and the facility's policy was not followed in this instance.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for three residents. Resident 25's MDS assessment inaccurately indicated that the resident did not receive antipsychotic medication during the seven-day look-back period, despite physician orders for Aripiprazole. The Social Worker confirmed the error, noting that the resident was on the medication during the assessment period. Resident 55's MDS assessment incorrectly reported no significant weight loss, despite clinical records showing an 18.37% weight loss within 30 days and 27.55% within 180 days. Both the MDS Coordinator and the Registered Dietician were unsure why the significant weight loss was not recorded accurately. Resident 246's MDS assessment inaccurately indicated that the resident was not edentulous and had no broken teeth, despite conflicting information in the clinical record. The Admission Nursing Assessment noted broken natural teeth, while the Admission Nutrition Assessment and care plan indicated the resident had no teeth and used full dentures. The MDS Coordinator admitted to not observing the resident's mouth and relying on second-hand information from other staff. The facility's RAI policy mandates the use of the current RAI Manual for comprehensive assessments, which was not adhered to in these cases.
Failure to Implement Care Plan Interventions for Fall Risk
Penalty
Summary
The facility failed to ensure care plan interventions were implemented for a resident reviewed for falls. On two separate occasions, the resident was observed with the call light not within reach, despite care plan interventions specifying that the call light and personal items should be within reach. The resident, who has Alzheimer's Disease with late onset, dementia, and generalized anxiety disorder, was identified as moderately cognitively impaired and a fall risk, requiring substantial to maximum assistance for mobility, transfer, and eating. The facility's Fall Management policy, revised in June 2023, mandates that all falls be discussed by the interdisciplinary team to determine root cause and other possible interventions to prevent future falls.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that documentation of interventions was revised for a resident who experienced a fall. Resident 56, who has a history of vascular dementia, aphasia following cerebral infarction, and fractures, was observed with a cast on her left arm. The resident's most recent MDS assessment indicated moderate cognitive impairment and a history of falls with major injury. Despite an unwitnessed fall resulting in two fractures to the right wrist, the care plan was not appropriately updated with new interventions to prevent future falls. An IDT note indicated that the resident had decreased safety awareness and communication deficits, and ambulated independently around the facility. However, the care plan was only updated to continue with current interventions, which the Director of Nursing acknowledged was not appropriate. The facility's Fall Management policy requires the interdisciplinary team to determine the root cause of falls and update the care plan with new interventions, which was not done in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medication was administered according to physician orders for Resident 246, who had diagnoses including hypotension and type 1 diabetes mellitus. Midodrine, a medication for low blood pressure, was given on three occasions when the resident's systolic blood pressure (SBP) was above the prescribed threshold of 110 mm/Hg. Additionally, the resident experienced a hypoglycemic episode and was administered intramuscular (IM) glucagon, despite the absence of an active order for this medication. The resident's clinical record indicated that the IM glucagon order had been discontinued and replaced with intranasal Baqsimi due to a back order of IM glucagon. However, the IM glucagon was still administered during the emergency without proper documentation or a new order from the primary care clinician. The Director of Nursing (DON) confirmed that midodrine was given outside of the prescribed parameters and that the IM glucagon administered was from a past order that had not been returned to the pharmacy. The DON also indicated that the nurse on duty had called the doctor for an order to administer IM glucagon but did not document the verbal order due to a busy night. The facility's policies on medication administration and unnecessary drugs were not followed, as medications were administered without proper orders and documentation. The clinical record lacked evidence of a verbal order for IM glucagon or instructions to hold the intranasal Baqsimi, leading to the deficiency in medication administration for Resident 246.
Failure to Provide Adequate Nutritional and Hydration Care
Penalty
Summary
The facility failed to provide adequate nutritional care and services to Resident 55, who experienced significant weight loss. Despite having severe cognitive impairment and requiring moderate assistance with eating, Resident 55 was often not assisted with meals. The clinical record showed multiple instances where the resident consumed 0% or less than 50% of their meals without being offered an alternative. Additionally, the facility failed to obtain weekly weights as ordered by the physician and did not notify the physician of the resident's significant weight loss. The care plan indicated that the resident should consume at least 50-75% of planned meals and be provided assistance with meals and hydration, but these interventions were not consistently followed. Observations and interviews confirmed that staff did not always assist the resident with meals, and documentation was often inaccurate or incomplete. Resident 75, who had diagnoses including failure to thrive, severe protein-calorie malnutrition, and type 2 diabetes mellitus with chronic kidney disease, also experienced inadequate care. The resident's care plan included measures to prevent dehydration, but documentation showed that the resident was provided with less than the minimum daily fluid requirement on multiple occasions. The clinical record lacked documentation of fluids offered or refused by the resident. The resident expressed concerns about excessive thirst and urination, and lab results indicated dehydration. The resident was eventually transferred to the hospital, where they were diagnosed with a urinary tract infection and received intravenous hydration. Interviews with staff, including the Director of Nursing and the Administrator, revealed ongoing issues with documentation and follow-through on care plans. The facility's policies on charting, documentation, and hydration were not consistently adhered to, leading to significant deficiencies in the care provided to the residents. The lack of proper documentation and failure to follow care plans contributed to the residents' weight loss and dehydration, highlighting systemic issues within the facility's care practices.
Failure to Ensure Proper Oxygen Equipment Labeling and Signage
Penalty
Summary
The facility failed to ensure proper labeling of oxygen equipment and the presence of oxygen administration signs for three residents. Resident 24 was observed wearing oxygen via a nasal cannula, with a CPAP machine at the bedside, but the tubing lacked a date and initials when changed. Additionally, there were no oxygen administration warning signs on the outside door frame. Resident 24's clinical record indicated diagnoses of COPD, heart failure, and anxiety, with physician orders for continuous oxygen at 3 liters per minute and weekly tubing changes. A CNA confirmed that rooms should have a sign indicating oxygen use and that tubing should be changed weekly by a nurse. Resident 73's oxygen tubing was observed draped across the concentrator without an oxygen administration sign on the outside door frame. The resident's clinical record showed diagnoses of COPD and dementia, with physician orders for oxygen administration as needed to maintain oxygen saturation above 88%. Resident 88's oxygen concentrator was found blocking airflow to the air intake, and the attached bag and tubing were not dated. The resident's clinical record included diagnoses of respiratory failure, COPD, and type 2 diabetes mellitus, with orders for continuous oxygen at 3 liters per minute. A policy on oxygen equipment dating and labeling was requested but not provided, and the existing policy on oxygen administration did not address the observed deficiencies.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain assessments and management for Resident 55, who was observed to be in significant pain. Despite the resident's severe cognitive impairment and diagnoses of Alzheimer's disease, Parkinson's disease, and low back pain, the facility did not consistently assess or manage her pain according to her comprehensive care plan. Observations noted the resident was restless, moaning, and crying out in pain, yet the administration records showed only a single as-needed pain medication administration over a span of three months. The care plan included interventions for non-verbal pain indicators and non-pharmacological interventions, but these were not effectively implemented or documented. Interviews with staff revealed that they were often unable to differentiate between the resident's pain and her usual restlessness due to her dementia. The facility's policy on pain assessment and management required the use of a standardized pain assessment instrument appropriate to the resident's cognition level, but this was not consistently applied. The failure to observe and report changes in the resident's condition, as well as the lack of consistent pain assessment, led to inadequate pain management for Resident 55.
Failure to Ensure CNA Certification
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) had a current and valid certificate to work. CNA 2's certificate expired, and despite this, CNA 2 worked on 10 shifts over a specified period. The Administrator indicated that Human Resources (HR) was responsible for ensuring licenses stayed current and that they were working to get CNA 2's certificate renewed. The facility's policy stated that if a Care Team Member's license is not renewed prior to expiration, they should be placed in a non-certified position or removed from the schedule until the license is renewed and verified via the state portal. This policy was not followed in the case of CNA 2, leading to the deficiency.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure it was free from a medication error rate greater than 5%, resulting in an error rate of 7.7%. During a medication administration observation, a Qualified Medication Aide (QMA) prepared and administered medications to a resident without obtaining a required blood pressure reading and did not check the Emergency Drug Kit (EDK) for an unavailable medication. The resident refused a Miralax mixture, and the QMA crushed all pills together, including Depakote capsules, and mixed them with applesauce before administration. The resident's clinical record indicated that Losartan was not available, and no blood pressure reading was documented before administration, which was against the medication order requirements. In another instance, a Registered Nurse (RN) prepared and administered insulin to a resident without priming the insulin pen needle as required by the facility's policy. The RN used an alcohol pad to clean the insulin vial and drew the medication into a syringe, then attached an insulin pen needle to a Lispro insulin pen and administered both insulins to the resident's right upper arm. The resident's clinical record indicated specific insulin orders, but the RN did not follow the proper procedure for insulin pen preparation and administration. The Director of Nursing (DON) confirmed that medications should be documented if given and that staff should check the EDK for unavailable medications.
Failure to Discard Deteriorated Medications
Penalty
Summary
The facility failed to ensure deteriorated medications were discarded for one of three medication carts observed. During a medication storage observation of the 100 Hall Cart 1, several loose and unlabeled medications were found, including various pills with and without imprints. An LPN confirmed that loose pills in the medication cart should be disposed of and subsequently discarded all 16 medications into the sharps container. The facility's policy on medication labeling, dated 2/1/18, requires that medication labeling must be typed or printed and clearly indicate specific information such as the resident's full name, prescription number, drug strength, and expiration date, among other details.
Failure to Accommodate Resident's Lactose Intolerance
Penalty
Summary
The facility failed to provide food that accommodated a resident's lactose intolerance. Specifically, Resident 246, who had a documented lactose intolerance, was given milk with his meal. This was observed on multiple occasions, including an instance where an unopened carton of milk was found on the resident's breakfast tray. The resident's clinical record confirmed the diagnosis of lactose intolerance, and the dietary restrictions were clearly noted in the resident's nutrition care plan and on a sign posted in the kitchen. Despite these precautions, the resident continued to receive milk, which was confirmed by both a family member and the Director of Nursing (DON). The facility's policy on dining and food preferences, which mandates offering alternate selections for residents with food allergies or intolerances, was not followed. This oversight indicates a failure in the facility's system to ensure that dietary restrictions are consistently honored.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure resident records were complete and accurate for three residents. For Resident 246, there was confusion regarding the insulin administration order. The order was unclear about whether insulin should be administered if the blood sugar level was between 151 and 209. This confusion was confirmed by both the LPN and the DON, who had to clarify the order with the Nurse Practitioner. The facility's policy required documentation to be complete and accurate, which was not adhered to in this case. Additionally, during a medication administration observation, QMA 9 prepared Miralax for Resident 15, who refused the medication. Despite the refusal, the administration record inaccurately indicated that the Miralax was administered. The facility's policy required documentation of medication refusals, which was not followed in this instance. For Resident 26, the facility failed to document vital signs on the Neurological Evaluation Flow Sheet after a fall. The resident, who was moderately cognitively impaired and a fall risk, was found on the floor mat after attempting to get more comfortable in bed. The flow sheet lacked documentation of vital signs at multiple time points, which was confirmed by RN 5. The facility's policy required all information, including vital signs, to be filled out on the neurological check flow sheet, which was not done in this case.
Infection Control Deficiencies During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices during wound care for two residents. In the first instance, during wound care for Resident 12, LPN 8 and CNA 7 did not change gloves or perform hand hygiene after cleaning the resident's buttocks following a bowel movement. LPN 8 continued to touch the resident and clean linen with the same gloves, and CNA 7 also failed to perform hand hygiene before placing new gloves on. This lack of proper hand hygiene and glove changes during wound care procedures was observed on 5/3/24. In the second instance, on 5/2/24, RN 5 and NP 19 were observed performing wound care for Resident 11, who required enhanced barrier precautions. NP 19 did not perform hand hygiene after removing soiled gloves multiple times during the wound care process. Additionally, NP 19 used a phone to take photos of the wounds and placed the phone in her pocket without proper sanitization. RN 5 and NP 19 did not adhere to the facility's hand hygiene and glove use policies, which were confirmed during an interview with RN 11 on 5/9/24.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 287 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Newburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Newburgh Health And Rehab | 0.9 mi | ★★★★★ | 29 | 0 |
| Hamilton Pointe Health And Rehab | 1.4 mi | ★★★★★ | 4 | 0 |
| Brickyard Healthcare - Woodlands Care Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Cypress Grove Rehabilitation Center | 3.1 mi | ★★★★★ | 7 | 0 |
| Evansville Protestant Home | 3.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.